Professional Documents
Culture Documents
Investigation 5 Why
Complete all 10 sections on this form
1. Investigation details
Safeguard incident number
31/01/2014
3. 5 WHYs
1. Why did the above
happen?
Verification
2. Why did 1 happen?
Verification
3. Why did 2 happen?
Verification
4. Why did 3 happen?
Verification
5. Why did 4 happen?
Verification
6. Why did 5 happen?
Verification
7. Why did 6 happen?
Verification
8. Why did 7 happen?
Verification
Risk Management/JSA
Controls or preventive systems inadequate
Hazard not recognised
No Risk Assessment
Potential consequences not understood
Leadership Accountability
Deviation is accepted
Inadequate resource allocation
Management expectations inadequately
documented, communicated, or enforced
Supervision/Work Direction
Inadequate selection of worker(s)
Inadequate work direction or unclear
expectations
Inadequate work oversight or enforcement
of work standards
Design
Design did not anticipate the conditions
Design did not consider human factors
Design review failed to uncover
inadequacies in design
Design standards did not exist
Design standards inadequate
Design standards not used
Emergency Response
Emergency response
Human Performance
Mental overload
Mistake or mental slip
Wilful deviation
Management of Change
Inadequate for design change
Inadequate for organisational change
Not used
Natural Phenomenon
Insect, reptiles, or other animals
Weather/wildfire
Training/Competency
No training exists
Trained but lack of competency/fluency
Training exists but inadequate
Training exists but individual was not
trained
5. Tenets broken
Address abnormal situations
Task
description:
Allocate action
to:
Scheduled
date:
Controls
hierarchy
Administrative
Engineering
PPE
Substitution
Action note:
Task
description:
Allocate action
to:
Scheduled
date:
Controls
hierarchy
Administrative
Engineering
PPE
Substitution
Action note:
Task
description:
Allocate action
to:
Scheduled
date:
Controls
hierarchy
Administrative
Action note:
Engineering
PPE
Substitution
Task
description:
Allocate action
to:
Scheduled
date:
Controls
hierarchy
Administrative
Engineering
PPE
Substitution
Action note:
Yes