Cause and Prevention Analysis Form

Last Report Generated (click to view or download)
  Incident Summary  
 Report Number 2010-8
 FROL ID Number 1214057
 Date Of Injury 02/10/2012
 Employer Golden Oldies Nursing
 Location Golden Oldies - Charlotte
 Department Maintenance
 Type Of Injury No Physical Injury
 Type Of Incident Not Defined
 Part Of Body Not Defined ()
        Classification
 Report Title:
 Incident classification:
 Property damage:
 Motor vehicle accident:
 Environmental:
 Employee Incident:
 Public or Liability Incident:
Comments (250 characters max)
        Unsafe Acts
        Direct Causes - select all that apply
 Operating tools/equipment without authority
 Failure to secure
 Operating tools/equipment at unsafe speeds
 Fail to warn or signal
 Defeating safety device
 Using defective/unsafe equipment
 Using equipment unsafely
 Taking unsafe position/posture
 Service energized equipment
 Not observing lockout/tagout procedures
 Riding hazardous equipment
 Horseplay
 Failure to use protective equipment
 Improper lifting, carrying or handling
 Improper use of tools or equipment
 Shortcut or hurrying
 Failure to follow operating procedures
 Under influence of drugs/alcohol
 Other - user defined
Narrative description (250 characters max)
        Indirect Causes - select all that apply
 Lack of job knowledge
 Lack of job skill
 Lack of hazard awareness
 Physical or mental incapacities
 Conflicting motivations - Save time and effort
 Conflicting motivations - Avoiding discomfort
 Conflicting motivations - Attracting attention
 Conflicting motivations - Asserting independence
 Conflicting motivations - Seeking group approval
 Conflicting motivations - Expressing resentment
 Other - user defined
Narrative description (250 characters max)
        Management Controls - select all that apply
 Inadequate hiring standards
 Inadequate placement standards
 Inadequate implementation of safe procedures
 Inadequate activity training
 Inadequate enforcement of safety standards
 Inadequate reward for good safety
 Inadequate supervisor training
 Other - user defined
Narrative description (250 characters max)
        Unsafe Conditions
        Direct Causes - select all that apply
 Inadequate safety devices/guarding
 PPE unavailable, dirty, or broken
 Inadequate warnings
 Fire or explosion hazards
 Unexpected movement hazard
 Poor housekeeping
 Unsafe/defective equipment
 Congestion/clearances
 Hazardous arrangement of tools, equipment, work environment
 Lack of good ergonomic arrangement of tools, equipment, work environment
 Unsafe atmosphere/ventilation
 Unsafe illumination
 Unsafe storage
 Unsafe clothing
 Other - user defined
Narrative description (250 characters max)
        Indirect Causes - select all that apply
 Attitude and actions of others - Production employees
 Attitude and actions of others - Maintenance employees
 Attitude and actions of others - Outside contractors
 Engineering
 Purchasing practices
 Normal wear and tear
 Abnormal wear and tear
 Lack of preventive maintenance
 Other - user defined
Narrative description (250 characters max)
        Management Controls - select all that apply
 Tolerance of man-made unsafe conditions
 Failure to design safety into facility
 Inadequate safety inspections
 Inadequate preventative maintenance
 Inadequate safety standards for purchasing
 Inadequate unsafe condition reporting
 Inadequate supervision of contractors
 Other - user defined
Narrative description (250 characters max)
        Preventive Measures
 Improve enforcement
 Improve storage/arrangement
 Identify/improve PPE
 Use other materials/supplies
 Improve ventilation
 Improve housekeeping
 Install/revise guards/devices
 Improve lighting
 Improve design/construction
 Repair/replace equipment
 Eliminate congestion
 Improve/change work method
 Training/retraining of employees
 Training/retraining of supervisors
 Mandatory pre-job instructions/checklists
 Procedure analysis to be completed
 Task analysis to be completed
 Ergonomic analysis to be completed
 Rotation of employee(s)
 Job reassignment of employee(s)
 Corrective counseling
 Other - user defined
Narrative description (250 characters max)
        Preventive Accountability
 Person responsible:
 Target completion date:
 Completion date:
        Loss Potential
 Probable recurrence:
 Loss severity potential:
        Training
 Did injured employee receive safety training regarding the activity prior to the accident?
 Does injured employee need safety training/retraining regarding the activity?
 Do other employees need safety training/retraining regarding the activity?
        Preparer
 Preparer name:
 Date prepared:
        Report History
Report History (click to view or download)