Surface causes Root Identify Use the diagram above as an example. contributing factors Every accident/incident is Surface cause: unsafe caused by a set of contributing behaviors and hazardous factors. These factors conditions. represent the surface or root Root underlying causes that led to the event. problems with The goal is to identify these by policies/procedures. analyzing how/why each consecutive event happened. Organize Engineering controls: Use guarding, less hazardous material or a possible solutions different design to Once the surface and root remove/reduce the causes have been Management controls: hazard. determined, you are ready to identify possible Use work practices, solutions. These should be scheduling, or job Personal protective equipment (PPE): prioritized based on their rotations to level of effectiveness. remove/reduce the Remember to list multiple exposure. solutions. Place a barrier, such as safety glasses, gloves, ear plugs, between employee and hazard. Note Your recommendations Identify who will be Report your findings to Remember to keep corrective should be relevant and responsible for completing members of management accident reports on file for measures concise. the action items on your list. who have the authority to act. record keeping purposes. The last ACTION step is to use your notes from the steps above to complete this form. How will you correct the issues addressed in the boxes above? Person assigned: Completion date: Supervisor/prepared by: Date: Copy: Safety Committee, Management Team, Owner/President Employee: Date: This is only an accident/incident analysis form. You will need to complete the workers’ compensation claim form (801) if the injury required medical treatment beyond first aid. There are also other Oregon record keeping requirements for recording and reporting work-related fatalities, injuries, and illnesses. Please reference http://www.orosha.org/subjects/recordkeeping.html for additional information on these requirements.
Surface causes Root Identify contributing factors Every accident/incident is caused by a set of contributing factors. These factors represent the surface or root causes that led to the event. The goal is to identify these by analyzing how/why each consecutive event happened. Use the diagram above as an example. Surface cause: unsafe behaviors and hazardous conditions. Root underlying problems with policies/procedures. Organize possible solutions Once the surface and root causes have been determined, you are ready to identify possible solutions. These should be prioritized based on their level of effectiveness. Remember to list multiple solutions. Engineering controls: Management controls: Personal protective equipment (PPE): Use guarding, less hazardous material or a different design to remove/reduce the hazard. Use work practices, scheduling, or job rotations to remove/reduce the exposure. Place a barrier, such as safety glasses, gloves, ear plugs, between employee and hazard. Note corrective measures The last ACTION step is to use your notes from the steps above to complete this form. Your recommendations should be relevant and concise. Identify who will be responsible for completing the action items on your list. Report your findings to members of management who have the authority to act. Remember to keep accident reports on file for record keeping purposes. How will you correct the issues addressed in the boxes above? Person assigned: Completion date: Supervisor/prepared by: Date: Copy: Safety Committee, Management Team, Owner/President Employee: Date: This is only an accident/incident analysis form. You will need to complete the workers’ compensation claim form (801) if the injury required medical treatment beyond first aid. There are also other Oregon record keeping requirements for recording and reporting work-related fatalities, injuries, and illnesses. Please reference http://www.orosha.org/subjects/recordkeeping.html for additional information on these requirements.
S924%20ACTION%20Form%20WORD%208.17.docx