Incident & Near Miss Root Cause Analysis Form
A structured form for documenting and analyzing incidents, near misses, and their root causes in compliance with OSHA and WorkSafeBC regulations. Use this template to conduct a formal RCA, identify systemic failures, and implement corrective actions.
This Root Cause Analysis (RCA) form is designed to comply with OSHA 1910.119 (Process Safety Management) and WorkSafeBC OHSR Part 3 (Incident Investigation). It guides investigators through the five core steps of an effective RCA: scene preservation, evidence collection, causal factor identification (using techniques such as 5 Whys or fishbone diagrams), root cause determination, and corrective action planning. Proper documentation of every near miss and recordable incident is critical for regulatory compliance and for reducing recurrence rates.
- Ensure the incident scene is secured and preserved for investigation. Restrict access to authorized personnel only.
- Assemble a cross‑functional investigation team (supervisor, safety officer, technical expert) with appropriate training in root cause analysis.
- Review all relevant documentation: machine manuals, lockout/tagout records, previous similar incidents, and job safety analyses.
RCA Investigation Checklist
| Status (P/F) | Checklist Item / Investigation Step | Compliance Standard | Action Required / Notes |
|---|---|---|---|
| [ ] Pass [ ] Fail | Immediate containment actions taken (e.g., first aid, equipment shutdown, scene isolation). | WorkSafeBC OHSR 3.13 | _________________ |
| [ ] Pass [ ] Fail | Witness statements collected and secured | OSHA 1910.119(m)(5) | _________________ |
| [ ] Pass [ ] Fail | Photographs / video of the scene taken before any alteration | Internal policy | _________________ |
| [ ] Pass [ ] Fail | Root cause identified using a formal method (5 Whys, fishbone, etc.) | OSHA 1910.119 App C | _________________ |
| [ ] Pass [ ] Fail | Contributing factor analysis completed | ANSI/ASSE Z590.3 | _________________ |
| [ ] Pass [ ] Fail | Corrective / preventive actions proposed and assigned | WorkSafeBC OHSR 3.17 | _________________ |
Incident / Corrective Action Log
| Date / Time | Item # | Safety Issue Identified | Corrective Action Taken | Assigned To |
|---|---|---|---|---|
| ___/___/_____ | _______ | _______________________________ | _______________________________ | _______ |
| ___/___/_____ | _______ | _______________________________ | _______________________________ | _______ |
| ___/___/_____ | _______ | _______________________________ | _______________________________ | _______ |
By signing below, the supervisor or designated competent person verifies that all investigation steps, root cause analysis, and corrective actions have been completed according to internal policy and local occupational health laws (OSHA / WorkSafeBC).