FIVE WHYs Work Sheet
Business Unit
Location
Incident date
Type of Process:
Type of Equipment:
RCA Team: Sponsor
Leader :
Facilitator :
Facility Name
Incident Number
Member :
Incident Brief Description:
FIVE WHYs
1. Why did the above happen?
Verification
2. Why did 1 happen?
3. Why did 2 happen?
4. Why did 3 happen?
5. Why did 4 happen?
6. Why did 5 happen?
7. Why did 6 happen?
8. Why did 7 happen?
1
Information Sensitivity: Company Confidential
Printed 25 August 2021.
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FIVE WHYs Work Sheet
2
Information Sensitivity: Company Confidential
Printed 25 August 2021.
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FIVE WHYs Work Sheet
Main Root Cause Category
Subset Causal Factor
Assessment, Inspections or
Audits
Assessment, inspection or audit was not conducted
Assessment, inspection or audit failed to uncover inadequacies in procedures or programs
Results of assessment, inspection or audit were not acted on
Inadequate verbal communication
Inadequate written communication
Inadequate shift turnover communication
Inadequate signalling
Inadequate signage
N/A
Communications
Contractor Health, Environment
and Safety Management
Design
Emergency Response
Human Performance
Incident and Near Miss
Investigation
Inspection/Quality Control
Leadership Accountability
Management of Change
Natural Phenomenon
Pre-Startup Safety Reviews
Preventive Maintenance/Repeat
Failure
Risk Management / JSA
Design standards not utilized
Design standards inadequate
Design standards did not exist
Design did not anticipate the conditions
Design Review failed to uncover inadequacies in design
Design did not consider human factors
N/A
Mistake or mental slip
Wilful deviation
Mental overload
N/A
Inspection inadequate
Inspection not conducted
Results of inspection not acted on
Management expectations inadequately documented, communicated or enforced
Deviation is accepted
Inadequate resource allocation
Management of Change not utilized
Management of Change inadequate for design change
Management of Change inadequate for organizational change
Weather/Wildfire
Insect, reptiles or other animal
Pre-Startup Review was not conducted
Pre-Startup Safety Review failed to uncover inadequacies in procedures and/or equipment
Results of Pre-Startup Safety Review were not acted on
Inadequate inspection or PM plan
Inspection or maintenance not conducted as required
Inadequate procedures or execution
Incorrect or deficient material installed
Requires additional investigation
Inadequate planning or execution
No Risk Assessment
Hazard not recognized
Potential consequences not understood
Controls or preventive systems inadequate
3
Information Sensitivity: Company Confidential
Printed 25 August 2021.
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Uncontrolled when printed.
FIVE WHYs Work Sheet
Procedures and Safe Work
Practices
Supervision/Work Direction
Training/Competency
Root cause category
HES Procedures or Safe Work Practices did not exist
HES Procedures or Safe Work Practices not available
HES Procedures or Safe Work Practices inadequate
HES Procedures or Safe Work Practices not utilized
HES Procedures or Safe Work Practices difficult to use
Operations Procedures did not exist
Operations Procedures not available
Operations Procedures inadequate
Operations Procedures not utilized
Operations Procedures difficult to use
Maintenance Procedures did not exist
maintenance Procedures not available
Maintenance Procedures inadequate
Maintenance Procedures not utilized
Maintenance Procedures difficult to use
Inadequate selection of worker(s)
Inadequate work oversight or enforcement of work standards
Inadequate work direction or unclear expectations
Not training exists
Training exists but inadequate
Training exists but individual was not trained
Trained but lack of competency/fluency
Description of root cause
Protective System
Protective Systems Did Not Work
Description of root cause
[Insert Protective System Name]
Protective Systems that Worked
[Insert Protective System Name]
Protective Systems that Would’ve
Worked but Do Not Exist
[Insert Protective System Name]
4
Information Sensitivity: Company Confidential
Printed 25 August 2021.
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Uncontrolled when printed.
FIVE WHYs Work Sheet
Tenets Broken
Operated within design or environmental limits?
Maintained integrity of dedicated systems?
Operated in a safe and controlled condition?
Complied with all applicable rules and regulations?
Ensure that safety devices where in place and functioning?
Addressed abnormal conditions?
Followed safe work practices and procedures?
Met or exceeded customer’s requirements?
Followed written procedures for high risk or unusual situations?
Involve the right people in decision that affect procedures and
equipment?
ACTION ITEMS AND TIMEFRAMES MUST BE AGREED WITH ACTIONEE PRIOR TO
COMPLETION OF THE REPORT
Action Items: (complete here or on the investigation report)
Action description:
Target completion date:
Assigned by:
Responsible department:
Action Description:
Target completion date:
Assigned by:
Responsible department:
Start date:
Assigned to:
Responsible location:
Start date:
Assigned to:
Responsible location:
5
Information Sensitivity: Company Confidential
Printed 25 August 2021.
Page 5 of 5
Uncontrolled when printed.