case study Workzone

Deliverables: Report and powerpoint


Each report should include the following:

One page for chain of events chart, and 3 pages for the other sections. Your report MUST include the following sections:

1. Chart that shows the Chain of Events, conditions, and causal factors

Use an event-based causal chart like the one described in the posted paper “Root Cause Analysis for Beginners” and try to identify as many relevant causal factors as you can. Indicate the relevant events, conditions and actions. Provide a description of the incident that accompanies the chart.

  • Indicate the causal factors on the chart (similar to the class example)
  • Human factors: What operation was the worker(s) performing? How? Did the worker perform safe, unsafe acts, errors, violations?
  • Production system: What were the elements of the production system that influenced the course of events, actions, conditions, etc. Work method, work organization, tools and equipment, material, jobsite organization, preparation, production goals and pressures, task assignments, production controls, supervision, etc..
  • Environment: What is the role of the physical and production environment?
  • Management role (the injured worker’s management). How management’s actions/inactions affected the conditions, actions and events of the case. Safety systems training, personnel management, Jobsite management, supervision. What were the conditions on the job? What was the hazards involved? How was the hazards addressed/managed
  • 3rd parties: How did others (coworkers, other trades, designer, owner, GC, etc.) influence the events?
  • PRIORITIZE THE CAUSES you identified in order of importance.
  • Allocate responsibility to (1) the Worker, (2) the worker’s Employer, and/or (3) 3rd Parties. The total should be 100%.
  • Justify your allocation: Indicate the responsibilities of the different parties. Identify and cite the relevant OSHA regulations and standards. Indicate WHO was in violation of what standards.
  • Use the hierarchy of controls to identify and prioritize solutions
  • Who was in the best position to prevent the accident? What actions/changes are needed and by whom?
  • Remember that the most effective interventions involve controlling the conditions, rather than the workers’ actions.
  • Prioritize the solutions in order of effectiveness.

2. Root cause analysis (Why it happened)

You should consider the following possible causal factors. To investigate causes, use the questions listed in the “Incident Investigation Guide.”

Try to explain why the worker(s) acted the way they did. Use the Human Factors framework: Task Demands, Work environment, Individual capabilities, and Human nature. What factors were likely to influence the actions in the case?

3. Allocate responsibility

4. Propose and prioritize controls

How would you plan and control the operation to prevent such accidents? What actions / conditions can be most effective in preventing them?

You can propose several solutions.


Prepare a 3 slides: Event Chart showing Primary causes, Liability, Solutions.

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