TORTUGA SAFETY & INSPECTION
Root Cause Investigation
Structured methodology: Timeline → 5 Whys → Fishbone → Root Cause → Corrective Actions. Designed to produce a defensible OSHA-compatible investigation record.
7 P's · PRIOR PROPER PLANNING PREVENTS PISS POOR PERFORMANCE
INVESTIGATION HEADER § 01
Establish scope and chain of custody. The incident report ID links this RCA to the original report so reviewers can find both.
TIMELINE RECONSTRUCTION § 02
Reconstruct the sequence of events leading up to and through the incident. Pull from witness statements, control room logs, equipment data, and physical evidence. Stick to facts — what was observed or recorded.
5 WHYS ANALYSIS § 03
Start with the immediate problem statement. Keep asking "why" until you reach a systemic cause — not just human error. If your last "why" is "the worker made a mistake," keep going.
CONTRIBUTING FACTORS — FISHBONE § 04
Catch what the linear "5 Whys" misses. List contributing factors across all six categories — not every category will apply, but consider each.
ROOT CAUSE STATEMENT § 05
A clear, single statement (or two) of the underlying cause. This is what your corrective actions must address. Symptoms get fixed once. Root causes prevent recurrence.
CORRECTIVE ACTIONS § 06
For each root cause, assign at least one action with an owner and due date. Use the hierarchy: elimination → substitution → engineering → administrative → PPE. PPE-only fixes are the weakest defense.
EVIDENCE — PHOTOS § 07
Document the scene, equipment, conditions, and any physical evidence. Photos should be wide context first, then specific detail.
SIGN-OFF § 08
By signing, I attest this investigation is complete and accurate.
