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ROOT CAUSE ANALYSIS

REPORT
FOR WORKING WITHOUT PERMIT
STT PUNE DC04

Issued on 08/11/2023
**Root Cause Analysis (RCA) Report**

*Subject*: Unauthorized Commencement of Work

without Permit

*Date*: [09/11/23]

Incident Background:

**Overview**:
On [08/11/2023], work commenced without the
required permit, violating company policies and
protocols.

**Factors Leading to Unauthorized Work

Initiation**:

1. **Misinterpretation or Lack of Understanding**:

- Failure to comprehend the significance of
permits and authorization before commencing
work.

2. **Lack of Supervisory Oversight**:

- Absence of adequate supervision to ensure
compliance with established procedures.

3. **Incomplete Training**:
- Insufficient training or awareness of the
importance of permit adherence for both workers
and supervisors.
Root Causes Identified:

1. **Training Gap**:
- Inadequate training and awareness regarding
permit requirements and procedures.

2. **Communication Breakdown**:
- Lack of clear communication or understanding
regarding the necessity of following permit
protocols.

3. **Supervisory Oversight**:
- Insufficient supervision or reinforcement of
permit acquisition protocols.

Corrective Actions:

**Training Enhancement**:
1. Comprehensive retraining sessions for all
involved to ensure a clear understanding of
permit protocols and their necessity before work
commencement.

**Improved Communication**:
2. Clear and concise communication regarding the
importance of adhering to permit regulations in
all future work activities.

**Supervisory Measures**:
3. Implementation of a stringent oversight system to
ensure compliance with permit procedures before
initiating any work.

Preventive Measures:

1. Regular Refresher Training: Scheduled recurrent

training sessions to keep all staff updated and aware
of permit protocols.
2. Clear Documentation: Ensuring all team
members are provided with accessible
documentation outlining permit requirements and
procedures.
3. Increased Supervision: Enforcing a dual-check
system to ensure permits are obtained before work
initiation, with a higher level of supervision in
place.

Conclusion:

The identification of these root causes and the

subsequent implementation of these corrective and
preventive measures aim to prevent any future
instances of commencing work without the
necessary permit.

This report should be reviewed, understood, and

used as a basis for implementing changes to prevent
a recurrence of such incidents.

*Submitted by: Machindra khaladkar

*Date of SSubmission:09/11/2023.