Deliverables: Report and Short Presentation.

REPORT
Each report should include the following:
One page for chain of events chart, and 3 pages for the other sections. Your report MUST
include the following sections:
1. Chart that shows the Chain of Events, conditions, and causal factors
Use an event-based causal chart like the one described in the posted paper “Root Cause
Analysis for Beginners” and try to identify as many relevant causal factors as you can. Indicate
the relevant events, conditions and actions. Provide a description of the incident that
accompanies the chart.
 Indicate the causal factors on the chart (similar to the class example)
2. Root cause analysis (Why it happened)
You should consider the following possible causal factors. To investigate causes, use the
questions listed in the “Incident Investigation Guide.”
 Human factors: What operation was the worker(s) performing? How? Did the worker
perform safe, unsafe acts, errors, violations?
Try to explain why the worker(s) acted the way they did. Use the Human Factors
framework: Task Demands, Work environment, Individual capabilities, and Human nature.
What factors were likely to influence the actions in the case?
 Production system: What were the elements of the production system that influenced
the course of events, actions, conditions, etc. Work method, work organization, tools
and equipment, material, jobsite organization, preparation, production goals and
pressures, task assignments, production controls, supervision, etc..
 Environment: What is the role of the physical and production environment?
 Management role (the injured worker’s management). How management’s
actions/inactions affected the conditions, actions and events of the case. Safety systems
training, personnel management, Jobsite management, supervision. What were the
conditions on the job? What was the hazards involved? How was the hazards
addressed/managed
 3rd parties: How did others (coworkers, other trades, designer, owner, GC, etc.)
influence the events?
 PRIORITIZE THE CAUSES you identified in order of importance.

3.Allocate responsibility

 Allocate responsibility to (1) the Worker, (2) the worker’s Employer, and/or (3) 3rd
Parties. The total should be 100%.
 Justify your allocation: Indicate the responsibilities of the different parties. Identify and
cite the relevant OSHA regulations and standards. Indicate WHO was in violation of
what standards.
4. Propose and prioritize controls
How would you plan and control the operation to prevent such accidents? What actions /
conditions can be most effective in preventing them?
You can propose several solutions.
 Use the hierarchy of controls to identify and prioritize solutions
 Who was in the best position to prevent the accident? What actions/changes are needed
and by whom?
 Remember that the most effective interventions involve controlling the conditions, rather
than the workers’ actions.
 Prioritize the solutions in order of effectiveness.
PRESENTATION
Prepare a presentation. 3 slides: Event Chart showing Primary causes, Liability,
Solutions.