Underlying Cause Analysis
Investigation Report
<<INCIDENT TITLE>>
<<date>>
IQMS Incident No: << >>
Brief Description of Incident:
Background / Interview Information:
Investigator Name:
Interviewed:
Report Prepared By:
Last reviewed: December 2010
Hydro Tasmania – UCA Template
CAUTION: Printed document is uncontrolled
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UCA Analysis
STEP 1
WHAT WAS THE
RESULT OF THIS
INCIDENT
STEP 2
WHAT WAS THE TYPE
OF INCIDENT?
Select one
STEP 3
WHAT WERE THE
IMMEDIATE CAUSES
STEP 4
WHAT WERE THE
UNDERLYING CAUSES
STEP 5
THE ROOT CAUSES
ARE
 Lost Time Injury (LTI)
 Medically Treated Injury (MTI)
 Minor Injury (MI)
 Near Miss
 Fire
 Hazard
 Environment
 Damage to Plant
 Damage to Equipment
 Loss of Production
 Struck by / struck against
 Fall / slip
 Caught in / on / between
 Contact with process fluid, electricity, heat
 Loss of containment
 Over-exertion
 Exposure to noise / heat / dust
 Exposure to gas
 Overpressure
 Fire / explosion
 Flooding
UNSAFE ACT
 Working without authority
Failure to follow procedures
 Not using safety devices
 Incorrect tools selected
 Improper lifting / movement
 Horseplay / inattention
 Failure to secure
 Improper position
 Rushing
UNSAFE CONDITION
 Lack of guards
 Inadequate equipment
 Defective tools
 Congested workplace
 Inadequate warning system
 Fire hazard
 Noise / heat / dust / light
 Poor housekeeping
 Poor ventilation
PERSONAL FACTORS
 Inadequate capability of individual
 Lack of knowledge
 Lack of skill
 Motivation (lack of, or too much)
 Stress - physical
 Stress - psychological
JOB FACTORS
 Inadequate leadership / supervision
 Inadequate engineering
 Inadequate purchasing
 Inadequate maintenance
 Abuse or misuse
 Poor process design
 Inadequate work standards
SYSTEMS FAILURE i.e. inadequate
 Leadership & accountability
 Customers and products
 Risk assessment & management
 Communications
People, training & behaviours
 Emergency management
 Engaging & working with contractors
 Incidents analysis & prevention
 Design, construction & change
 Health and hygiene
 Safe work practices & rules
 Hiring & placement
 Reward & recognition
 Measurement & evaluation
 Information & documentation
 Planning & scheduling
N.B. – for each box that you ticked please expand on information in sections below
Last reviewed: December 2010
Hydro Tasmania – UCA Template
CAUTION: Printed document is uncontrolled
Revision: 1
Page 2 of 3
Incident result
Type of Incident
Immediate Causes
Underlying Cause
Root cause
Other findings
Recommendations
Actions entered into IQMS
RECOMMENDATIONS
1.
2.
3.
4.
5.
6.
7.
Last reviewed: December 2010
BY WHO
Hydro Tasmania – UCA Template
CAUTION: Printed document is uncontrolled
BY WHEN
Revision: 1
Page 3 of 3