Root Cause Analysis Template

Root Cause Analysis
Incident investigation workbook: 5 Whys, fishbone (6M), risk matrix and corrective actions.

1	Yellow cells are for you to fill in. Grey cells are formulas — do not type over them.
2	5 Whys: write the problem as facts, then ask "why?" five times. Each answer should be backed by evidence. The check line turns to OK when all five answers and the root cause are filled in.
3	Fishbone: list every possible cause under one of the 6M categories and mark whether the evidence shows it contributed (Yes/No). Counts per category update automatically.
4	Risk matrix: rate likelihood and severity from 1 to 5 before and after the actions. Score = likelihood × severity; the level (Low, Medium, High, Critical) is set by formula.
5	Corrective actions: one row per action with one owner, a due date and a status. Set the "as of" date; days overdue and progress are calculated.
6	Use the same incident reference as on the incident report. Copy the root cause and the action list into the lessons learned document.
	Levels: Low 1–4 · Medium 5–9 · High 10–15 · Critical 16–25.

	Input cell
	Formula cell

5 Whys
Ask why until you reach a cause you can act on in a process, not a person.
Incident ref	INC-2026-0142
Problem	At 06:52 on 22 Oct 2026 reach truck RT-07, reversing out of aisle C-14 with a load, came within about 3 ft (1 m) of an order picker crossing the main aisle. The picker stepped back, tripped over a pallet left in the walkway and grazed his left palm. No contact with the truck.

Step	Why? (question)	Because (answer)	Evidence
Why 1	Why did the truck get so close to the picker?	The operator was reversing and did not see the picker until the last moment; the picker came from the blind side at the aisle end.	Operator and witness statements W-01, W-02; CCTV camera 7
Why 2	Why did neither of them get a warning earlier?	The rear blue warning light on RT-07 was not working, and the convex mirror at the end of aisle C-14 had been knocked out of alignment.	Maintenance inspection 22 Oct, 08:15; photos P-03, P-04
Why 3	Why was RT-07 in use with a failed warning light?	The failed light was ticked as "fail" on the pre-use checklist on 20 Oct, but no work order was raised and the truck stayed in service.	Pre-use checklists 20-22 Oct; CMMS shows no work order
Why 4	Why was no work order raised?	The paper checklist has no step for reporting a defect. Sheets are filed by the supervisor at end of shift and maintenance never sees them.	SOP WH-07 rev. 2; interview with night shift supervisor
Why 5	Why does the procedure have no escalation step?	SOP WH-07 was written in 2019 for counterbalance trucks and was not reviewed when the reach truck fleet arrived in 2025. The SOP has no named owner or review date.	SOP register; fleet delivery records

Root cause	The pre-use inspection procedure (SOP WH-07) has no defect-escalation step and no owner, so defects found on trucks do not reach maintenance and trucks stay in service with failed safety equipment.

Whys answered	5
Check	OK: every why is answered and the root cause is recorded

Fishbone (6M)
People · Methods · Machines · Materials · Measurement · Environment. Mark Yes only where evidence shows the cause contributed.

#	Category	Possible cause	Contributed?	Evidence
1	People	Picker took a shortcut across the main aisle instead of the marked route	Yes	W-01, CCTV
2	People	Operator reversing at shift change under time pressure to finish put-away	Yes	Operator interview
3	People	Operator not fatigued; within hours limits	No	Rota, 6.5 h into a 10 h shift
4	Methods	Pre-use checklist has no defect-escalation step	Yes	SOP WH-07 rev. 2
5	Methods	Put-away and picking both run in the main aisle at 06:45-07:10	Yes	WMS task log
6	Methods	SOP WH-07 has no owner or review date	Yes	SOP register
7	Machines	Rear blue warning light failed on RT-07	Yes	Maintenance inspection
8	Machines	Reverse alarm on RT-07 working	No	Tested 22 Oct, 08:15
9	Materials	Empty pallet left in pedestrian walkway at C-14	Yes	Photo P-02
10	Measurement	No check of mirror alignment in the weekly safety walk	Yes	Safety walk checklist
11	Measurement	Near misses at aisle ends not tracked as a trend	Yes	2 similar reports in 2026, not linked
12	Environment	Pedestrian crossing paint worn at the end of C-14	Yes	Photo P-01
13	Environment	Lighting at aisle end 310 lux, within site standard	No	Light meter reading 22 Oct
14	Environment	Background noise high at shift change (dock doors, chargers)	Yes	Supervisor observation
15
16
17
18
19
20
21
22
23
24
25

	Summary
	Category	Causes listed	Contributed
	People	3	2
	Methods	3	3
	Machines	2	1
	Materials	1	1
	Measurement	2	2
	Environment	3	2
	Total	14	11
	Check	OK: every cause has a category and Yes/No

Risk matrix
Likelihood 1 (rare) to 5 (almost certain) × severity 1 (negligible) to 5 (catastrophic). Rate before and after the actions.
		Before actions					After actions
#	Hazard / risk	Likelihood	Severity	Score	Level	Actions (IDs)	Likelihood	Severity	Score	Level
R1	Reach truck strikes a pedestrian at an aisle end (zone C)	4	4	16	Critical	CA-02, CA-05, CA-06	2	4	8	Medium
R2	Truck used with failed safety equipment (lights, alarm, mirrors)	4	4	16	Critical	CA-01, CA-03, CA-04	1	4	4	Low
R3	Trip over pallets or stock left in walkways	3	2	6	Medium	CA-09	2	2	4	Low
R4	Congestion of trucks and pickers in the main aisle at shift change	4	3	12	High	CA-06	2	3	6	Medium
R5	Staff unaware of pedestrian routes and truck blind spots	3	3	9	Medium	CA-07	2	3	6	Medium






	Risks by level
	Level	Before	After
	Critical	2	0
	High	1	0
	Medium	2	3
	Low	0	2
	Average score	11.80	5.60

	Score grid (likelihood × severity)
	Likelihood ↓ / Severity →	1	2	3	4	5
	5	5	10	15	20	25
	4	4	8	12	16	20
	3	3	6	9	12	15
	2	2	4	6	8	10
	1	1	2	3	4	5

Corrective actions
One owner per action. Each row becomes a task for its owner. Status: Not started, In progress, Done.
As of	16 Nov 2026	Days overdue are counted to this date.

ID	Action	Type	Owner	Risk	Due date	Status	Completed on	% done	Days overdue	Est. cost (USD)
CA-01	Replace the rear blue warning light on RT-07 and check the lights on all 12 reach trucks	Corrective	Kevin O'Hara	R2	23 Oct 2026	Done	23 Oct 2026	100%		85.00
CA-02	Realign and lock the convex mirrors at every aisle end in zone C	Corrective	Kevin O'Hara	R1	30 Oct 2026	Done	29 Oct 2026	100%		240.00
CA-03	Add a defect-escalation step to SOP WH-07: any "fail" item = truck tagged out and work order raised in the same shift	Preventive	Rachel Kim	R2	6 Nov 2026	Done	5 Nov 2026	100%		0.00
CA-04	Move the pre-use checklist to a digital form that raises a work order automatically	Preventive	Daniel Foster	R2	30 Nov 2026	In progress		40%	0	3,600.00
CA-05	Repaint the main-aisle pedestrian crossings and add "Stop - look" floor signs at zone C aisle ends	Corrective	Kevin O'Hara	R1	13 Nov 2026	In progress		60%	3	2,150.00
CA-06	Stagger shift change: no put-away in the main aisle from 06:45 to 07:10	Preventive	Daniel Foster	R4	9 Nov 2026	Done	9 Nov 2026	100%		0.00
CA-07	Toolbox talk on pedestrian routes and blind spots for all three shifts, with sign-off sheet	Preventive	Sophie Martin	R5	6 Nov 2026	In progress		75%	10	0.00
CA-08	Give every warehouse SOP a named owner and a review date	Preventive	Rachel Kim	R2	15 Dec 2026	Not started		0%	0	0.00
CA-09	Add a walkway check (no pallets in pedestrian routes) to the start-of-shift 5S round	Preventive	Dana Whitfield	R3	2 Nov 2026	Done	2 Nov 2026	100%		0.00







	Summary
	Actions	9
	Done	5
	Open	4
	Overdue	2
	Total days overdue	13
	Average % done	75%
	Corrective / preventive	3 / 6
	Estimated cost (USD)	6,075.00
	Check	IF(COUNTA(B6:B20)=0,"No actions yet",IF(SUMPRODUCT((B6:B20<>"")*((D6:D20="")+(F6:F20="")+(G6:G20="")))=0,"OK: every action has an owner, a due date and a status","Some actions have no owner, due date or status"))