Root Cause Analysis Form

Import Existing RCA

Reopen and amend a previous report by uploading its JSON file.

Basic details about this RCA record and who prepared it.

Report ID

Report Date

Prepared By

Department / Team

Client Name

What happened, where, when, and who was involved.

Incident Title

Incident Reference / Ticket #

Incident Date

Location

Reported By

Problem Description

Describe how the incident affected people, process, equipment, and customers.

Impact on People (safety, wellbeing, staffing)

Impact on Process (delays, rework, non-conformance)

Impact on Equipment / Assets

Impact on Customer / Stakeholders

Actions taken straight away to make the situation safe or stable.

Immediate Containment / Mitigation Actions

Explain how you analysed the problem and what you concluded.

Method Used (e.g. 5 Whys, Fishbone, FMEA)

Root Cause

Contributing Factors

Actions to fix the problem and prevent recurrence.

Add as many actions as needed; completely blank rows will be ignored.

How you will check effectiveness, and what you will change longer-term.

Verification of Effectiveness (how will you confirm actions worked?)

Lessons Learned

Preventive Measures (to stop recurrence)

Sign-off from the investigator and responsible manager.

Investigator Name

Investigator Signature Date

Manager / Approver Name

Manager Approval Date