morenci contractor team root cause analysis incident investigation report site name: ---------- date of incident: -------

MORENCI CONTRACTOR
TEAM ROOT CAUSE ANALYSIS
INCIDENT INVESTIGATION REPORT
SITE NAME:
----------
DATE OF INCIDENT:
-----------------
INCIDENT TYPE:
--------------
NATURE OF INJURY (if applicable):
---------------------------------
I. BRIEF SUMMARY OF INCIDENT
----------------------------

II. BACKGROUND AND DETAILS OF INCIDENT
III. PERSONNEL AND EQUIPMENT INVOLVED IN THE INCIDENT
-----------------------------------------------------
1.
Personnel Information (Involved)
Name:
Employee ID #:
Job Title:
Date of Hire:
# Years Experience in Current Position:
Immediate Supervisor:
Incident History:
2. Immediate Supervisor’s Information
Name:
Employee ID #:
Job Title:
Date of Hire:
# Years Experience in Current Position:
Immediate Supervisor:
Incident History:
Activity at Time of Incident:
Location at Time of Incident:
3. Witness Information (Direct)
Name:
Employee ID #:
Job Title:
Department:
Immediate Supervisor:
Activity at Time of Incident:
Location at Time of Incident:
4. Witness Information (Indirect)
Name:
Employee ID #:
Job Title:
Department:
Immediate Supervisor:
Activity at Time of Incident:
Location at Time of Incident:
5. Equipment
Property Type:
Property ID Number:
Function of Property:
6. Spilled Materials (Optional)
Name/Source of Spill:
Type: (flammable, toxic, etc.)
Quantity of Spill:
IV. CHRONOLOGICAL EVENTS OF THE INCIDENT
1.
V. FACT FINDING (CRITICAL FACTORS)
----------------------------------
1.
VI. ROOT CAUSES ANALYSIS
1. Immediate Causes: Substandard Practices
Comments:

2. Immediate Causes: Substandard Conditions
Comments:
3. Basic/Root Causes: Personal Factors
Comments:
4. Basic/Root Causes: Job Factors
Comments:
5. Management Control (System, Standards, Compliance)
Comments:
VII. ACTION PLAN TO PREVENT RECURRENCE
#
Action Item
Person Responsible
Start
Date
Complete
Date
Comments
1
2
3
4
5
VIII. INVESTIGATION TEAM/COMMITTEE
Print Name
Signature
Team Leader
Member
Member
Member
Member
IX. ACTION PLAN EFFECTIVENESS CHECK
Assigned to:
Due Date:
This Section To Be Completed After Due Date
Plan Effective?
Revised Action Items:
(if necessary)
Check Completed:
Print Name
Signature
ATTACHMENTS: (photos, statements, sketches, maps, forms, etc.)
BASIC/ROOT CAUSE ANALYSIS
circle category numbers for entry into the IMS (Incident Management
System)
INJURY
1. PART OF BODY
1.
Head
2.
Eye
3.
Nose
4.
Tooth/Teeth
5.
Jaw
6.
Face
7.
Ear
8.
Neck
9.
Shoulder
10.
Upper Arm
11.
Elbow
12.
Lower Arm
13.
Wrist
14.
Hand
15.
Finger
16.
Chest
17.
Abdomen
18.
Upper Back
19.
Lower Back
20.
Hip
21.
Buttocks
22.
Groin
23.
Upper Leg
24.
Knee
25.
Lower Leg
26.
Ankle
27.
Foot
28.
Toe
29.
Internal
30.
Systemic
2. NATURE OF INJURY
1.
Abrasion
2.
Allergy
3.
Amputation
4.
Bite / Sting
5.
Bruise / Contusion
6.
Burn (chemical)
7.
Burn (electrical)
8.
Burn (heat)
9.
Concussion
10.
Crack / Chip
11.
Crushing
12.
Cut / Laceration
13.
Dislocation
14.
Exhaustion
15.
Food Poisoning
16.
Foreign body [embedded]
17.
Foreign body [loose]
18.
Fracture
19.
Headache
20.
Hernia
21.
Hypothermia
22.
Inhalation
23.
Irritation
24.
Obstruction
25.
Poisoning
26.
Puncture
27.
Shock
28.
Sprain / Strain
29.
Suffocation
30.
Wound
CONTACT
3. AGENCY INVOLVED (choose only ONE)
1.
Aircraft/Watercraft
2.
Animal/Wildlife
3.
Boiler & Pressure Vessel
4.
Building/Structure
5.
Chemicals
6.
Container
7.
Conveyor
8.
Dust
9.
Electrical Apparatus
10.
Elevator/Tram
11.
Explosive Device
12.
Fixed Walkway
13.
Gases
14.
Hand Tools
15.
Heavy Equipment
16.
Highly Flammable Hot
17.
Hoisting Apparatus
18.
Installation
19.
Ladder/Stair/Walkway
20.
Light Vehicle
21.
Machinery
22.
Material/Goods (wet muck, boulder, etc.)
23.
Mechanical Power Transmission
24.
Obstruction
25.
Projectile
26.
Radiation/Radiating Substances
27.
Sharp Edge
28.
Stressing/Ground Pressure
29.
Working Surface
4. MECHANISM OF INJURY (choose only ONE)
1.
Aggravation
2.
Bite or Sting
3.
Blast
4.
Bodily Reaction
5.
Caught in (Pinch point)
6.
Caught on (Snag, Hung)
7.
Caught under or between (Crushed or Amputated)
8.
Contact with (Hot, Cold, Radiation, Chemical, Noise)
9.
Exposure to temperature extremes
10.
Fall from elevation
(To lower level)
11.
Fall from same level
(Slip and fall, Trip over)
12.
Foreign Bodies in eye (dust, chip, particle, etc)
13.
Inhalation, Absorption, Swallowing
14.
Lifting, Pulling, Pushing
15.
Overexertion / Stress
(Overload, Overexposure)
16.
Rubbed or Abraded
17.
Shock / Arc / Flash
18.
Slip (not fall)
19.
Struck against (Running, Bumping into)
20.
Struck by / with (Hit by moving object)
IMMEDIATE CAUSES
5. SUBSTANDARD PRACTICES (choose only ONE)
1.
Failure to follow rule or procedure
2.
Inadequate work area inspection
3.
Inadequate pre-op inspection
4.
Inadequate assessment of risk
5.
Failure to initiate corrective action
6.
Operating without authority
7.
Failure to warn
8.
Failure to secure
9.
Operating at improper speed
10.
Removing/defeating safety devices
11.
Using defective equipment
12.
Using equipment improperly
13.
Failing to use personal protective equipment
14.
Improper loading
15.
Improper placement
16.
Improper lifting
17.
Improper position for task
18.
Horseplay
19.
Under influence of alcohol and/or other drugs
20.
Unfit for duty
6. SUBSTANDARD CONDITIONS (choose only ONE)
1.
Inadequate guards or barriers
2.
Inadequate or improper protective equipment
3.
Defective tools, equipment or materials
4.
Congestion or restricted action
5.
Inadequate warning system
6.
Fire and explosion hazards
7.
Poor housekeeping; disorderly workplace
8.
Hazardous environmental conditions: gases, dusts, smokes, fumes,
vapors
9.
Noise exposure
10.
Radiation exposures
11.
High or low temperature exposures
12.
Inadequate or excessive illumination
13.
Inadequate ventilation
BASIC/ROOT CAUSES
7. PERSONAL FACTOR (choose ONE or no more than TWO)
1.
INADEQUATE PHYSICAL/PHYSIOLOGY CAPABILITY
1.
Inappropriate height, weight, size, strength, reach, etc.
2.
Restricted range of body movement
3.
Limited ability to sustain body position
4.
Limitation or incompatibility with assigned task (permanent
disability)
5.
Limitation or incompatibility with assigned task (temporary
disability)
6.
Substance sensitivities or allergies
7.
Sensitivities to sensory extremes (temperature sounds, etc.)
8.
Vision deficiency
9.
Hearing deficiency
10.
Other sensory (touch, taste, smell, balance)
11.
Respiratory incapacity
12.
Other permanent disabilities
13.
Temporary disabilities
2.
INADEQUATE MENTAL/PSYCHOLOGICAL CAPABILITY
1.
Limitation or incompatibility with assigned task (permanent
disability)
2.
Limitation or incompatibility with assigned task (temporary
disability)
3.
Fears and phobias
4.
Emotional disturbance
5.
Mental illness
6.
Intelligence level
7.
Inability to comprehend
8.
Poor judgment
9.
Poor coordination
10.
Slow reaction time
11.
Low mechanical aptitude
12.
Low learning aptitude
13.
Memory failure
14.
Inadequate initial training
7.3 PHYSICAL OR PHYSIOLOGICAL STRESS
1.
Injury or illness
2.
Fatigue due to task load or duration
3.
Fatigue due to lack of rest
4.
Fatigue due to sensory overload
5.
Exposure to health hazards
6.
Exposure to temperature extremes
7.
Oxygen deficiency
8.
Atmospheric pressure variation
9.
Constrained movement
10.
Blood sugar deficiency
11.
Drugs
12.
Non-work related medical condition/medication
4.
MENTAL OR PSYCHOLOGICAL STRESS
1.
Emotional overload
2.
Fatigue due to mental task load or speed
3.
Extreme judgment/decision demands
4.
Routine, monotony, demand for uneventful vigilance
5.
Extreme concentration/perception demands
6.
“Meaningless” or “degrading” activities
7.
Confusing directions
8.
Conflicting demands
4.
LACK OF KNOWLEDGE
7.5.1 Lack of experience
7.5.2 Inadequate orientation
7.5.3 Inadequate initial training
7.5.4 Inadequate update training
7.5.5 Misunderstood directions
4.
LACK OF SKILL
7.6.1 Inadequate initial instruction
7.6.2 Inadequate practice
7.6.3 Infrequent performance
7.6.4 Lack of coaching
4.
IMPROPER MOTIVIATION
7.7.1 Improper performance is rewarded
7.7.2 Proper performance is punished
7.7.3 Lack of incentives
7.7.4 Excessive frustration
7.7.5 Inappropriate aggression
7.7.6 Improper attempt to save time or effort
7.7.7 Improper attempt to gain attention
7.7.8 Inappropriate peer pressure
7.7.9 Inappropriate leadership example
7.7.10 Inadequate performance feedback
7.7.11 Inadequate reinforcement of proper behavior
7.7.12 Improper production incentives
BASIC/ROOT CAUSES
8. JOB FACTORS (choose ONE or no more than TWO)
1.
INADEQUATE LEADERSHIP AND/OR SUPERVISION
1.
Unclear or conflicting reporting relationship
2.
Unclear or conflicting assignment of responsibility
3.
Improper or insufficient delegation
4.
Giving inadequate policy, procedure, practices or guidelines
5.
Inadequate work planning or programming
6.
Inadequate instructions, orientation, and/or training
7.
Providing inadequate reference documents, directives and
guidance publications
8.
Inadequate identification and evaluation of loss exposures
9.
Lack of leader/management job knowledge
10.
Inadequate matching of individual qualifications and job/task
requirements
11.
Inadequate performance measurement and evaluation
12.
Inadequate or incorrect performance feedback
2.
INADEQUATE ENGINEERING
1.
Inadequate assessment of loss exposure
8.2.2 Inadequate consideration of human factors/ergonomics
8.2.3 Inadequate standards, specifications, and/or design criteria
4.
Inadequate monitoring of construction
5.
Inadequate assessment of operational readiness
6.
Inadequate monitoring of initial operation
7.
Inadequate evaluation of changes
3.
INADEQUATE PURCHASING
1.
Inadequate specifications on requisitions
2.
Inadequate research on materials/equipment
3.
Inadequate standards, specifications to vendors
4.
Inadequate mode or route acceptance
5.
Inadequate receiving inspection and acceptance
6.
Inadequate communication of safety and health data
7.
Improper handling of materials
8.
Improper transportation of materials
9.
Inadequate identification of hazardous items
10.
Inadequate salvage and/or waste disposal
8.4 INADEQUATE MAINTENANCE
1.
Inadequate preventative - assessment of needs
2.
Inadequate preventative - lubrication and servicing
3.
Inadequate preventative - adjustment/assembly
4.
Inadequate preventative - cleaning or resurfacing
5.
Inadequate reparative - communication of needs
6.
Inadequate reparative - scheduling of work
7.
Inadequate reparative - examination of units
8.
Inadequate reparative- part substitution
8.5 INADEQUATE TOOLS AND EQUIPMENT
1.
Inadequate assessment of needs and risks
2.
Inadequate human factors/ergonomics considerations
3.
Inadequate standards or specifications
4.
Inadequate availability
5.
Inadequate adjustment/repair/maintenance
6.
Inadequate salvage and reclamation
7.
Inadequate removal and replacement of unsuitable items
6.
INADEQUATE WORK STANDARDS
(Inadequate development of standards)
1.
Inadequate inventory and evaluation of exposures and needs
2.
Inadequate coordination with process design
3.
Inadequate employee involvement
4.
Inadequate/inconsistent standards/procedures/rules
(Inadequate communication standards)
5.
Inadequate publication
6.
Inadequate distribution
7.
Inadequate translation to appropriate languages
(Inadequate maintenance standards)
5.
Inadequate tracking of work flow
6.
Inadequate updating
8.6.10 Inadequate monitoring use of standards/procedures/rules
8.7 WEAR AND TEAR
1.
Inadequate planning of use
2.
Improper extension of service life
3.
Inadequate inspection and/or monitoring
4.
Improper loading or rate of use
5.
Inadequate maintenance
6.
Use by unqualified or untrained people
7.
Use for wrong purpose
7.
ABUSE OR MISUSE
1.
Condoned by supervision – intentional
2.
Condoned by supervision – unintentional
3.
Not condoned by supervision – intentional
4.
Not condoned by supervision – unintentional
MANAGEMENT CONTROL
9. MANAGEMENT CONTROL (SYSTEMS, STANDARDS, COMPLIANCE)
For each basic/root cause identified, refer to the management systems
below to assist in determining your corrective action to eliminate
an/or improve Management Control
1.
EMPLOYEE DEVELOPMENT
9.1.1 Training needs regularly analyzed
9.1.2 Training materials developed/formalized
9.1.3 Training provided to new employees
9.1.4 Training regularly updated
9.1.5 Refresher training
9.1.6 Training records maintained
9.1.7 Instructor qualifications
9.1.8 Competency evaluations conducted
9.1.9 Training effectiveness measured/monitored
2.
EMPLOYEE ACCOUNTABILITY
1.
Accountability system established/formal
2.
Roles/expectations for all job classes
3.
Accountability measurement systems
4.
Accountability evaluations regularly conducted
5.
Accountability in place for negative/positive behavior
3.
RISK/CHANGE MANAGEMENT
1.
Risks identified
2.
Risks analyzed and rated
3.
Risk controls identified
4.
Risk action plan
5.
Risks mitigated (ALARP)
6.
Risk measurement/monitoring system
7.
Change management identification system
8.
Change management identification process
9.
Change management communication process
10.
Risk/change management employee involvement
9.4 COMMUNICATIONS
9.4.1 Communications for entire audience
9.4.2 Top – down – up communications
9.4.3 Task instructions
9.4.4 Personal contacts
9.4.5 Group employee meetings
9.4.6 Audited for effectiveness/timeliness
9.5 INSPECTIONS/AUDITS
9.5.1 Planned general inspection process
9.5.2 Workplace examination process
9.5.3 Equipment inspection process
9.5.4 Job/Task observation process
9.5.5 Management involvement
9.5.6 Employee involvement
9.5.7 Corrective action follow-up process
9.5.8 Effectiveness measured/monitored
9.5.9 Evaluation for practices and conditions
9.6 EMERGENCY PREPAREDNESS
9.6.1 Administrative roles established
9.6.2 Identification of potential emergencies
9.6.3 Written emergency plans
9.6.4 Emergency contact information
9.6.5 Emergency teams trained
9.6.6 Emergency equipment available
9.6.7 Coordination with outside agencies
9.6.8 Emergency/evacuation drills
9.6.9 Employee emergency training
9.7 POLICIES/GUIDELINES//JSA’S/SOP’S/WI’S
9.7.1 Developed for jobs/tasks
9.7.2 Available to employees
9.7.3 Reviewed as part of job training
9.7.4 Reviewed before job/tasks begin
9.7.5 Reviewed/revised regularly
8.
CONTRACTORS/MATERIALS MANAGEMENT
1.
Written policy/procedures established
2.
Procurement of goods and services include safety reviews
3.
H&S review of contractor selection
4.
Onsite management of contractors
5.
H&S review of incoming services
6.
H&S training of contractors
7.
System/training in place for MSDS
8.
ENGINEERING/DESIGN
1.
Regulations/codes followed
2.
Hazard/risk identification conducted
3.
H&S review of projects
4.
H&S analysis conducted
5.
Operational/work process controls in place
8.
OPERATIONS & MAINTENANCE
1.
Preventative maintenance system in place
2.
Critical processes/parts identified/reviewed
3.
Pre-use equipment process in place
4.
Work order system in place
8.
OCCUPATIONAL HEALTH
1.
Hazard identification/evaluation/controls in place
2.
IH monitoring in place and conducted
3.
Information and training in place
4.
Medical surveillance conducted
5.
Recordkeeping tracked and maintained
8.
HUMAN ENGINEERING
1.
Ergonomic designed equipment in place
2.
Ergonomic reviews conducted
3.
Ergonomic education provided
4.
Fatigue factors identified
5.
Fatigue awareness training provided
8.
HUMAN RESOURCES
1.
Job capability requirements evaluated and established
2.
Pre-placement exam provided
3.
New hire skills analysis completed
4.
General orientation/training conducted
5.
Pre-employment qualification checks made
6.
Mentoring systems in place
8.
ENVIRONMENTAL
9.14.1 Spill release reporting/controls in place

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