Incident Root Cause & Causal Factor Analysis — Chemical Manufacturing Facility (1,540 personnel)
| Incident ID | Date | Department | Severity | Root Cause | Quality Score | Recurrence |
|---|---|---|---|---|---|---|
| INC-2024-0087 | Mar 14, 2024 | Reactor Maint. | DAFW | Procedural Deficiency | 8.1 | Yes |
| INC-2024-0082 | Mar 6, 2024 | Packaging | Recordable | Human Error | 6.9 | No |
| INC-2024-0078 | Feb 28, 2024 | Reactor Maint. | DAFW | Procedural Deficiency | 7.8 | Yes |
| INC-2024-0071 | Feb 19, 2024 | Warehouse | Near-Miss | Equipment Failure | 7.4 | No |
| INC-2024-0065 | Feb 10, 2024 | Quality Lab | Recordable | Training Gap | 6.5 | No |
| INC-2024-0058 | Jan 30, 2024 | Reactor Maint. | Recordable | Procedural Deficiency | 7.6 | Yes |
| INC-2024-0051 | Jan 22, 2024 | Process Operations | DAFW | Equipment Failure | 8.3 | No |
| INC-2024-0043 | Jan 12, 2024 | Packaging | Near-Miss | Human Error | 7.1 | No |
Event: 4 recordable incidents in Reactor Maintenance in 6 weeks (Feb-Mar 2024)
Root Cause: Procedure revision not cascaded to shift crews; supervision accountability gap
Corrective Action: Implemented change management protocol with sign-off verification (42-day completion)
Result: Zero procedural incidents in Reactor Maint. for 8 weeks post-implementation