SOURCE Investigators Toolkit (Word Version)

SOURCE
(Seeking Out the Underlying Root Causes of Events)
Investigators Toolkit (Word Version)
This version is intended to be completed manually
CONTENTS
1.

List of Contacts..........................................................................................................................................1

2.

Simple Investigation Plan..........................................................................................................................2

3.

Investigation Data Needs...........................................................................................................................3

4.

Test Plan Parts Analysis.......................................................................................................................5

5.

Test Plan Sample/Chemical Analysis...................................................................................................7

6.

Photographic Record.................................................................................................................................9

7.

Position Data Form..................................................................................................................................10

8.

Data Log Form........................................................................................................................................11

9.

Data Checkout Form................................................................................................................................12

10. Change Analysis Form............................................................................................................................13

11. 5 Whys Worksheet..................................................................................................................................14
12. Root Cause Summary Table....................................................................................................................15

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SOURCE Investigators Toolkit (Word Version)

1. List of Contacts
Investigation:______________________________________________
Name

Date:____________________

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Title

Investigation Number:_____________________________________________
Company

Phone/E-mail

Other

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SOURCE Investigators Toolkit (Word Version)

2. Simple Investigation Plan
Investigation for:_____________________________________________________________________________ Incident #:___________________________
Incident date:________________________ Time:________________________ Budget:___________________ Charge #:____________________________
Report due:______________________________________________________________________________________________________________________
Team room:________________________ Room phone #:_______________________________________________ Fax #::__________________________
Role

Individual

Notes

Team leader
Investigation techniques
Process engineering/system expertise
Process operation (operator if incident occurred
with facility in operation)
Contract employee (if contractors involved or
affected)
Maintenance (mechanical, electrical,
instrumentation and controls)
Regulatory interface
Media interface
Restart interface
Others/consultants

Date:____________________

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SOURCE Investigators Toolkit (Word Version)

3. Investigation Data Needs

Event number/description:_________________________________________________________________________________________

People

Position

Paper
(documentation, computer
data)

Physical
(components, chemicals)

Date:___________________

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SOURCE Investigators Toolkit (Word Version)

Examples of Typical Data Sources

People
Operators
on-shift
other shifts
Maintenance personnel
Process engineers
Design engineers
Emergency responders
Warehouse personnel
Purchasing agents

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Position
People
participants
observers
victims
Physical
operating equipment
safety equipment
stains and residues
levels
scattered objects

Physical
Operating components
Safety devices
Support equipment
Chemical samples
Stains
Residues
Foreign objects
Damaged equipment

Paper
Procedures
Logs
Computer records
Hazard and risk assessments
Policies and programs
Purchasing records
Design specifications
Training records
Management of change records
Previous incident reports
Process description

SOURCE Investigators Toolkit (Word Version)

4. Test Plan Parts Analysis

Test plan #:_______________________________ Incident/report #:________________________
Test plan for:______________________________________________________________________
Photos of equipment:_______________________________________________________________
Purpose of Test
Provide a brief description of the purpose of the test and the information that the test will provide.
Explain how this is related to the events and conditions on the causal factor chart or fault tree.

Visual Examination
Persons performing visual examination________________________ JSA needed?

yes

no

Location of visual examination_______________________________________________________

Scheduled time of visual examination__________________________________________________

Operational Tests
Persons performing operational tests__________________________ JSA needed?

yes

no

Location of operational tests_________________________________________________________

Scheduled time of operational tests____________________________________________________

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SOURCE Investigators Toolkit (Word Version)

4. Test Plan Parts Analysis (continued)

Field Disassembly
Persons performing disassembly_______________________________ JSA needed? yes no
Location of disassembly_____________________________________________________________
Scheduled time of disassembly________________________________________________________

Shop/Bench Testing, Shop Disassembly

Persons performing shop testing/disassembly_______________________ JSA needed? yes no
Location of shop testing/disassembly____________________________________________________
Scheduled time of shop testing/disassembly_______________________________________________

Approvals
Test plan written by _________________________________________ Title________ Date______
Test plan approved by _______________________________________ Title________ Date______
_______________________________________ Title________ Date______
_______________________________________ Title________ Date______
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SOURCE Investigators Toolkit (Word Version)

5. Test Plan Sample/Chemical Analysis

Test plan #:_________________________________ Incident/report # :______________________
Test plan for sampling of:____________________________________________________________
Photos of equipment/sample point:____________________________________________________
Purpose of Test
Provide a brief description of the purpose of the test and the information that the test will provide.
Explain how this is related to the events and conditions on the causal factors chart or fault tree.

Drawing the Sample

Persons drawing the sample __________________________________ JSA needed?

yes no

Location where sample will be drawn___________________________________________________

Scheduled time of draw sample________________________________________________________
Note: All equipment used in drawing the sample should be clean to prevent contamination of the
sample.
Equipment needed for drawing sample (lines, hoses, containers, etc.):
______________________________________

________________________________________

______________________________________

________________________________________

Safety equipment (including personal protective equipment) required for drawing sample:
______________________________________ ________________________________________
______________________________________ ________________________________________
Description of sampling process (include container requirements, flushing times, volume of samples,
etc.). Attach JSA/procedure, if needed.

Visual Examination of Sample Drawn/Collected

Persons performing visual examination _________________________________________________
Location of visual examination _______________________________________________________
Scheduled time of visual examination __________________________________________________
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SOURCE Investigators Toolkit (Word Version)

5. Test Plan Sample/Chemical Analysis (continued)

Marking of Containers
Mark the containers with the following information; also record the information below.
Container Number
1

Sample number
Container (size,
material, color,
etc.)
Time and date of
sample
Description of what
was sampled
Sample drawn
by/date/time

Transport/Storage of Samples
Persons performing ________________________________________________________________
Container Number
1

Storage location (if

required)
Analysis to be
performed on
sample (refer to
procedure number
if appropriate)
Chain of custody
form

Results (attach report to this form)

Analysis report number _____________________________________________________________
Approvals
Test plan written by _____________________________________________

Title __________ Date ________

Test plan approved by ____________________________________________

Title __________ Date ________

____________________________________________

Title __________ Date ________

____________________________________________

Title __________ Date ________

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SOURCE Investigators Toolkit (Word Version)

6. Photographic Record
Investigation for: _________________________________________________________________________________________________
Event/report #: __________________________________ Lighting: ______________________ Film roll #: ______________________
Time
Number

Date: _____________

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Description

Date

Time

Orientation

Paper Reference
(documentation,
drawing)

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SOURCE Investigators Toolkit (Word Version)

7. Position Data Form

Incident number/description:_______________________________________________________________________________________
Object
Number

Date: __________

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Description

Reference
Point

Distance

Direction

Notes

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SOURCE Investigators Toolkit (Word Version)

8. Data Log Form

Incident number/description:_______________________________________________________________________________________
Data Type/Data Number
Document

Computer
File

Date:___________

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Component

Chemical

Description

Storage Location

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SOURCE Investigators Toolkit (Word Version)

9. Data Checkout Form

Incident number/description: ______________________________________________________________________________________
Item
Number

Description

Checked Out By

Checked Out

Date: ___________

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Returned

Initials

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SOURCE Investigators Toolkit (Word Version)

10. Change Analysis Form

Event Description:__________________________________________________________ Date:_______ Event Number:___________
Problem Situation (describe): ______________________________________________________________________________________
________________________________________________________________________________________________________________
Problem-free Situation (describe): __________________________________________________________________________________
________________________________________________________________________________________________________________
Circle One (Actual/Test/Procedure/Ideal/Experience/Future)
Conditions Found
in Problem Situation

Conditions Found in
Problem-free Situation

Differences Between
the Two Situations

Resulting Effects on Problem

Date: ___________

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SOURCE Investigators Toolkit (Word Version)

11. 5 Whys Worksheet

Event description:_________________________________________________________________
Event #: _______________________________ Causal factor #: ___________________________
Description:

Background:

Why:

Why:

Why:

Why:

Why:

Recommendations:

Date: ________

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SOURCE Investigators Toolkit (Word Version)

12. Root Cause Summary Table

Event Description:_________________________________ Event #:________________________
Causal Factor #
Description:

Paths Through Root Cause Map

Recommendations

Background:

Date:_____________

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