Root Cause Analysis Worksheet
Editable Word root cause analysis worksheet for Queensland workplaces: timeline, a 5 whys chain, contributing factors, failed controls by the hierarchy of controls, root causes and corrective actions with owners.
RG
Written by Ryan Graham, health and safety professional (16 years on Queensland sites)
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About this template
A three page worksheet for a supervisor or investigation team to find why an incident or near miss happened. It works from the facts through a 5 whys chain to system causes, checks which controls failed or were missing, and lists corrective actions to carry to the Corrective Action Request Form. It says plainly that the 5 whys is good practice and not a method the law names.
What Is Included In Our Root Cause Analysis Worksheet?
- Event details with a notifiable incident check
- A timeline of events with the source of each fact
- A 5 whys chain with evidence for each answer
- Contributing factors: task, equipment, people, environment, organisation, supervision, procedures and training
- Controls that failed or were missing, by level of the hierarchy
- Root causes tested as system causes
- Corrective actions with level of control, owner and due date
- Consultation, review of controls and sign-off
Legislation and Codes of Practice Referenced
- Work Health and Safety Act 2011 (Qld): ss 38 and 39
- Work Health and Safety Regulation 2011 (Qld): ss 35 to 38
What You Get
- An editable Microsoft Word form (3 pages), A4 portrait, to fill in on screen or print
- Tick boxes and date pickers that work in Word
- Business details typed once and filled in on every page, plus a space for your logo
- Sign-off and document control
Review it and adjust it to suit your business, your sites and the way your team works, and talk it through with your workers. If you have any trouble downloading this template, you can contact us at any time. Please make sure you read our Disclaimer before downloading.
Having trouble with your download? Contact us any time. Please read our Disclaimer before downloading.
How to use it
From download to site in three steps
Buy and download
Check out with card, Apple Pay or Google Pay. Your download buttons appear straight away and the links are emailed to you. Links work for 3 months, so save your copies.
Make it yours
Open it in Microsoft Word or Excel. Add your logo, business details, site and job information, and adjust it to how the work is done.
Brief your crew
Talk it through with the workers doing the job, have them sign on, and keep it on site. Review it whenever the job or conditions change.
What format is it?
Microsoft Word. Edit it in Word, or free in Word for the web, and add your own logo and business details.
How do I get it after I pay?
Your download buttons appear as soon as checkout finishes, and the links are emailed to you. You can re-download from your account at any time.
Is it compliant with Queensland law?
It's written around Queensland's Work Health and Safety Act 2011 and Regulation 2011. Tailor it to your site, consult your workers and review it whenever conditions change; no template can guarantee compliance on its own.
What if it isn't right for my job?
If it doesn't match its description or has a fault, tell us and we'll fix it. If you're still not happy, we'll refund you or give you store credit, your choice. Check the sample pages first, as we don't refund a change of mind.
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