Safety OS

The 5 W's — Incident Facts

📅 When

📍 Where

👤 Who (reported by)

🏷️ Event Type (Ford et al. 2012 / RO-ILS taxonomy)

📋 What (description)

💡 Why (initial statement)

🗺️ Linked Process Step

📊 Causality Categories (Ford et al. taxonomy — select all that apply)

🏢 Organizational Mgmt ⚙️ Technical / Equipment 👤 Human Behavior 📋 Procedural Issues 🏥 Patient-Related

Root Cause Analysis — 5 Whys Chain (based on chain-of-event model)

Ask "Why?" iteratively toward the systemic root cause. Suitable for complicated issues.

Why 1

Why 2

Why 3

Why 4

Why 5

ROOT
CAUSE

🔧 Corrective Action & Owner

Status

📁 Linked Policies to Review / Update Select all P&Ps this incident implies should be reviewed or amended

CAST-Informed Analysis — Systems Approach (based on STAMP systemic model — Leveson 2004)

For Significant or Serious events, go beyond 5 Whys. CAST examines each decision-maker's context and the systemic control structure flaws that allowed the accident to occur. Based on Wong & Pawlicki, JACMP 2025.

🔒 Safety Constraint Violated

👥 Controller Analysis — Decision-Makers Involved

Controller	Contribution to incident	Process model flaw (what did they believe?)	Contextual factors
RTT / Therapist
Physicist
Dosimetrist
Management
Equipment / Vendor

🔗 Systemic Flaw (cross-cutting pattern across controllers)

🛡️ System-Level Intervention Recommended

Note: Pawlicki et al. (Med Phys 2019) found that 73% of causal scenarios in RT are non-technical — organizational management (33%), procedural (23%), human behavior (14%). Only 27% were equipment-related. CAST is designed to surface the 73%.

📋 New Daily Huddle

Step Details

New Incident Report

⚡ Load TG-100 Canonical FMEA Templates

📄 Literature Examples

SAFETY OS

📋 New Daily Huddle

Step Details

New Incident Report

⚡ Load TG-100 Canonical FMEA Templates

📄 Literature Examples

New Process Map

Add Process Step

New FMEA Project

Add Failure Mode

Add Policy to Directory