Conducting a full and proper root cause analysis is important to completing an accident investigation. This worksheet will aid in a full root cause analysis.

Including this form in your accident investigation toolkit, will aid those conducting an investigation after a safety incident.


Using the Root Cause Investigation Worksheet

Example Accident: “An employee comes into the lobby, with uncovered marble flooring during a rain storm, and slips on water puddled near door; spraining their wrist.”

Even if this specific accident didn’t result in a serious injury, they can result in broken bones or head injuries. No matter the level of injury, each accident should be investigated equally to prevent future accidents that may result in a more serious injury.

Using the root cause worksheet, you read the environmental section and see multiple applicable items.

Blank root cause worksheet section 1





So, applying this to the above example, you can identify:

  • adverse weather: raining outside
  • walking/working surface: uncovered marble floor
  • poor housekeeping: water puddled at entrance on floor

as causes of this instance. So which is a root cause and which is a causal factor of the incident? You can find that by applying some simple questions:

  • If it were raining outside, and the floor was covered with an anti-slip rug, would this have occurred?
  • If housekeeping had cleaned up the water pooled, would the person have slipped?
  • If there was no puddled water, but the person’s shoes were slick with rain could they have slipped on the marble floor?

Applying those questions, you will realize that the adverse weather and the poor housekeeping were contributing factors, while the walking/working surface was the root cause. Because a simple anti-slip rug could have stopped this, even if there wasn’t a puddle and it was raining outside, or if there was a puddle and it wasn’t raining outside.

completed root cause analysis




If you follow through with this root cause analysis, and take action and place an anti-slip mat at the lobby entrance, you have negated the possibility for further accidents.

You can see how this root cause worksheet is a good tool to have as part of an accident investigation program.

Ensure you give your team the tools and training required to fully implement a quality accident investigation program, which includes ensuring they are aware of their roles in the program, that they have been trained on their responsibilities, and they know how to follow-up to create change.

Check out the following related program components available for free:


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