OCHS3004 Emergency Management and Incident Investigation - Case Study Report

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Case Study 2

Present a critical analysis following incident summaries from WorkSafe WA*:

  • h p://www.dmp.wa.gov.au/Documents/Safety/MSH_SIR_249.pdf

Your tasks are as follows:

  • Present an Event and Causal Chart and one (1) of the analytical the incident (use the RCA chart using the fishbone template)
  • Summarise your findings based on your analyses (what are the immediate/direct cause(s) of the incident? What are the contributing factors? What are the likely root cause(s) to the incident?)
  • Based on the incident summary:
    • Evaluate and discuss whether the investigation found all relevant cause(s) for the incident;
    • Are the recommendations appropriate and practicable?
    • How would you classify the level of success of this investigation? What difficulties may investigators find in investigating this incident?

Maximum words for report: 1500 words


*the definitions of immediate/contributing/root cause(s) may not necessarily correspond directly to the language used in the safety alert – use your judgement based on your knowledge from OCHS3004 in itemizing these.

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