7/30/2019 Comprehensive Root Causes

http://slidepdf.com/reader/full/comprehensive-root-causes 1/1

1 1. W or k P la nn i ng1111--11 Inadequatework

planning1111--22 Inadequatepreventive

maintenance• assessment of 

needs• lubrication/

servicing• adjustment/

assembly• cleaning/

resurfacing1111--33 Inadequaterepair 

• communicationof neededrepair 

• schedulingofwork• examinationof 

parts• partssubstitution

1111--44 Excessivewearandtear 

• inadequateplanningforuse

• extensionofservicelife

• improperloading• usebyuntrained

people• useforwrong

purpose1111--55 Inadequatereference

materialsor publications1111--66 Inadequateaudit/

inspection/ monitoring• nodocumentation• nocorrection

responsibilityassigned

• noaccountabilityforcorrective action

1111--77 Inadequatejobplacement

• appropriatepersonnelnotidentified

• appropriatepersonnelnotavailable

• appropriatepersonnelnotprovided

11-8 Other 

oNotApplicable

2 . P hy s ic alCondition

22--11 Previousinjuryor illness

22--22 Fatigue•duetoworkload

•duetolackof rest

•duetosensoryoverload

22--33 Diminishedperformance

•duetotemperatureextremes

•dueto oxygendeficiency

•duetoatmosphericpressurevariation

22--44 Bloodsugar insufficiency

22--55 Impairmentduetodrugoralcoholuse

2-6 Other 

o NotApplicable

10. Engineer ing /Design

1010--11 Inadequatetechnicaldesign

•designinputobsolete

•designinput notcorrect

•designinput notavailable

•designoutputinadequate

•designinputinfeasible

•designoutputunclear 

•designoutput notcorrect

•designoutputinconsistent

•noindependentdesignreview

1010--22 Inadequatestandards,specifications,and/ordesigncriteria

1010--33 Inadequateassessmentof potentialfailure

1010--44 Inadequateergonomicdesign

1010--55 Inadequate

monitoringof construction

1010--66 Inadequateassessmentof operationalreadiness

1010--77 Inadequatemonitoringofinitialoperation

1010--88 Inadequateevaluationand / or documentationof change

10-9 Other 

o NotApplicable

1. Physical Capabi li ty11--11 Visiondeficiency11--22 Hearingdeficiency11--33 Othersensory

deficiency11--44 Reducedrespiratory

capacity11--55 Otherpermanent

physicaldisabilities11--66 Temporary

disabilities11--77 Inabilityto sustain

bodypositions11--88 Restrictedrangeof 

bodymovement11--99 Substance

sensitivitiesor allergies

11--1010 Inadequatesize or strength

11--1111 Diminishedcapacitydueto medication

1-12 Other 

o NotApplicable

POSSIBLE SYSTEM CAUSES

Comprehensive List of CausesComprehensive List of CausesA T O O L F O R R O O T C A U S E A N A L Y S I SA T O O L F O R R O O T C A U S E A N A L Y S I S

IMPLEMENTAT ION & RESEARCH PHASES:

EVIDENCE GATHER ING

People

Solutions

Parts

Positions Paper • Document thetype/ severityof 

event

• Cover thewho/ what / when/where/ howasknownat thetime

DESCRIPTION OF

INCIDENT

• Gather relevant evidence

• Implementationphase=direct evidence(sceneandwitnesses)

• Researchphase=indirect evidence(writtensources)

• Consider People/ Parts / Position/ Paper 

ANALYSIS PHASE:

IDENTIFICATION OF CRITICAL FACTORS

• Organiseall evidence

• Mapevidence

• Identifycritical factors

• UseCLCtoidentify all immediateandroot causes

13. Tools & Equipment1313--11 Inadequate

assessmentof needsandrisks

1313--22 Inadequatehumanfactors/ ergonomicsconsiderations

1313--33 Inadequatestandardsorspecifications

1313--44 Inadequateavailability1313--55 Inadequateadjustment

/repair/maintenance

1313--66 Inadequatesalvageandreclamation

1313--77 Inadequateremoval /replacement of unsuitableitems

1313--88 Noequipmentrecordhistory

1313--99 Inadequateequipmentrecordhistory

13-10 Other 

oNotApplicable

PERSONAL FACTORS JOB FACTORS

1 . F ol lo wi ngProcedures1-1 Violationbyindividual1-2 Violationbygroup1-3 Violationbysupervisor 1-4 Operationofequipmentwithoutauthority1-5 Improperpositionorpostureforthetask1-6 Overexertionofphysicalcapability1-7 Workormotionatimproperspeed1-8 Improperlifting1-9 Improperloading1-10 Shortcuts1-11 Other 

2. Use of Tools or Equipment2-1 Improperuseofequipment2-2 Improperuseoftools2-3 Useofdefectiveequipment(aware)2-4 Useofdefectivetools(aware)2-5 Improperplacementoftools,equipmentor 

materials2-6 Operationofequipmentat improperspeed2-7 Servicingofequipmentinoperation2-8 Other 

3. Use of Protective Methods3-1 Lackofknowledgeofhazardspresent3-2 Personalprotectiveequipmentnotused3-3 Improperuseofproperpersonalprotective

equipment3-4 Servicingofenergizedequipment3-5 Equipmentormaterialsnotsecured3-6 Disabledguards,warningsystemsorsafety

devices3-7 Removalofguards,warningsystemsorsafety

devices3-8 Personalprotectiveequipmentnotavailable3-9 Other 

4. Inat tent ion /Lack of Awareness4-1 Improperdecisionmakingorlackof judgment4-2 Distractedby otherconcerns4-3 Inattentiontofootingandsurroundings4-4 Horseplay4-5 Actsofviolence4-6 Failuretowarn4-7 Useofdrugsoralcohol4-8 Routineactivitywithoutthought4-9 Other 

5 . P r ot ec t iv e S ys t em s5-1 Inadequateguardsorprotectivedevices5-2 Defectiveguardsorprotectivedevices5-3 Inadequatepersonalprotectiveequipment5-4 Defectivepersonalprotectiveequipment5-5 Inadequatewarningsystems5-6 Defectivewarningsystems5-7 Inadequateisolationofprocessor equipment5-8 Inadequatesafetydevices5-9 Defectivesafetydevices5-10 Other 

6. Tools,Equipment & Vehic les6-1 Defectiveequipment6-2 Inadequateequipment6-3 Improperlypreparedequipment6-4 Defectivetools6-5 Inadequatetools6-6 Improperlypreparedtools6-7 Defectivevehicle6-8 Inadequatevehiclefor thepurpose6-9 Improperlypreparedvehicle6-10 Other 

7. Work Exposures to7-1 Fireorexplosion7-2 Noise7-3 Energizedelectricalsystems7-4 Energizedsystems,otherthanelectrical7-5 Radiation7-6 Temperatureextremes7-7 Hazardouschemicals7-8 Mechanicalhazards7-9 Clutterordebris7-10 Stormsoracts ofnature7-11 Slipperyfloorsor walkways7-12 Other 

8. Work Place Envi ronment / Layout8-1 Congestionor restrictedmotion8-2 Inadequateorexcessiveillumination8-3 Inadequateventilation8-4 Unprotectedheight8-5 Inadequateworkplacelayout

• controlslessthanadequate• displayslessthanadequate• labelslessthanadequate• locationsoutofreachorsight• conflictinginformationispresented

8-6 Other 

POSSIBLE IMMEDIATE CAUSES

 ACTIONS CONDITIONS

Foreachidentifiedcriticalfactor,considerifanyof thelistedrootcausecategoriesapply.If 'yes,' circlethespecificrootcause.Ifnoneof therootcausesin thecategoryapply,thencheckthe'notapplicable' boxatthebottomofthecolumn.

• Alignwith‘GettingHSERight’elements

Leadership andLeadership and Accountabilit y Accountabilit y

Risk Assessment andRisk Assessment andManagementManagement

People, Training andPeople, Training andBehavioursBehaviours

Working withWorking withContractors and OthersContractors and Others

Information andInformation andDocumentationDocumentation

Customers andCustomers andProductsProducts

ELEMENTS OF GETTING HSE RIGHT

CORRECT IVE PHASE: PROPOSALS FOR CORRECT IVE ACT ION

6. Skil l Level66--11 Inadequate

assessmentof requiredskills

66--22 Inadequatepracticeof skill

66--33 Infrequentperformanceof skill

66--44 Lackofcoachingonskill

66--55 Insufficientreviewofinstructiontoestablishskill

6-6 Other 

oNotApplicable

12. Purchasing,Mater ialHandling & MaterialControl

1212--11 Incorrectitemreceived

•inadequatespecificationstovendor •inadequatespecificationsonrequisition•inadequatecontrolonchangestoorders•unauthorizedsubstitution•inadequateproductacceptancerequirements•noacceptanceverificationperformed

1212--22 Inadequateresearchonmaterials/equipment

1212--33 Inadequatemodeor routeof shipment

1212--44 Improper handlingof materials

1212--55 Improperstorageof materialsorspareparts

1212--66 Inadequatematerialpackaging

1212--77 Materialshelfli feexceeded

1212--88 Improperidentificationofhazardousmaterials

1212--99 Impropersalvageand/orwastedisposal

1212--1010 Inadequateuseof safetyandhealth data

12-11 Other 

oNotApplicable

9 . C o nt r ac t or  Selection &Oversight

99--11 Lackof contractor pre-qualifications

99--22 Inadequatecontractor pre-qualifications

99--33 Inadequatecontractorsel ection

99--44 Useofnon-approvedcontractor 

99--55 Lackofjoboversight99--66 Inadequateoversight

9-7 Other 

oNotApplicable

7. Training /KnowledgeTransfer 

77--11 Inadequateknowledgetransfer 

•inabilitytocomprehend

•inadequateinstructor qualifications

•inadequatetrainingequipment

•misunderstoodinstructions

77--22 Inadequaterecallof training material

•training notreinforcedonthe job

•inadequaterefresher trainingfrequency

77--33 Inadequatetrainingeffort

•inadequatetrainingprogramdesign

•inadequatetraininggoals/ objectives

•inadequatenewemployeeorientation

•inadequateinitialtraining

•inadequatemeanstodetermineif 

qualifiedfor job77--44 Notraining provided

•needfortrainingnotidentified

•training recordsincorrectoroutof date

•newworkmethodsintroducedwithouttraining

•decisionmadenot totrain

7-5 Other 

o NotApplicable

4. Mental Stress44--11 Preoccupationwith

problems44--22 Frustration44--33 Confusing

directions/demands

44--44 Conflictingdirections/demands

44--55 Meaninglessor degradingactivities

44--66 Emotionaloverload44--77 Extremejudgment/

decisiondemands44--88 Extreme

concentration/perceptiondemands

44--99 Extremeboredom

4-10 Other 

o NotApplicable

3 . M en t al S t at e33--11 Poorj udgment33--22 Memoryfailure33--33 Poorcoordination

orreactiontime33--44 Emotional

disturbance33--55 Fearsorphobias33--66 Lowmechanical

aptitude33--77 Lowlearning

aptitude33--88 Influencedby

medication

3-9 Other 

o NotApplicable

14. Work Rules /Pol ic ies /Standards / Procedures (PSP)

1414--11 LackofPSPforthetask•lackof definedresponsibilityforPSP•lackof jobsafetyanalysis•inadequatejobsafetyanalysis

1414--22 Inadequatedevelopmentof PSP•inadequatecoordinationwithprocess/ equipmentdesign•inadequateemployeeinvolvementin thedevelopment•inadequatedefinition of correctiveactions•inadequateformatfor easyuse

1414--33 Inadequateimplementationof PSP,dueto deficiencies

•contradictoryrequirements•confusingformat•morethanoneactionper step•nocheck-offspacesprovided•inaccuratesequenceofsteps•confusinginstructions•technical error/ missingsteps•excessivereferences•potentialsituations notcovered

1414--44 Inadequateenforcementof PSP•inadequatemonitoringof work•inadequatesupervisoryknowledge•inadequatereinforcement•non-compliance notcorrected

1414--55 Inadequatecommunicationof PSP

•incompletedistribution toworkgroups•inadequatetr anslationtoappropriatelanguages•incompleteintegration withtraining•outofdaterevisionsstillinuse

14-6 Other 

oNotApplicable

1 5. C o mm u ni c at i on1515--11 Inadequatehorizontal

communicationbetweenpeers

1515--22 Inadequateverticalcommunicationbetweensupervisor andperson

1515--33 Inadequatecommunicationbetweendifferentorganizations

1515--44 Inadequatecommunicationbetweenworkgroups

1515--55 Inadequatecommunicationbetweenshifts

1515--66 Inadequatecommunicationmethods

1515--77 Nocommunicati onmethodavailable

1515--88 Incorrectinstructions1515--99 Inadequate

communicationdueto jobturnover 

1515--1010 Inadequatecommunicationof safetyandhealthdata,regulationsor guidelines

1515--1111 Standardterminologynotused

1515--1212 Verification/repeatbacktechniquesnotused

1515--1313 Messagestool ong1515--1414 Speechinterference

15-15 Other 

oNotApplicable\

Facilities Design andFacilities Design andConstructionConstruction

Operations andOperations andMaintenanceMaintenance

Management of Management of ChangeChange

Community andCommunity andStakeholder AwarenessStakeholder Awareness

Crisis and EmergencyCrisis and EmergencyManagementManagement

Incidents Analysis andIncidents Analysis andPreventionPrevention

 Assessment, Assu rance Assessment, Assu ranceand Improvementand Improvement

5 . B eh av io r  55--11 Improperperformance

isrewarded•savestimeoreffort•avoidsdiscomfort•gainsattention

55--22 Impropersupervisoryexample

55--33 Inadequateidentificationof criticalsafebehaviors

55--44 Inadequatereinforcementof criticalsafe behaviors

•proper performanceiscriticized

•inappropriate peer pressure

•inadequateperformancefeedback

•inadequatedisciplinaryprocess

55--55 Inappropriateaggression

55--66 Improperuseof productionincentives

55--77 Supervisorimpliedhaste

55--88 Employeeperceivedhaste

5-9 Other 

oNotApplicable

8 . M an ag em en t /Supervision /EmployeeLeadership

88--11 Conflictingroles /responsibilities

•unclearreportingrelationships

•conflicting reportingrelationship

•unclearassignmentof responsibility

•conflictingassignmentofresponsibility

•improperor insufficient delegationofauthority

88--22 Inadequateleadership•standardsof performancemissingor notenforced

•inadequateaccountability

•inadequateor incorrectperformancefeedback

•inadequateworksitewalk-through

•inadequatesafetypromotion

88--33 Inadequatecorrectionof priorhazard / incident

88--44 Inadequateidentification

ofworksite/ jobhazards88--55 Inadequatemanagement

ofchangesystem88--66 Inadequateincident

reporting/ investigationsystem

88--77 Inadequateorlack of safetymeetings

88--88 Inadequateperformancemeasurement&assessment

8-9 Other 

o NotApplicable