5 Whys Incident Investigation Report

Incident Title (Short Description):

Incident Date: Time: Lead Investigator (Supervisors Name):

Incident Description and Timeline:

Incident Description

People

Equipment

Environment

Procedure / Policy

Complete 5 Whys Analysis (See Page 2)

Investigation Team:

Analysis Team

Actions (how will we prevent this from happening again):

Hierarchy of
Action Description Person Responsible Due date
control

Sign Off:

Role Name Signature Date

Accountable
Manager

Accountable
Superintendent

Safety Health
Representative
 5 Whys Incident Investigation Report

Instructions:
1. Insert the key events or points of control into the Time Line boxes in the first row (use your incident description and timeline to assist).
2. For each key event or point of control, complete a 5 Why’s analysis by asking: how has this event contributed to the final outcome? (Swiss cheese effect).
3. Think about the Equipment, Environment, People, Systems & Procedures and circle the “Why’s” that have contributed to the event.
4. For each circled “Why” create an action to prevent a re-occurrence.

Key Events

Why 1

Why 2

.
Why 3 .

Why 4

Why 5