Inident Investigation Root Cause Analysis

7/21/2019 Inident Investigation Root Cause Analysis

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Incident Investigation & Root Cause Analysis

H|S|E|Q – Trainers, Consultants and Risk Management Advisors

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1.0 Incident Investigation – An Introduction

1.1 Fundamental Defininitions / Terminology.

Incident:Work related events in which an injury or ill health (Regardless of severity) orfatality occurred or could have occurred.

Accident:

An event that results in harm to persons or property.

Near Miss Incident:

An unplanned, uncontrolled event that can cause or has the potential to causeinjury to personnel or damage to equipment.

Unsafe Act / Practice / Behavior:

Any human action(s) that could result in a near miss, incident or injury

Unsafe Condition

Any situation in a workplace that, if left uncorrected, could result in a near-miss orincident.

Minor First Aid Injury:

An accident that results in an injury for which no medical care beyond first aid isrequired.

Recordable Injury/Illness:

An on-the-job injury/illness that results in required medical attention beyond firstaid, initial doctors‟ visit, including stitches, loss of consciousness, use ofprescription drugs, and/or work restriction.

Lost Time Accident /Lost time illness:

A work-related injury/illness that results in a loss of at least one full scheduledworkday or shift.

1.2 Incident Reporting

Statutory and Regulatory Requirements

Nature and type of incidents to be reported are classified into three main categories:

Operational: Electricity – generation, transmission, distribution

Desalinated water – production, transmission

Health and Safety:

Fatality

Major Injury

Ill-health and

Dangerous Occurrences

Environmental

Air, Water, Land









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1.7 Accident Investigation – Key Facts Checklist

Should determine:

What happened

How it happened

Why it happened

What should be done to avoid recurrence

The objective is to identify the causal factors and recommendcorrective actions. The investigation report should offer adequate,but not excessive, recommendations for corrective actions.

Check list for identifying key facts:

1. Nature of Injury.

Foreign body Cut

Bruises Strain & sprain

Fracture Burns

Amputation Puncture wound

Hernia Dermatitis

Abrasions Others

2. Part of Body.

Head &neck (scalp, eyes, ears, mouth, teeth, neck, face, skull, etc.)

Upper extremities (shoulders, arms, elbows, forearms, wrists, hands, fingers,thumbs, palms, etc.)

Body, back, chest, abdomen, groin, etc.

Lower extremities (hips, thighs, legs, knees, ankles, feet, toes, etc.)

3. Accident Type.

Stuck against rough / sharp object

Struck by flying objects

Struck by sliding, falling or other movingobjects

Caught in or in between

Falls (on same level or to different level)

Over exertion

Slip, Burns

Contact with temperature extremes

Inhalation, absorption, ingestion, poisoning

Electric shock





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4. Hazardous Condition.

Improperly / inadequately guarded or unguarded

Defective tools, equipment, substances

Unsafe design or construction

Hazardous arrangement / layout / congested area

Improper illumination / ventilation

Improper dress / PPE

Poor housekeeping

5. Agency of Accident.

Machines Vehicles

Hand tools Sheet stock / scrap

Conveyors & elevators Hoists / cranes

Floors & surfaces Chemicals

Electrical apparatus Fire

High pressure / temperature releases Stairs/ladders/platforms/ scaffoldings

6. Unsafe Acts.

Operating without authority

Operating at off-design conditions

Making safety devices inoperative

Failure to warn / secure

Using defective equipment / materials/ tools / vehicles

Failure to use proper personal protective equipment

Poor housekeeping

Unsafe loading / placing / mixing

Horseplay

Unsafe lifting / carrying

Taking an unsafe position

Adjusting / cleaning machinery in motion

7. Contributing Factors.

Disregard of instructions

Bodily defects

Lack of knowledge or skill

Act of other than injured





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2.0 Incident Investigation – The Four Step Process Investigation is a four-step process comprising the following necessary stages:

Contr ol the Scene (I ni tial Response)

Gather Data (Implementation & Research)

Analyze Data (Analysis)

Write Report (Correction)

These steps in accident investigation are simple: the accident investigators gatherinformation, analyze it, draw conclusions, and make recommendations. Although theprocedures are straightforward, each step can have its pitfalls. As mentioned earlier,

an open mind is necessary in accident investigation: preconceived notions may resultin some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is agood practice but conclusions should not be drawn until all the information isgathered.

2.1 Initial Response

The first response must be to:

Take all steps necessary to provide emergencyrescue and medical help for the injured.

Take those actions that will prevent or minimize therisk of further accidents, injury or property damage.

These immediate actions may include:

Securing, barricading or isolating the scene

Collecting transient or perishable evidence

Determining the extent of damage to equipment, material or building facilities

Restoring the operating functions

An effective initial response includes the following essential steps

1. Take Control

2. Ensure First Aid

3. Control Secondary Accidents

4. Identify Sources of Evidence

5. Preserve Evidence

6. Determine Loss Potential

7. Notify Managers

The above steps do not have to be in the same sequence. The actual sequence will bedetermined by the nature of the incident and the circumstances surrounding it.

A proper & positive initial response results in the following benefits:





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Valuable opportunity to reduce the extent of loss

Preserve valuable information necessary to learn what actually happened

Key to getting the investigation on the right track

2.2 Gathering Data

The next step of the investigation process is gathering data. There are four majorcategories of data or sources of evidence. These are referred to as the “four Ps”:

Positions

People

Parts

Paper

Positions

This is the most fragile of all evidence as it canbe easily moved / altered. It includes, amongother things:

Hand notes,

Sketches, maps & measurements

Photographs

As little time as possible should be lost between the moment of an accident or nearmiss and the beginning of the investigation. In this way, one is most likely to be able toobserve the conditions as they were at the time, prevent disturbance of evidence, andidentify witnesses. The tools that members of the investigating team may need (pencil,paper, camera, film, camera flash, tape measure, etc.) should be immediately availableso that no time is wasted.

The physical environment, and especially sudden changes to that environment, arefactors that need to be identified. The situation at the time of the accident is what isimportant, not what the "usual" conditions were. For example, accident investigatorsmay want to know:

What were the weather conditions?

Was poor housekeeping a problem?

Was it too hot or too cold?

Was noise a problem? Was there adequate light?

Were toxic or hazardous gases, dusts, or fumes present?

Before attempting to gather information, examine the site for a quick overview, takesteps to preserve evidence, and identify all witnesses. Physical evidence is probablythe most non-controversial information available. It is also subject to rapid change orobliteration; therefore, it should be the first to be recorded. Based on your knowledgeof the work process, you may want to check items such as:

positions of injured workers

equipment being used materials being used





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safety devices in use

position of appropriate guards

position of controls of machinery

damage to equipment

housekeeping of area

weather conditions

lighting levels

noise levels

You may want to take photographs before anything is moved, both of the general areaand specific items. Later careful study of these may reveal conditions or observationsmissed previously. Sketches of the accident scene based on measurements taken mayalso help in subsequent analysis and will clarify any written reports. Broken equipment,

debris, and samples of materials involved may be removed for further analysis byappropriate experts. Even if photographs are taken, written notes about the location ofthese items at the accident scene should be prepared.

People

In some situations witnesses may be your primarysource of information because you may be calledupon to investigate an accident without being able toexamine the scene immediately after the event.Because witnesses may be under severe emotionalstress or afraid to be completely open for fear ofrecrimination, interviewing witnesses is probably the

hardest task facing an investigator.

Witnesses should be interviewed as soon as practicable after the accident. If witnesseshave an opportunity to discuss the event among themselves, individual perceptionsmay be lost in the normal process of accepting a consensus view where doubt existsabout the facts.

Witnesses should be interviewed alone, rather than in a group. You may decide tointerview a witness at the scene of the accident where it is easier to establish thepositions of each person involved and to obtain a description of the events. On theother hand, it may be preferable to carry out interviews in the quiet of an office wherethere will be fewer distractions. The decision may depend in part on the nature of theaccident and the mental state of the witnesses.

This category of evidence includes:

Direct Witnesses

– Injured / Co-workers

– Others in area

Indirect Witnesses

– Contractors

– Maintenance Personnel

– Equipment Designers

– Spares Purchasers





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The major technique or method for obtaining information from people is throughinterviews. All witnesses should be interviewed, because it may require severalwitnesses‟ versions to determine or reconstruct the entire series of events.Confirmation of observations by various witnesses is very important.

Developing a scenario is a good idea if certain questions are unanswered, particularlyquestions that have to do with the exact physical relationship between the employeeand his or her environment. Typical questions during interviews may include:

Was a safe work procedure used?

Had conditions changed to make the normal procedure unsafe?

Were the appropriate tools and materials available?

Were they used?

Were safety devices working properly?

Was lockout used when necessary?

For most of these questions, an important follow-up question is " If not, why not?"

The physical and mental condition of those individuals directly involved in the eventmay be explored. The purpose for investigating the accident is not to establish blameagainst someone but the personal characteristics still need to be considered. Somefactors will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done?

Had they been adequately trained?

Can they physically do the work?

What was the status of their health? Were they tired?

Were they under stress (work or personal)?

Management holds the legal responsibility for the safety of theworkplace and therefore the role of supervisors and highermanagement must always be considered in an accidentinvestigation.

Answers to any of the preceding types of questions logically lead to further questionssuch as:

Were rules communicated to and understood by all employees?

Were written procedures available?

Were they being enforced?

Was there adequate supervision?

Were workers trained to do the work?

Had hazards been previously identified?

Had procedures been developed to overcome them?

Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?

Were regular safety inspections carried out?





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Interviewing

Interviewing is an art that cannot be given justice in a brief document such as this, buta few do's and don'ts can be mentioned. The purpose of the interview is to establish anunderstanding with the witness and to obtain his own words describing the event:

DO...

put the witness, who is probably upset, at ease

emphasize the real reason for investigation, to determine what happened and why

let the witness talk, listen

confirm that you have the statement correct

try to sense any underlying feelings of the witness

make short notes only during the interview

DO NOT...

intimidate the witness

interrupt

prompt

ask leading questions

show your own emotions

make lengthy notes while the witness is talking

Ask open-ended questions that cannot be answered by simply "yes" or "no". The actualquestions you ask the witness will naturally vary with each accident, but there are

some general questions that should be asked each time: Where were you at the time of the accident?

What were you doing at the time?

What did you see, hear?

What were the environmental conditions (weather, light, noise, etc.) at the time?

What was (were) the injured worker(s) doing at the time?

In your opinion, what caused the accident?

How might similar accidents be prevented in the future?

If you were not at the scene at the time, asking questions is a straightforward approachto establishing what happened. Obviously, care must be taken to assess the credibilityof any statements made in the interviews. Answers to a first few questions willgenerally show how well the witness could actually observe what happened.

Generally, people aren't used to being interviewed. After a traumatic experience, awitness may not be able to recall the details. But, witnesses should be interviewed assoon as possible. People react differently. Don't be surprised if a witness who wasclose to the incident has an entirely different story from someone who saw it at adistance. Witnesses may remember more clues after the shock has worn off, so beopen to follow-up sessions. Some witnesses may offer biased testimony if they feel aneed to influence the findings. Witnesses may omit entire sequences of events if they

don't realize their importance. Finally, eyesight, hearing, reaction time, and the generalcondition of each witness may affect his or her ability to observe.





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Good interviewing skills are developed with experience. The most experienced teammember should lead the interviews. It may be helpful to have someone with a legalbackground on the interview team. Use the checklist below to help with your interviews.

After the interviews, the team should analyze each witness' statement, and may wantto re-interview some witnesses to confirm or clarify key points. Even withinconsistencies in the statements, the investigation team should assemble all of theavailable testimony into a logical order. Consider the statements along with data fromthe incident site in your report.

Have you appointed a speaker for the team?

Have you obtained preliminary statements as soon as possible from all witnesses?

Has each witness located his or her position on a map of the site (including thedirection of view)?

Is the interview conducted at a convenient time and place?

Have you told the witnesses that the investigation's purpose is accidentprevention?

Have you introduced the team and tried to make the witness comfortable?

Do you record each witness' identity and qualifications?

Are your questions worded carefully, and do you ensure the witness understandseach question?

Do you ask open-ended questions requiring more than a "yes" or "no" reply?

Do you let the witness speak freely while you listen?

Do you take notes without distracting the witness and use a tape recorder only with

the witness' consent? Do you record the witness' exact words?

Do you let the witness use sketches and diagrams?

Do you confirm direct observation and identify opinion or hearsay?

Are you polite and careful not to lead the witness or to argue?

Do you supply each witness with a copy of his or her statement?

• Gather just the facts… make no judgments or statements

• Conduct interviews one on one

• Be friendly but professional• Interview all supervisors

• Use sketches & diagrams to help witness.

• Let each witness speak freely & take notes without distracting witness (avoid use oftape recorder).

• Emphasize areas of direct observation & label hearsay accordingly.

• Provide feedback but don‟t lead the witness or put the person on defensive or givea “true-false” test.

• Look out for corroborations & inconsistencies.

• End with a positive note & keep the line open





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Interviewing Process

Parts

The third category of evidence is parts and includes physical evidence such as:

Tools, equipment, parts, materials & PPE

Worn or failed equipment parts

Improper tools & equipment

Incorrect use of tools & equipment

Process liquid/solid samples; before & after

To seek out possible causes resulting from theequipment and materials used, investigators might ask:

Was there an equipment failure?

What caused it to fail?

Was the machinery poorly designed?

Were hazardous substances involved?

Were they clearly identified?

Was a less hazardous alternative substance possible and available?

Was the raw material substandard in some way?

Should personal protective equipment (PPE) have been used?

Was the PPE used?

Again, each time the answer reveals an unsafe condition, the investigator must askwhy this situation was allowed to exist.

Paper

This is the last category of evidence and includes:

Maintenance logs & schedules

Employee training records

Work procedures & practices, codes & regulations





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Checklists, work orders, work permits, etc.

Building plans, layouts, Flow diagrams, P&Ids

Safety Inspections, audits, observations, etc.

Similar investigation reports

Employee medical history & health records

Job / shift schedules, overtime records

Parts / equipment / materials inspection & certification

Equipment / instruments calibration records

Design specifications & materials of construction

MSDS / Chemical analysis report

Risk assessments & HAZOP Contractor prequalification & contract terms & conditions

Environmental monitoring / emission reports

These are seldom at the scene of the incident & hence, are often neglected.Consequently, it is often an overlooked source of information, All available and relevantinformation must be extracted and recorded from documents such as technical datasheets, maintenance reports, past accident reports, formalized safe-work procedures,and training reports. Any pertinent information should be studied to see what mighthave happened, and what changes might be recommended to prevent recurrence ofsimilar accidents.

Summarizing the information gathered Where and when did the adverse event happen? Who was injured/suffered ill health or was otherwise involved with the adverse

event? How did the adverse event happen? (Note any equipment involved). What activities were being carried out at the time? Was there anything unusual or different about the working conditions? Were there adequate safe working procedures and were they followed? What injuries or ill health effects, if any, were caused? If there was an injury, how did it occur and what

caused it? Was the risk known? If so, why wasn‟t it controlled?

If not, why not? Did the organization and arrangement of the work

influence the adverse event? Was maintenance and cleaning sufficient? If not,

explain why not. Were the people involved competent and suitable? Did the workplace layout influence the adverse

event? Did the nature or shape of the materials influence the adverse event? Did difficulties using the plant and equipment influence the adverse event?

Was the safety equipment sufficient? Did other conditions influence the adverse event?





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2.3 Collecting & Sifting Evidence (Analysis)

Facts must be separated from opinions, direct evidence from circumstantial evidenceand eyewitness statements from hearsay testimony. Your investigation should beexhaustive. Look for all relevant facts, not just the obvious. Usually an accident hasseveral causal factors, yet some investigators will stop after discovering the first one.Study the accident scene carefully.

Divide the data collected into following categories:

Hard Evidence.

Data that usually cannot be disputed, e.g., time & place of accident, logs & otherwritten reports & the position of physical evidence (providing investigators canestablish that it has not been moved).

Witness Statement.

Statements from persons who saw the accident happen & from those who came uponthe scene immediately afterwards

Circumstantial Evidence.

The logical interpretation of facts that leads to a single, but un-proven conclusion.

Critical Factors

• Negative events or undesirable conditions that influence the course of events

• Major contributions to the incident

• Events or conditions, which if eliminated, would have either prevented theoccurrence or reduced its severity

An investigator who believes that incidents are caused by unsafe conditions will likelytry to uncover conditions as causes. On the other hand, one who believes they arecaused by unsafe acts will attempt to find the human errors that are causes. Therefore,it is necessary to examine briefly some underlying factors in a chain of events thatends in an accident.

The important point is that even in the most seemingly straightforward incidents ,seldom, if ever, is there only a single cause . For example, an "investigation" whichconcludes that an accident was due to worker carelessness, and goes no further, failsto seek answers to several important questions such as:

Was the worker distracted? If yes, why was

the worker distracted? Was a safe work procedure being followed?

If not, why not?

Were safety devices in order? If not, whynot?

Was the worker trained? If not, why not?

An inquiry that answers these and relatedquestions will probably reveal conditions thatare more open to correction than attempts toprevent "carelessness".







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Corrective Actions

Temporary actions (immediate)

generally address the unsafe acts & conditions

Permanent actions (long-term)

generally address personal & job factors

Aimed at:

Reducing likelihood of occurrence

Reducing severity of consequences

Corrective Actions – General Principles

Recommendations must be based on key contributory factors and underlyingcauses.

Must be appropriate and adequate Recommendation(s) must be communicated clearly.

Must be S.M.A.R.T. (smart, measurable, achievable, realistic, time bound

Strict time table must be established.

Follow up must be conducted.

What are the existing barriers in place to prevent this incident?

Why didn‟t the existing barriers work

Fix or improve existing barriers before creating new ones.

Make sure each cause you identify is covered by a corrective action.

Ensure that the corrective actions meet the following criteria

Report Forms and Formats

Statutory and Regulatory Reports

All incidents shall be reported by the PGM / PM or his representative to the projectcompany in accordance with the following:

a) The ECRA “Initial Incident Reporting Form” should be submitted by the ProjectCompany or owner to the office of Vice Governor Regulatory Affairs within twobusiness days of the occurrence of an Incident.





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Structure of Initial Incident Reporting Form Contents:

1. General information

Name of licensee / Company,

Incident reference,

Location of incident-area, unit, equipment,

Date and time of incident – start, finish.

2. Contact details

Name of person making notification,

Contact details- telephone number, e-mail, etc.,

Date and time of notification to Authority.

3. Incident classification

Operational – electricity, desalinated water,

Health & safety – fatality, major injury, III- health,

Dangerous occurrence,

Environmental – air, water, land.

4. Incident description

Sequence of events – description of events leading to incident,

Consequences – impact on operations, people or environment,

Causation – immediate causes, nature of defect, failures, etc., Remedial actions – present status, actions taken to rectify situation.

5. Other information

Any other relevant information – police presence, media interest, etc.

b) The ECRA “Incident Investigation Report” should be submitted by the project companyor owner to the office of Vice Governor Regulatory Affairs within 20 business days ofthe occurrence of an Incident or any other shorter period as decided by the ECRA.

Structure of Incident Investigation Report Contents

1. Executive summary

A brief description of the incident

the consequential losses (people, assets, demand and / or Generation affected (MW)

Environment and licensee reputation and major recommendations.

2. Introduction

A brief description of why the report is being prepared and legal obligations forundertaking the investigation.

3. Incident description

Detailed description of scene – location, people involved, etc.,

Sequence of events





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Impact of the event – people, environment and property

Emergency procedures – actions taken, agencies involved

Work activities – identified and controlled

4. Investigation and observations

Investigation procedure – background information

Documentation review

Interviews and discussions

Site visits

Equipment analysis and review

5. Analysis and conclusions

Summary of key findings

Immediate causes

Root causes

6. Recommendations and action plan

Immediate actions – short term

Follow – up actions – long term

Action plan – tracking, times and responsibilities

7. Appendices

Documentation – examples but not limited to; Letters, emails, faxes, minutes of meetings, contracts, etc.

Log sheets, work permits, etc.

HSE plans, risk assessments, method statements, etc.

Surveys, inspections, etc.

Excerpts from procedures, manuals, instructions, etc.

Testing and inspection certificates, etc.

Charts, maps, illustrations, sketch, etc.

Photos with narrative

c) The ECRA “Final Close-out Report” should be submitted to the office of Vice GovernorRegulatory Affairs within the period agreed with the Authority.

As a minimum, the final close-out report shall contain:

1. a summary of the incident;

2. a review of the main and contributory causes;

3. a review of key issues identified and preventative action taken and

4. a table listing original recommendations, action parties and action taken to close-out each point.

5. Basic information regarding equipments to the incident occurring.





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NOMAC Reports

The site first aider or doctor shall fill the First Aid Treatment form(NC/QHSE/SP-006/FM-001) for Injury incidents requiring first aid treatment.

The immediate supervisor shall fill the Initial Incident Report form(NC/QHSE/SP-006/FM-002) within 24 hours of the incident occurrence.

Any employee observing a Near Miss, unsafe act or condition shall fill theNear Miss Reporting form (NC/QHSE/SP-006/FM-003) and drop the form indesignated Near Miss stations/ boxes. These forms shall be collected by thesite HSEE/O.

All final written investigation reports shall be completed and approved within 3 weeks(15 working days) of the incident occurrence by the incident investigation team leader.





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3.0 Root Cause Analysis

System Defects > Root Causes > Immediate Causes > Contact > Incident

Possible Immediate Causes

ACTIONS:

Not following procedures

Improper use of tools or equipment

Inadequate use of protective methods

Inattention / lack of awareness

CONDITIONS:

Inadequate protective systems

Inadequate tools, equipment & vehicles

Work exposures

Workplace environment / layout

Examples of unsafe acts:

– Unauthorized operation of equipment

– Running - Horse Play

– Not following procedures

– By-passing safety devices

– Not using protective equipment

– Under influence of drugs or alcohol

– Taking short-cuts

Do not use examples such as carelessness or not using common sense. (These areneither visible not measurable)

Examples of unsafe conditions:

– Ergonomic Hazards

– Environmental hazards

– Inadequate housekeeping

–

Blocked walkways – Improper or damaged PPE

– Inadequate machine guarding

Root or System Causes

The most basic causes that can reasonably be identified, that management has controlto fix, and for which effective corrective actions for preventing recurrence can begenerated.

Possible Basic (System) Causes

PERSONAL FACTORS:

Physical capability Physical condition







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Event & Condition Mapping Human Error Analysis Change Analysis

The main classes of accident models are (based on Kjellén, 2000):

Causal-sequence models Process models Energy model Logical tree models Human information-processing models SHE management models

Some of the Core Analytical Techniques include:

•

Event & Causal Factor Charting & Analysis (ECFA)• Barrier Analysis• Change Analysis• Causal Factor Analysis

Some of the more Complex Analytical Techniques include:

• Fault Tree Analysis• MORT (Management Oversight Risk Tree)• PET (Project Evaluation Tree Analysis)• Tripod Beta• Tap-RooT

These techniques are generally used for complex accidents with multiple systemfailures.

In addition to these, certain Specific Analytical Techniques include:

• Human Factor Analysis• Failure Modes & Effect Analysis• Software Hazards Analysis• Materials & Structure Analysis• Atmospheric Dispersion Analysis





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DOE’s core analytical techniques5

Events and causal factors charting (ECFC)

Events and causal factors charting is a graphical display of the accident‟s chronology and is

used primarily for compiling and organizing evidence to portray the sequence of theaccident‟s events.

The events and causal factor chart is easy to develop and provides a clear depiction of thedata. Keeping the chart up-to-date helps insure that the investigation proceeds smoothly,that gaps in information are identified, and that the investigators have a clear representationof accident chronology for use in evidence collection and witness interviewing.

Events and causal factors charting is useful in identifying multiple causes and graphicallydepicting the triggering conditions and events necessary and sufficient for an accident tooccur.

Events and causal factors analysis is the application of analysis to determine causal factors

by identifying significant events and conditions that led to the accident. As the results fromother analytical techniques are completed, they are incorporated into the events and causalfactors chart. “Assumed” events and conditions may also be incorporated in the chart.

The following figure gives an overview over symbols used in an event and causal factorchart and some guidelines for preparing such a chart.

The Figure below shows a simplified event and causal factors chart in general.





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Barrier analysisBarrier analysis is used to identify hazards associated with an accident and the barriers thatshould have been in place to prevent it. A barrier is any means used to control, prevent, orimpede the hazard from reaching the target.

Barrier analysis addresses:

• Barriers that were in place and how they performed

• Barriers that were in place but not used

• Barriers that were not in place but were required

• The barrier(s) that, if present or strengthened, would prevent the same or similar accidents

from occurring in the future.The following Figure shows types of barriers that may be in place to protect workers fromhazards.

Physical barriers are usually easy to identify, but management system barriers may be lessobvious (e.g. exposure limits). The investigator must understand each barrier‟s intendedfunction and location, and how it failed to prevent the accident. There exists different ways inwhich defences or barriers may be categorized, i.e. active or passive barriers (see e.g.Kjellén, 2000), hard or soft defences (see e.g. Reason, 1997), but this topic will not be

discussed any further in this report.





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To analyze management barriers, investigators may need to obtain information aboutbarriers at three organizational levels responsible for the work; the activity, facility andinstitutional levels. For example, at the activity level, the investigator will need informationabout the work planning and control processes that governed the work activity, as well as

the relevant safety management systems. The investigator may also need information aboutsafety management systems at the facility level. The third type of information would beinformation about the institutional-level safety management direction and oversight providedby senior line management organizations.

The basic steps of a barrier analysis are:

Step 1 Identify the hazard and the target. Record them at the top of the worksheet

Step 2 Identify each barrier. Record in column one.

Step 3 Identify how the barrier performed (What was the barrier‟s purpose? Was the barrierin place or not in place? Did the barrier fail? Was the barrier used if it was in place?) Recordin column two.

Step 4 Identify and consider probable causes of the barrier failure. Record in column three.

Step 5 Evaluate the consequences of the failure in this accident. Record in column four.

The investigator should use barrier analysis to ensure that all failed, unused, or uninstalledbarriers are identified and that their impact on the accident is understood. The analysisshould be documented in a barrier analysis worksheet.

Change analysis

Change is anything that disturbs the “balance” of a system operating as planned. Change isoften the source of deviations in system operations.

Change analysis examines planned or unplanned changes that caused undesired outcomes.

In an accident investigation, this technique is used to examine an accident by analysing thedifference between what has occurred before or was expected and the actual sequence ofevents.

The investigator performing the change analysis identifies specific differences between theaccident –free situation and the accident scenario. These differences are evaluated todetermine whether the differences caused or contributed to the accident.

The change analysis process is described in the following Figure.

When conducting a change analysis, investigators identify changes as well as the results ofthose changes. The distinction is important, because identifying only the results of changemay not prompt investigators to identify all causal factors of an accident. When conducting a

change analysis, it is important to have a baseline situation that the accident sequence maybe compared to.





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The table below shows a simple change analysis worksheet.

The investigators should first categorize the changes according to the questions shown inthe left column of the worksheet, i.e., determine if the change pertained to, for example, adifference in:

• What events, conditions, activities, or equipment were present in the accident situation thatwere not present in the baseline (accident-free, prior, or ideal) situation (or vice versa)

• When an event or condition occurred or was detected in the accident situation versus thebaseline situation

• Where an event or condition occurred in the accident situation versus where an event or

condition occurred in the baseline situation• Who was involved in planning, reviewing, authorizing, performing, and supervising thework activity in the accident versus the accident-free situation.

• How the work was managed and controlled in the accident versus the accident-freesituation.

To complete the remainder of the worksheet, first describe each event or condition ofinterest in the second column. Then describe the related event or condition that occurred (orshould have occurred) in the baseline situation in the third column. The difference betweenthe event and conditions in the accident and the baseline situations should be brieflydescribed in the fourth column. In the last column, discuss the effect that each change had

on the accident.





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The differences or changes identified can generally be described as causal factors andshould be noted on the events and causal factors chart and used in the root cause analysis.

A potential weakness of change analysis is that it does not consider the compoundingeffects of incremental change (for example, a change that was instituted several yearsearlier coupled with a more recent change). To overcome this weakness, investigators maychoose more than one baseline situation against which to compare the accident scenario.

Events and causal factors analysis

The events and causal factors chart may also be used to determine the causal factors of anaccident, as illustrated in the Figure below. This process is an important first step in laterdetermining the root causes of an accident. Events and causal factors analysis requiresdeductive reasoning to determine which events and/or conditions that contributed to theaccident.

Before starting to analyse the events and conditions noted on the chart, an investigator mustfirst ensure that the chart contains adequate detail.

Examine the first event that immediately precedes the accident. Evaluate its significance inthe accident sequence by asking:

“If this event had not occurred, would the accident have occurred?”

If the answer is yes, then the event is not significant. Proceed to the next event in the chart,working backwards from the accident. If the answer is no, then determine whether the eventrepresented normal activities with the expected consequences. If the event was intendedand had the expected outcomes, then it is not significant. However, if the event deviatedfrom what was intended or had unwanted consequences, then it is a significant event .

Carefully examine the events and conditions associated with each significant event byasking a series of questions about this event chain, such as:

• Why did this event happen?

• What events and conditions led to the occurrence of the event?

• What went wrong that allowed the event to occur?

• Why did these conditions exist?





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• How did these conditions originate?

• Who had the responsibility for the conditions?

• Are there any relationships between what went wrong in this event chain and other events

or conditions in the accident sequence?• Is the significant event linked to other events or conditions that may indicate a moregeneral or larger deficiency?

The significant events, and the events and conditions that allowed the significant events tooccur, are the accident‟s causal factors.

Root cause analysis

Root cause analysis is any analysis that identifies underlying deficiencies in a safetymanagement system that, if corrected, would prevent the same and similar accidents fromoccurring. Root cause analysis is a systematic process that uses the facts and results fromthe core analytic techniques to determine the most important reasons for the accident. While

the core analytic techniques should provide answers to questions regarding what, when,where, who, and how, root cause analysis should resolve the question why. Root causeanalysis requires a certain amount of judgment.

A rather exhaustive list of causal factors must be developed prior to the application of rootcause analysis to ensure that final root causes are accurate and comprehensive.

Fault tree analysis

Fault tree analysis is a method for determining the causes of an accident (or top event). Thefault tree is a graphic model that displays the various combinations of normal events,equipment failures, human errors, and environmental factors that can result in an accident. An example of a fault tree is shown in the Figure below.

A fault tree analysis may be qualitative, quantitative, or both. Possible results from theanalysis may be a listing of the possible combinations of environmental factors, humanerrors, normal events and component failures that may result in a critical event in the systemand the probability that the critical event will occur during a specified time interval.

The strengths of the fault tree, as a qualitative tool is its ability to break down an accidentinto root causes.





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The undesired event appears as the top event. This event is linked to the basic failureevents by logic gats and event statements. A gate symbol can have one or more inputs, butonly one output. A summary of common fault tree symbols is given in the Figure below.

Event tree analysis

An event tree is used to analyse event sequences following after an initiating event. Theevent sequence is influenced by either success or failure of numerous barriers or safetyfunctions/ systems. The event sequence leads to a set of possible consequences. Theconsequences may be considered as acceptable or unacceptable. The event sequence is

illustrated graphically where each safety system is modelled for two states, operation andfailure.

The following Figure illustrates an event tree of the situation on Rørosbanen just before the Åsta-accident. This event tree reveals the lack of reliable safety barriers in order to preventtrain collision at Rørosbanen at that time.

An event tree analysis is primarily a proactive risk analysis method used to identify possibleevent sequences. The event tree may be used to identify and illustrate event sequences andalso to obtain a qualitative and quantitative representation and assessment. In an accidentinvestigation we may illustrate the accident path as one of the possible event sequences.This is illustrated with the thick line in the Figure below.





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MORT

MORT provides a systematic method (analytic tree) for planning, organizing, and conductinga comprehensive accident investigation. Through MORT analysis, investigators identifydeficiencies in specific control factors and in management system factors. These factors areevaluated and analyzed to identify the causal factors of the accident.

Basically, MORT is a graphical checklist which contains generic questions that investigators

attempt to answer using available factual data. This enables investigators to focus onpotential key causal factors. The upper levels of the MORT diagram are shown in the Figure.

MORT requires extensive training to effectively perform an in-depth analysis of complexaccidents involving multiple systems. The first step of the process is to select the MORTchart for the safety program area of interest. The investigators work their way down throughthe tree, level by level. Events should be coded in a specific color relative to the significanceof the accident. An event that is deficient or Less Than Adequate (LTA) in MORTterminology is marked red. The symbol is circled if suspect or coded in red if confirmed. Anevent that is satisfactory is marked green in the same manner. Unknowns are marked inblue, being circled initially and colored if sufficient data do not become available, and anassumption must be made to continue or conclude the analysis.

When the appropriate segments of the tree have been completed, the path of cause andeffect (from lack of management control, to basic causes, contributory causes, and rootcauses) can easily be traced back through the tree. The tree highlights quite clearly wherecontrols and corrective actions are needed and can be effective in preventing recurrence ofthe accident.

PET (Project Evaluation Tree) and SMORT (Safety Management and Organisations ReviewTechnique) are both methods based on MORT but simplified and easier to use. PET andSMORT will not be described further. PET is described by DOE (1999) and SMORT byKjellén et al (1987).





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Systematic Cause Analysis Technique (SCAT)

The International Loss Control Institute (ILCI) developed SCAT for the support ofoccupational incident investigation. The ILCI Loss Causation Model is the framework for theSCAT system (see Figure below).

The result of an accident is loss, e.g. harm to people, properties, products or theenvironment. The incident (the contact between the source of energy and the “victim”) is theevent that precedes the loss.

The immediate causes of an accident are the circumstances that immediately precede thecontact. They usually can be seen or sensed. Frequently they are called unsafe acts orunsafe conditions, but in the ILCI-model the terms substandard acts (or practices) andsubstandard conditions are used. Substandard acts and conditions are listed in the Figure

below.





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Basic causes are the diseases or real causes behind the symptoms, the reasons why thesubstandard acts and conditions occurred. Basic causes help explain why people performsubstandard practices and why substandard conditions exists. An overview of personal and job factors are given in the following Figure.

There are three reasons for lack of control:1. Inadequate program2. Inadequate program standards and3. Inadequate compliance with standards

The following Figure shows the elements that should be in place in a safety program. Theelements are based on research and experience from successful safety programs in

different companies.





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The Systematic Cause Analysis Technique is a tool to aid an investigation and evaluation ofincidents through the application of a SCAT chart. The chart acts as a checklist or referenceto ensure that an investigation has looked at all facets of an incident. There are five blockson a SCAT chart. Each block corresponds to a block of the loss causation model. Hence, the

first block contains space to write a description of the incident. The second block lists themost common categories of contact that could have led to the incident under investigation.The third block lists the most common immediate causes, while the fourth block listscommon basic causes. Finally, the bottom block lists activities generally accepted asimportant for a successful loss control program. The technique is easy to apply and issupported by a training manual.

STEP (Sequential timed events plotting)

The STEP-method was developed by Hendrick and Benner (1987). They propose asystematic process for accident investigation based on multi-linear events sequences and aprocess view of the accident phenomena.

STEP builds on four concepts:1. Neither the accident nor its investigation is a single linear chain or sequence of events.Rather, several activities take place atthe same time.

2. The event Building Block format for data is used to develop the accident description in aworksheet. A building block describes one event, i.e. one actor performing one action.

3. Events flow logically during a process. Arrows in the STEP worksheet illustrate the flow.

4. Both productive and accident processes are similar and can be understood using similarinvestigation procedures. They both involve actors and actions, and both are capable ofbeing repeated once they are understood.

With the process concept, a specific accident begins with the action that started the

transformation from the described process to an accident process, and ends with the lastconnected harmful event of that accident process.

The STEP-worksheet provides a systematic way to organise the building blocks into acomprehensive, multi-linear description of the accident process. The STEP-worksheet issimply a matrix, with rows and columns. There is one row in the worksheet for each actor.The columns are labeled differently, with marks or numbers along a time line across the topof the worksheet. The time scale does not need to be drawn on a linear scale, the main pointof the time line is to keep events in order, i.e., how they relate to each other in terms of time.

An event is one actor performing one action. An actor is a person or an item that directlyinfluences the flow or events constituting the accident process. Actors can be involved in twotypes of changes, adaptive changes or initiating changes. They can either change reactivelyto sustain dynamic balance or they can introduce changes to which other actors must adapt. An action is something done by the actor. It may be physical and observable, or it may bemental if the actor is a person. An action is something that the actor does and must bestated in the active voice.

The STEP worksheet provides a systematic way to organise the building blocks (or events)into a comprehensive, multi-linear description of the accident process. Figure 23 shows anexample on a STEP-diagram of an accident where a stone block falls off a truck and hits acar.





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The above STEP-diagram also shows the use of arrows to link tested relationships amongevents in the accident chain. An arrow convention is used to show precede/follow and logicalrelations between two or more events. When an earlier action is necessary for a latter tooccur, an arrow should be drawn from the preceding event to the resultant event. Thethought process for identifying the links between events is related to the change of stateconcepts underlying STEP methods. For each event in the worksheet, the investigator asks,“Are the preceding actions sufficient to initiate this actions (or event) or were other actionsnecessary?” Try to visualize the actors and actions in a “mental movie” in order to developthe links.

MTO-analysis

The basis for the MTO-analysis is that human, organizational, and technical factors shouldbe focused equally in an accident investigation. The MTO-analysis is based on threemethods:

1. Structured analysis by use of an event- and cause-diagram.

2. Change analysis by describing how events have deviated from earlier events or commonpractice.

3. Barrier analysis by identifying technological and administrative barriers in which havefailed or are missing.

The first step in an MTO-analysis is to develop the event sequence longitudinally andillustrate the event sequence in a block diagram. Identify possible technical and humancauses of each event and draw these vertically to each event in the diagram.

Further, analyze which technical, human or organizational barriers that have failed or wasmissing during the accident progress.

Assess which deviations or changes in which differ the accident progress from the normal

situation. These changes are also illustrated in the diagram.The basic questions in the analysis are:





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• What may have prevented the continuation of the accident sequence?

• What may the organization have done in the past in order to prevent the accident?

The last important step in the MTO-analysis is to identify and present recommendations. The

recommendations should be as realistic and specific as possible, and might be technical,human or organizational.

A checklist for identification of failure causes is also part of the MTO-methodology. Thechecklist contains the following factors:

1. Organization

2. Work organization

3. Work practice

4. Management of work

5. Change procedures

6. Ergonomic / deficiencies in the technology

7. Communication

8. Instructions/procedures

9. Education/competence

10. Work environment

For each of these failure causes, there is a detailed checklist for basic or fundamentalcauses. Examples on basic causes for the failure cause work practice are:

• Deviation from work instruction

• Poor preparation or planning • Lack of self inspection

• Use of wrong equipment

• Wrong use of equipment

TRIPOD

The idea behind TRIPOD is that organisational failures are the main factors in accidentcausation. These factors are more “latent” and, when contributing to an accident, are alwaysfollowed by a number of technical and human errors. The following diagram shows the logic.





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Substandard acts and situations do not just occur. They are generated by mechanismsacting in organizations, regardless whether there has been an accident or not. Often thesemechanisms result from decisions taken at high level in the organization. These underlyingmechanisms are called Basic Risk Factors (BSFs). These BSFs may generate various

psychological precursors in which may lead to substandard acts and situations. Examples onpsychological precursors of slips, lapses and violations are time pressure, being poorlymotivated or depressed. According to this model, eliminating the latent failures categorizedin BRFs or reducing their impact will prevent psychological precursors, substandard acts andthe operational disturbances. Furthermore, this will result in prevention of accidents.

The identified BRFs cover human, organizational and technical problems. The differentBasic Risk Factors are defined in the Table below. Ten of these BRFs leading to the“operational disturbance” (the “preventive” BRFs), and one BRF is aimed at controlling theconsequences once the operational disturbance has occurred (the “mitigation” BRF). Thereare five generic prevention BRFs (6 – 10 in the Table) and five specific BRFs (1 – 5 in theTable). The specific BRFs relate to latent failures that are specific for the operations to be

investigated (e.g. the requirements for Tools and Equipment are quite different in a oil drillingenvironment compared to an intensive care ward in a hospital).

These 11 BRFs have been identified as a result of brainstorming, a study of audit reports,accident scenarios, a theoretical study, and a study on offshore platforms. The division isdefinitive and has shown to be valid for all industrial applications.





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CLC Glossary Guidance

This Glossary is provided to the user of Comprehensive List of Causes (CLC) chart, as aguide to further define and explain the various causes. Since the causes selected will beused for trend analysis, accuracy in selecting the appropriate cause is important. Users areexpected to use this Glossary to ensure proper understanding of each cause category.

In each category, “Other” is listed as the last option, in case none of the above causes fit thecircumstances. While appropriate in some cases, the use of “Other” should be minimized, asit adds little value in trend analysis. In all cases – if you use the „other‟ cause, you mustexplain what that cause is.

Users are reminded that any cause selected must meet two conditions. First, it must besupported by the facts of the case. Additionally, a selected cause must help explain why theCritical Factor under consideration existed at the time of the incident.

One of the key issues for a quality investigation is ensuring each selected cause isaddressed through an appropriate recommendation to avoid similar events in the future.

There must be symmetry between the cause selected and the type of recommendation.Guidance is provided in the right hand column of this Glossary to help the investigator toachieve this symmetry.

Glossary

Possible immediate causes

Immediate causes are covered in the first two sections entitled: Actions and Conditions.

Actions

There are four major categories of actions, with an additional level of detail under each of the

major categories. In actions we are focused on people and their behavior.1. Did not follow existing procedures

1.1 Violation (by individual): One individualintentionally chose to violate an establishedsafety practice.

An investigation team should only select thiscause when there is a clear safety practiceor rule in place & that practice or rule isknown by the person involved. Violationsare behaviors, and require a behavioralrecommendation. An additional A-B-Canalysis can be useful.

1.2 Violation (by group): more than oneindividual was involved in the decision tointentionally violate an established safetypractice.

See above. Additionally, if a procedure hasbeen routinely violated by many, this is anindication of an organizational or culturalissue, which can be further explored inColumns 16, 17 and 22.

1.3 Violation (by supervisor): a supervisor orother management person either personallyviolated an established safety practice ordirected people under their supervision to doso.

See above.





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1.4 Procedure not available: the person doingthe work did not have access to the procedureand consequently relied on memory to do the

work properly.

This can be addressed either by reinforcing„Stop work when not sure‟ or by making theprocedure available.

1.5 Procedure was not understood: theperson relying on the procedure could notcomprehend the procedure, due to language,technical capability or complexity.

This is a training issue, which can beaddressed either by additional training orassignment of different personnel. Thequality / content of the procedure is coveredin column 22 – Standards/Practices/Procedures.

1.6 Other: must define. The use of „other‟ without comment orexplanation has no value to your

investigation. See above.

2. Use of tools, plant/equipment or vehicle

2.1 Plant/Equipment or vehicle used in thewrong way: equipment or vehicle was used foractivities for which it was not designed or theequipment or vehicle was misused, forexample, using a forklift to lift a pallet for useas a work platform, or using a handrail as aladder.

To make a good recommendation,investigation needs to determine if thisaction was intentional or due to lack ofknowledge. If intentional, this is a behavioralissue which requires a behavioralrecommendation. An A-B-C analysis canhelp understand why the person acted thisway. If lack of knowledge, then a trainingsolution is appropriate.

2.2 Tools used in the wrong way: tools wereused for activities for which they were notdesigned or tools were misused, for example,using a wrench as a hammer, or a screwdriveras a pry bar.

See above.

2.3 Use of plant/equip or vehicle with knowndefect: the person using the equip had

identified it as being defective, yet continuedto use that equip, for example, using a vehiclewith inoperative lights or a ladder with abroken rung. (Hidden or unidentified defectsare covered in Column 6 – Tools, Plant/Equip& Vehicles.)

Since the defect was identified, this is abehavioral issue, and requires a behavioral

recommendation. An A-B-C analysis can behelpful in identifying factors which causedthe person to act this way.

2.4 Use of tools with a known defect: theperson using the tool had identified it as beingdefective, yet continued to use that tool, forexample, using a grinder without a guard, or aextension cord with frayed wires. (Hidden or

unidentified defects are covered in Column 6.)

See above.





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2.5 Incorrect placement of tools, equip ormaterials: the tools, material or equip in usewere placed in a position creating a hazard,

eg., tools placed overhead fell & struck theperson or a truck was parked on a slope &rolled down.

The investigation needs to determine if thiswas intentional, due to lack of knowledge ordue to poor risk awareness. Depending on

that conclusion, the recommendation canbe behavioral, training or procedural.

2.6 Operation of plant/equip or vehicle atimproper speed: once a known operating limitwas exceeded, the person did not take theappropriate actions to correct the situation.(Note – this can apply to any process plantoperating limitation – temperature, flow,pressure etc.)

This cause is used when there was anintent or effort to correct the situation. Thisis typically a training issue and requires atraining solution. If there is no effort tocorrect the situation, then the behavior isintentional and violation of procedure is abetter cause to select.

2.7 Other: must define. The use of „other‟ without comment orexplanation has no value to yourinvestigation.

3. Use of protective equipment or methods

3.1 Need for protective equip or methods notrecognized: the person performing the workdid not recognize the situation requiredprotective equipment or methods.

This is training deficiency, in either riskassessment or hazard awareness and atraining recommendation is appropriate.

3.2 PPE or methods not used: the equip ormethods necessary in this situation were notused by the person doing the work.

A behavioral situation equivalent to aviolation. An A-B-C analysis can be used tohelp understand factors underlying thebehavior.

3.3 Incorrect use of PPE or methods: therequired PPE or methods were used, but notin a correct way to afford the neededprotection. Examples could be an incorrectrespirator or an incomplete lockout/tagout.

This is likely a training issue and additionaltraining on selection, use and limitationswould be appropriate.

3.4 PPE or methods not available: the needfor PPE or methods was recognized, but theequipment was either not available or wasimpossible to employ, yet the work continued.Examples would include no respirators instock, or no place to install a lock for lockout.

This is a combination of procedural andbehavioral issues, but is best addressed viaprocedural changes to ensure theequipment or methods are present andusable.

3.5 Disabled guards, warning systems orsafety devices: the correct guards, warningsystems or other safety devices were in place,

but were disabled or overridden to allow thework to proceed without these protections.

This is a behavioral situation equivalent to aviolation. An A-B-C analysis can be used tohelp understand the factors underlying the

behavior.





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This includes de-activation or bypassing ofinterlocks or safety instrumented systems.

3.6 Removal of guards, warning systems orsafety devices: the correct guards, warningsystems or other safety devices had beenremoved at some prior time, & not reinstalledor reactivated. (Equip that was never installedor was defective is covered in Column 5 – Protective Systems)

This is a behavioral situation equivalent to aviolation. An A-B-C analysis can be used tohelp understand the factors underlying thebehavior.


4. Lack of focus or inattention

4.1 Distracted by other concerns: the personinvolved was distracted & not attentive to thework in progress, & the person was not awareor became aware too late that something hadgone wrong. This would include failure tocontrol visitors, inadequate alarm managementor personal issues.

This is a behavioral issue, but there isevidence of a work setting which did notallow the person to concentrate on theirwork. This can be addressed byeliminating the distraction or training theperson to minimize the distraction beforeproceeding.

4.2 Inattention to surroundings: the person wasnot alert to their surroundings & just tripped orran into something that was clearly visible &obvious.

A behavioral situation & requires abehavioral solution. An A-B-C analysis canbe used to help understand the factorsunderlying the behavior.

4.3 Inappropriate workplace behaviour: theperson(s) involved were engaged ininappropriate activities, such as practical jokes,clowning around or acts of violence.

This is a behavioral situation equivalent toa violation. An A-B-C analysis can be usedto help understand the factors underlyingthe behavior.

4.4 No warning provided: a person had

awareness of a dangerous condition or activity,but did not warn current or future persons of theexposure, for example, did not tag a defectivetool, did not install a safety barrier around aspill or disabled alarms or interlocks.

If there is a clear expectation that a person

should have done something to warnothers, this is a behavioral issue. If there isnot a clear expectation, this can beaddressed through training or procedures.

4.5 Unintentional human error: this cause is theopposite of violations, which are intentionalacts. Unintended human error can consist ofperception errors, memory errors, decisionerrors or action errors. (If this cause is selected,further inquiry & investigation are required to

determine the error type & reasons why the

This is a special situation where thebehavior itself was unintentional, and not just the outcome of that behavior. Thissituation requires special analysis – youshould contact a Master Level Root CauseSpecialist.





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error was made.)

4.6 Routine activity without thought: the person

involved was performing a routine activity, suchas walking, sitting down, stepping, etc., withoutconscious thought, & was exposed to a hazardas a result.

This is a behavioral situation and requires

a behavioral solution. An A-B-C analysiscan be used to help understand the factorsunderlying the behavior.


Conditions

There are four major categories of conditions, with an additional level of detail under each of

the major categories. In conditions, we are focused on the physical working space and theequipment.

5. Protective systems

5.1 Guards or protective devices not effective:guards or protective devices needed to protectthe worker were present & working, but did notprevent the incident. For example, a highwayguardrail failed to stop a vehicle or a machineryguard did not restrain flying pieces.

This is typically an equipment issue andrequires an equipment solution.

5.2 Defective guards or protective devices:guards or protective devices needed to protectthe worker were present, but failed when theywere needed. For example, a handrailcollapsed when a person fell against it.

This is either an equipment or maintenanceissue and the recommendation mustaddress the suitability or reliability of theequipment.

5.3 Incorrect PPE: the PPE used was notcorrect for the situation at the time of theincident or the wrong type of PPE wasspecified. For example, a dust respirator wasprovided when an organic vapour respirator

was needed, or a cloth glove was providedwhen an impervious material glove wasneeded.

This cause should be limited to situationswhere the wrong PPE was supplied. If theperson involved was knowledgeable andwell trained, yet opted for the wrong PPE,that is a behavioral issue – an action – not

a condition.

5.4 Defective PPE: the PPE was correctlyspecified, but the specific piece of PPE wasdefective at the time of the incident. Forexample, the seam of a glove opened &allowed material to contact the hand.

This cause is either addressed as a qualitycontrol issue or through a proceduralchange for user inspections.

5.5 Warning systems not effective: a warning

system was present and working but failed toprovide sufficient notice at the time of the

This is typically an equipment issue and

requires an equipment solution.





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incident. For example, an evacuation alarmwhich could not be heard in all locations.

5.6 Defective warning systems: a warningsystem was present but failed at the time of theincident. For example, a tank high level alarmfailed to activate.


5.7 Safety devices were not effective: safetydevices such as pressure relief valves orturbine overspeed trips were present andworking, but did not act quickly enough toprevent the accident.

This is typically an equipment issue andrequires an equipment solution.

5.8 Defective safety devices: safety devicessuch as pressure relief valves or turbine overspeed trips failed to activate when needed.This would also include interlocks or safetyinstrumented systems which failed to operate.(Note: safety devices which are intentionallydisabled or over-ridden are covered in Column1 – Did Not Follow Existing Procedures.)



6. Tools, plant/equipment and vehicles

6.1 Plant/equip malfunction: the right equipwas selected & used, but the specific piece ofequip involved did not operate properly. Forexample, a drawer of a file cabinet beingopened came all the way out and fell.

This cause is limited to equip malfunctionswhich are invisible or hidden to the user.Defects which are known to the user arebest found in Column 2; defects whichshould be identified in a pre-use check arein Column 22.

6.2 Preparation of plant/equip: the equip wasnot prepared correctly prior to the job or maint.work, for example, a vessel was notthoroughly cleaned of process chemicals priorto entry.

The investigation needs to determine if thisis an equipment issue, a procedural issue ora behavioral issue and then verify therecommendation fits their conclusion.

6.3 Tool malfunction: the right kind of tool wasselected and used, but the tool involved didnot operate properly. For example, an electrictool had a short that shocked the user.

This cause is limited to tool malfunctionswhich are invisible or hidden to the user.Defects which are known to the user arebest found in Column 2; defects whichshould be identified in a pre-use check arein Column 22.





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6.4 Preparation of tools: the tools were notprepared correctly before the job, for example,an air monitoring instrument was not

calibrated prior to use.

The investigation needs to determine if thisis a tool and equipment issue, a proceduralissue or a behavioral issue and then verify

the recommendation fits their conclusion.

6.5 Vehicle malfunction: the right type ofvehicle was selected & used, but the vehicledid not operate correctly. For example, theload indicator on a crane did not properlymeasure the weight being lifted.

This cause is limited to vehicle malfunctionswhich are invisible or hidden to the user.Defects which are known to the user arebest found in Column 2; defects whichshould be identified in a pre-use check arein Column 22.

6.6 Preparation of vehicle: the right vehiclewas being used, but the vehicle had not been

correctly repaired or serviced for use. Forexample, a vehicle suffered a blow out of atire because the tire was not set correctly onthe rim.

The investigation needs to determine if thisis a vehicle issue, a procedural issue or a

behavioral issue and then verify therecommendation fits their conclusion.


7. Unanticipated exposure to...

7.1 Fire and explosion: the person wasinvolved in the immediate aftermath of a fireand/or explosion.

This column is limited to unanticipatedexposures. If the hazard was anticipated, orif procedures exist to control the hazard,better causes are found in Columns 19 or22. If the hazard was unanticipated,recommendations need to address eitherthe underlying cause of the event or thelack of risk assessment.

7.2 Noise: the person was exposed to a shortterm episode of unusually high noise levels,

such as a blast or depressurization event.

See above.

7.3 Energized electrical systems: the personwas exposed to electrical energy in a systemthat was believed to have been isolated.

See above.

7.4 Energized sources other than electrical:the person was exposed to sources of energyother than electrical, such as gravitational,pneumatic, hydraulic, chemical energy orradiation sources.

See above.





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7.5 Temperature extremes: the person wasexposed to unusually high or low ambienttemperatures, or by touching an object or

surface that was unusually hot or cold.

See above.

7.6 Hazardous chemicals: the person wasexposed to hazardous chemicals in an amountor dose capable of causing an adverse healtheffect.

See above.

7.7 Mechanical hazards: the person wasexposed to sharp edges, moving equip orfalling materials.

See above.

7.8 Storms or acts of nature: the person wasexposed to the immediate effects of a storm,tornado, hurricane, ice storm, or other acts ofnature.

See above.


8. Workplace layout

8.1 Congestion: the layout of the workplacedid not provide enough clearance fromhazards, accessibility to equipment or toolswas obstructed, or persons working could notachieve a correct posture.

This is an issue with plant design and arecommendation addressing this causemust modify the layout or allow work to bedone in a different location.

8.2 Illumination: the workplace illuminationwas so low or so bright, that it impacted aperson‟s ability to see.

This is an issue with design and arecommendation addressing this causemust modify the lighting system or provideshielding if too bright.

8.3 Ventilation: there was insufficient airmovement, which led to increasingtemperature or concentrations of chemicals ora decrease in oxygen levels.

This is an issue with either the design of theworkplace or the way a particular job isbeing done, and a recommendation mustaddress how the ventilation will beimproved.

8.4 Unprotected height: work was being donein a location where tie-off to a fall arrestsystem was not possible and other means ofprotection, such as guardrails or nets were notpresent.

This issue is limited to situations where fallprotection is not present. Where fallprotection is available & not used, see:Column 1 – Did Not Follow ExistingProcedures; or Column 13 – Behaviors. If

this cause is used, a recommendation must





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address how fall protection will be provided.

8.5 Workplace displays: displays used to

provide information to workers did not givenecessary information to the worker.Examples would include labels which were notreadable, warning lights that were burnt out,mislabeled equip or chemicals, or inaccurateprocess info. or alarms.

A recommendation addressing the cause

must cover how the information flow to theworker will be improved.


Possible system causes

System causes are covered in the final two sections entitled: Personal Factors and JobFactors. Personal Factors are internal to the individual. Job Factors relate to theorganizational issues where the work is being done.

Personal factors

There are six categories of personal factors, with an additional level of detail under each ofthe major categories.

9. Physical capabilities

Note: Capabilities refer to a permanent issue with this person.

9.1 Vision deficiency: an existing visiondeficiency affected the person‟s ability toperform their job. This could include colourblindness or an uncorrected vision problemsuch as cataracts.

As this cause represents a permanentcondition, the recommendation for thiscause must address either a permanent jobre-design or a strategy to move the personto another job which can accommodate theirlimitation.

9.2 Hearing deficiency: an existing hearingdeficiency affected the person‟s ability toperform their job. This could includepermanent hearing loss up to deafness.

See above.

9.3 Other sensory deficiency: an existingdeficiency, in taste, touch or smell, affected ona person‟s ability to perform their job.

See above.

9.4 Other permanent physical disabilities: allother permanent physical disabilities whichaffected a person‟s ability to perform their job.Examples would include restriction of range of

motion, inability to maintain proper workposture, lifting restrictions or reduced

See above.





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respiratory capacity.

9.5 Substance sensitivities or allergies: an

existing sensitivity or allergy affected aperson‟s ability to do their job. This couldinclude allergies to bee stings or someonediagnosed with multiple chemical sensitivity.

See above.

9.6 Size or strength limitations: the personassigned to the work did not have the size orstrength to complete the task safely, forexample, couldn‟t reach, couldn‟t lift.

See above.

9.7 Other: must define. The use of „other‟ without comment or

explanation has no value to yourinvestigation.

10. Physical condition

10.1 Previous injury or illness: the personassigned to the work had a previous injury orillness that affected their ability to performtheir job. This previous injury or illness can beeither work related or not work related and theinjury or illness may or may not have beenreported to us.

If the previous injury or illness was known tous, then this is a procedural issue & therecommendation must address why theperson was still assigned to that work. If theinjury or illness was not reported, that is abehavioral issue & the recommendationmust address why it wasn‟t reported.

10.2 Fatigue: the person involved in theincident was fatigued due to high workload orto lack of rest. This cause can include workschedules of extended hours on a given day,numerous overtime shifts in a row, ornumerous days of work without a day off.Fatigue may also be present with normal workhours and a failure to rest adequately while offduty.

The investigation needs to determine if thisis a procedural issue, a training issue or abehavioral issue and then verify therecommendation fits the conclusion.

10.3 Diminished performance: thesurroundings or work site conditions led toless than normal performance. This can bedue to temperature or humidity extremes, lackof oxygen due to high elevations, oratmospheric pressure changes, such asencountered during diving work.

The presence of such factors should beidentified and controlled through a riskassessment. If the risk assessment did notidentify or effectively control these hazards,then the recommendation must addresshow this will be better managed.

10.4 Impairment due to drug, alcohol ormedication: at the time of the incident, theperson‟s performance was affected by drugs,

alcohol or medications.

This is usually a behavioral issue and therecommendation must address that. Thiscan also be a training issue if the person is

unaware of the side effects of certain





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medications.



11. Mental capability

Note: Capabilities refer to a permanent issue with this person.

11.1 Memory failure: the person‟s jobperformance was affected by their inability toremember or recall information necessary tocomplete the work.

Use of this cause should be limited to workthat is expected to be done from memory, &not for situations where the work should bedone with written procedures or checklists.The cause also assumes the person was

adequately trained.

11.2 Poor co-ordination or reaction time: theper son‟s job performance was affected bytheir inability to co-ordinate all the requiredactions or their reaction time was too long.

This cause will usually require some jobredesign. In some situations, it may bepossible to address this cause with trainingto build this capability.

11.3 Emotional status: the person‟s jobperformance was impacted by their emotionalstatus. This can include post traumatic stresssituations or flashbacks.

The use of this cause requires medicalevidence. This cause is usually addressedwith job placement. There may be limitedtraining opportunities to build better coping

skills.

11.4 Fears or phobias: the person‟s jobperformance was affected by an existing fearor phobia, for example, someone who is afraidof working at heights, or climbing ladders orwho is claustrophobic.

If the fear or phobia was known, this is aprocedural issue as to why the person wasassigned such work. If the fear or phobiawas not known, then it is a behavioral issue.

11.5 Low mechanical aptitude: the person‟s job performance was affected because theydid not understand basic elements of how

mechanical things work.

This is a training issue and therecommendation must address how thisaptitude will be improved.

11.6 Low learning aptitude: the person‟s jobperformance was affected because they didnot comprehend standard training materialswhich have been verified as adequate.

This is a training issue and therecommendation must address howadditional or enhanced training will beprovided. (Poor learning due to languageissues are in columns 15 or 23.)

11.7 Incorrect judgment: a person‟s jobperformance was affected by their inability tomake an appropriate judgment when

confronted by an ambiguous situation.

This cause is only appropriate when judgment is required. When an instruction ispresent which dictates a person‟s actions, &

the person does not execute to thatinstruction, that is a violation, not a





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judgment. The recommendation for thiscause is difficult – teaching better judgmentis not easy.


12. Mental stress

Note: Capabilities refer to a permanent issue with this person

12.1 Preoccupation with problems: theperson‟s job performance was affectedbecause they were preoccupied with problems

and were not fully concentrating on theactivities in progress.

This is a behavioral situation and requires abehavioral solution. An A-B-C analysis canbe used to help understand the factors

underlying the behavior.

12.2 Frustration: the person‟s job performancewas affected by high levels of frustration,which led to the person acting inappropriately.

See above.

12.3 Confusing directions/demands: theperson‟s job performance was affected byinconsistent directions, instructions ordemands. Examples would include procedures

that do not match the existing equipment, alack of priority to assigned work or too manypeople giving instructions.

This cause is usually an issue ofprocedures and a proper recommendationwill address how the procedures and/orinstructions will be modified to eliminate

confusion.

12.4 Conflicting directions/demands: theperson‟s job performance was affectedbecause two or more directions, instructions ordemands were in conflict, making complianceimpossible.

This cause is usually an issue ofprocedures and a proper recommendationwill address how the procedures and/orinstructions will be modified to eliminate theconflict.

12.5 Extreme decision demands: the work

being done required decision making underhigh stress, leading to an incorrect decision.Examples would include time sensitivedecisions, incomplete information on which tobase the decision, or dangerous situations.

This cause is best addressed by a

recommendation that clarifies the inputsinto the decision or reduces the stressaround the decision process. Sophisticatedtraining involving simulations can also beused.

12.6 Unusual concentration or perceptiondemands: the work being done required greatconcentration, & the person lost situationalawareness.

This cause is best addressed by movingsuch work into a hazard free area or byproviding a spotter or watcher.

12.7 Other emotional overload: the person‟s job performance was affected by high stress

This is a behavioral situation and requires abehavioral solution. An A-B-C analysis can





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levels from either work or personal issues,leading to inappropriate actions.

be used to help understand the factorsunderlying the behavior.


13. Behaviour

Note: Investigators need to understand the behavior of those involved.

This is best done by performing a structured A-B-C Analysis.

13.1 Antecedent not present: antecedents arethe things present before a person behaves insome way. Examples include signage,

training, procedures and the expectations ofothers.

This cause is appropriate if the A-B-Canalysis indicates a needed antecedent wasnot present prior to the behavior. Proper

recommendation will specify whatantecedent is missing and how it will becreated in the work environment.

13.2 Antecedent not effective: a neededantecedent to the behaviour was present butdid not trigger the proper behaviour.

A proper recommendation will specify whatantecedent was inadequate & what needsto be done to strengthen that antecedent soit will trigger the proper behavior.

13.3 Incorrect behaviour reinforced: theperson performing a specific behaviourreceived a positive consequence for doing so. A positive consequence can be saving time oreffort, approval of co-workers or avoidingdiscomfort.

This cause is appropriate when the A-B-Canalysis indicates this consequence was animportant factor in the person‟s actions. Aproper recommendation will address howthis consequence can be minimized and/orhow other more powerful consequences forthe proper behavior can be implemented.

13.4 Incorrect behaviour not confronted: aperson‟s inappropriate behaviour was notconfronted or challenged by supervisors orpeers, and therefore there was no negativeconsequence to that behaviour.

This cause is appropriate when there wereopportunities to intervene, but people didnot do so. A proper recommendation willaddress how future interventions will bemore strongly encouraged.

13.5 Proper behaviour not rewarded: a personperforming a proper behaviour did not receiveany positive consequence for doing so,thereby reducing the motivation to continue toperform proper behaviours.

This cause is appropriate when an A-B-Canalysis indicated the lack of positiveconsequence was an important factor in theperson‟s actions. A proper recommendationwill address how positive consequences willbe made more frequently.

13.6 Behavioral analysis process not effective:there was no systematic use of A-B-C analysisto understand behaviours or to create better

antecedents and consequences to influence

This cause is appropriate only if there is noeffort in place. A proper recommendationwould address the need to understand and

utilize behavioral tools to improve safety.





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behaviours.



14. Skill level/competency

Note: Skill is the ability to execute a task a person has been trained to do.

Competency is the overall ability and capacity to perform.

14.1 Assessment of required skills orcompetency not effective: the personassigned to do the work had the skills andcompetency believed necessary to do so, but

in fact, the job required a person with a higherset of skills and competency.

This cause represents a procedural issue,with the quality of the job assessment. Aproper recommendation will addressimproving the assessment of required skills

and competency.

14.2 Practice of skill not effective: the personwas properly trained, but did not use the skillsenough to ever firmly establish the skill.

This is a training and certification issue, anda proper recommendation will address howthe verification of skill can be improved.

14.3 No coaching on skill: the person wasproperly trained, but did not have access to anexperienced person who could monitor andcoach their proper performance of that skill.

This is a training and certification issue, anda proper recommendation will address howadditional support will be made available toassure skills are properly developed.

14.4 Infrequent performance of skill: theperson was properly trained and verified tohave the appropriate skill level initially, but theskill was not used frequently enough tomaintain the skill.

This is a procedural issue. A properrecommendation will address theprocedures necessary to allow adequatepractice & periodically assess skill level. (arecommendation to retrain will not beeffective – it is practice that is needed.)


Job factors

There are nine categories of job factors, with an additional level of detail.

15. Training/knowledge transfer

Note: Training is used to increase knowledge on a specific issue.

15.1 No training provided: the person was nottrained in a specific subject. Examples caninclude not identifying necessary training,

reliance on out of date or inaccurate trainingrecords, a change in work methods or a

This cause is usually a procedural issue,although a conscious decision to foregotraining is a behavioral issue. Proper

recommendation will address a bettermeans to determine if training is required





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decision to forego training. and/or better records on which to base sucha decision.

15.2 Training effort not effective: some trainingwas conducted, but it did not accomplish thenecessary knowledge transfer, due to suchfactors as training program design, poorlydeveloped training objectives, inadequateorientation programs, inadequate initialtraining efforts or poor means to determine ifstudents have indeed mastered the materialbeing taught.

This is a training issue & should identify thespecific shortcoming. A properrecommendation must address how thetraining program in question will beimproved before it is offered to additionalpeople.

15.3 Knowledge transfer not effective: a welldeveloped training effort was in place, but did

not transfer the necessary knowledge, due tosuch factors as the inability of students tocomprehend (material beyond their level,language difficulties), inadequate instructorqualifications, inadequate training equipment(lack of props or means to illustrate the topic)or misunderstood directions on the part of thestudents.

This is a training issue and should identifythe specific shortcoming. A proper

recommendation must address how thetraining program in question will beenhanced or how the prerequisites for theclass will be modified before it is offered toadditional people.

15.4 Training materials not recalled: a welldeveloped training effort was successful in

transferring the necessary knowledge, butstudents did not recall the material whenneeded. This could be the result of training notbeing reinforced on the job, or an inadequateretraining frequency.

This is a procedural issue and a properrecommendation will address how additional

reinforcements or reminders will beprovided or how the retraining frequency willbe adjusted.


16. Management/supervision/employee leadership

Note: Can apply to all levels of management / supervision. Peer or co-worker issues shouldbe addressed in Column 13.

16.1 Behaviors not reinforced: the leaders inan area did not demonstrate appropriatepersonal behaviours with respect to their rolein understanding the safety behaviours ofothers and responding to both positive andinappropriate behaviour.

This is a behavioral situation & requires abehavioral solution. An A-B-C analysis canbe used to help understand the factorsunderlying the leaders‟ behavior. Properrecommendation needs to address theissues which are driving the leader s‟personal behavior.





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16.2 Participation in safety efforts not effective:the leaders in an area did not demonstrateappropriate personal behaviours with respect

to their role in visibly participating & leadingsafety activities. Would also include notfostering widespread workforce involvement insafety efforts.

See above.

16.3 Consideration of safety in staffing noteffective: the leaders in an area did notdemonstrate appropriate personal behaviourswith respect to their role considering safetybehaviours & performance when makingdecisions to recruit, select, develop, reward &advance people & when selecting &influencing contractors & partners.

See above.

16.4 Resourcing for safety not effective: theleaders in an area did not demonstrateappropriate personal behaviours with respectto their role in providing adequate financial &human resources to deliver safetyperformance.

See above.

16.5 Support of people not effective: theleaders in an area did not demonstrateappropriate personal behaviours with respectto their role in seeking out & supporting thoseindividuals who identify & speak out aboutsafety issues & concerns, or those peopleaffected by an incident.

See above.

16.6 Monitoring/auditing of safety process noteffective: the leaders in an area did notdemonstrate appropriate personal behaviourswith respect to their role in monitoring orauditing the effectiveness of the safety

management system using rigorous processesand metrics.

See above.

16.7 Lessons learned not embedded: previousinvestigations had identified a lesson to belearned, but that learning was not effectivelyembedded with the workforce.

This cause could be the result of a numberof different issues and the investigationwould need to explore the reasons why thelessons were not embedded.





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16.8 Leadership or accountability: the leadersin an area did not set the right direction or tonefor safety or allowed roles and responsibilities

for safety activities to be unclear or undefined.

This is a behavioral situation & requires abehavioral solution. An A-B-C analysis canbe used to help understand the factors

underlying the leaders‟ behavior. Properrecommendation needs to address theissues which are driving the leaders‟personal behavior.

16.9 Employee involvement not effective: theleaders in an area did not obtain sufficientemployee involvement to foster safetyawareness. This can include failing to involveappropriate staff in reviewing procedures orfailing to involve operators in PHA‟s.

This is a behavioral situation and requires abehavioral solution. An A-B-C analysis canbe used to help understand the factorsunderlying the behavior.

16.10 Risk analysis or tolerance not effective:the leaders in an area did not fully understandthe level of risk present or had a tolerance foran unacceptable level of risk.

This can be either a training or a behavioralissue. If the risk is not understood, trainingwould be an appropriate recommendation.If risk acceptance is the issue, an A-B-Canalysis might be helpful.


17. Contractor Selection and Oversight

17.1 No contractor pre-qualification process:there was no standard contractor pre-qualification process to assess the capabilityof a contractor company prior to hiring thatfirm.

This is a procedural issue, and a properrecommendation would address the need toenhance the local safety managementsystem to include such a process.

17.2 Contractor pre-qualification process noteffective: a pre-qualification process was inplace and utilized, but it did not identify

relevant deficiencies in the contractor‟scapabilities.

This is a procedural issue and a properrecommendation would address the neededimprovements in the pre-qualification

process.

17.3 Use of a non-approved contractor: acontractor firm who did not meet pre-qualification requirements or criteria was hiredto perform work.

This cause could be the result of a numberof different issues & the investigation wouldneed to explore the reasoning behind thisdecision.

17.4 Contractor selection not effective: theselection of a contractor was made without allrelevant data, or without proper consideration

of safety capabilities of the contractor for thiswork.

This is a procedural issue and a properrecommendation would address the neededimprovements in the pre-qualification

process.





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17.5 No job oversight process: no processwas in place to monitor or inspect a contractorfirm‟s work to identify deficiencies in methods

or performance.

This is a procedural issue, and a properrecommendation would address the need toenhance the local safety management

system to include such a process.

17.6 Job oversight not effective: a processwas in place to monitor or inspect a contractorfirm‟s work, but deficiencies in methods orperformance were not identified or corrected.

This is a procedural issue and a properrecommendation would address the neededimprovements in the job oversight process.

17.7 Other: must define The use of „other‟ without comment orexplanation has no value to yourinvestigation.

18. Engineering/design

Note: This category refers to the design of our facilities.

18.1 Technical design not correct: the designof the facilities involved in the incident was notsuitable for the intended use. (Note this doesnot cover misuse or facilities which havedeteriorated.) Examples would includeinappropriate metallurgy for the intendedservice or incorrect support for the intendedload. This would also include designs which

were not risk assessed, where management ofchange was not followed, or where inherentlysafer design issues were not considered.

This cause is not typically a root cause andthe investigator will need to determine howthis occurred. For example, this could be atraining/skills issue with the designer, or acalculation error not discovered in thereview process.

18.2 Design standards, specifications orcriteria not correct: the information available tothe designer was not suitable for use.Examples would include information that waswrong, incomplete or not understandable.

This cause is not typically a root cause &the investigator will need to determine howthis occurred. For example, the issue mightbe why the information provider did notunderstand what was needed, or the issuemight be why the designer did not recognizethe deficiency.

18.3 Incorrect ergonomic or human factordesign: the facilities where the event occurredwere not designed in an ergonomically correctway. Examples would include work areaslocated too high or low or valves out of normalreach, or poor allocation of function betweenpersons & systems.

A proper recommendation will be specific inwhat piece of equipment is not proper andwhat should be done to address the issue.

18.4 Monitoring of construction not effective:design specifications & criteria were proper,

but the facility was not constructed inaccordance with the design.

This cause can be either procedural (if noone was assigned to monitor the

construction) or behavioral (if someone wasassigned but did not do so.)





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18.5 Assessment of operational readiness noteffective: the procedure for handover fromconstruction to operation did not exist, was not

correct or was not followed. Examples wouldinclude operational readiness or pre-startupreviews.

This cause can be either procedural (if noone was assigned to perform theassessment) or behavioral (if someone was

assigned but did not do so.)

18.6 Monitoring of initial operation noteffective: the procedure to monitor the initialstart-up of equipment to assure properfunctioning did not exist, was not correct orwas not followed.

This cause can be either procedural (if noone was assigned to monitor the initialoperation) or behavioral (if someone wasassigned but did not do so.)

18.7 Technical analysis for risk not effective:

the design of a plant or equipment was notproperly risk assessed, or the design did nottake into account and mitigate a high risklevel. This would include a failure to performappropriate PHSER, HAZOP or LOPAanalysis.

This cause can be either a procedural issue

or a violation, depending on theexpectations in place.


19. Control of Work (CoW)

19.1 No work planning or risk assessmentperformed: the work being done was notplanned or was not risk assessed prior tostarting that work.

Assuming this requirement is in place, thefailure to perform planning or a riskassessment is a behavioral issue. An A-B-Canalysis can help determine why thisundesired behavior exists.

19.2 Risk assessment not effective: the workbeing done was risk assessed, but that riskassessment did not identify all the hazards

present, or the controls specified did notprotect the people doing the work.

This is likely a training issue, if the persondoing the risk assessment did not haveappropriate knowledge to complete an

acceptable assessment. A properrecommendation will address this trainingdeficiency.

19.3 Required permit not obtained: the type ofwork being performed required a writtenpermit, but a permit was not obtained.

Investigation will need to determine if thiswas due to lack of procedures, lack ofknowledge or a failure to follow CoWinstructions.

19.4 Specified controls not followed: thepeople performing the work were informed of

the controls necessary to mitigate the hazardspresent, but did not follow those controls.

This is likely a behavioral issue and an A-B-C analysis can be used to help understand

why the undesired behavior was present.





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19.5 Change in job scope: as the workprogressed, there was a change in job scopebeyond what was risk assessed & authorized,

but the work was not stopped until a riskassessment could be redone.

This is likely a behavioral issue and an A-B-C analysis can be used to help understandwhy the undesired behavior was present.

19.6 Worksite not left safe: work wascompleted or interrupted, but one or morehazards were not completely controlled oreliminated.

This is likely a behavioral issue and an A-B-C analysis can be used to help understandwhy the undesired behavior was present.


20. Purchasing, material handling and material control

20.1 Incorrect item ordered: the incorrect itemwas unintentionally ordered. Reasons for thiscan include incorrect specifications tovendors, inaccurate information on therequisition, or inadequate control on who canmodify orders.

This can be either procedural or behavioral.Investigation must understand what led tothe incorrect order. If procedural, therecommendation should address how theprocedure will be modified. If behavioral,then an A-B-C analysis may be helpful.

20.2 Incorrect item received: the correct item

was ordered, but an incorrect item received.Reasons can include unauthorizedsubstitution by vendor, inadequate productacceptance procedures or a failure to verifyreceipt of proper goods.

This cause can be either procedural (if no

one was assigned to verify proper receipt)or behavioral (if someone was assigned butdid not do so).

20.3 Handling or shipping not effective: thematerials were damaged in the handling orshipping.

This cause can be either procedural orbehavioral. Investigation must understandwhat led to incorrect handling or shipping. Ifprocedural, the recommendation shouldaddress how the procedure will be modified.

If behavioral, then an A-B-C analysis maybe helpful.

20.5 Labeling of materials not effective: thematerials were not labeled or identifiedcorrectly, allowing a wrong selection or notproviding relevant health & safety information.

This cause is usually procedural, & therecommendation must address howimproved labeling will be done.


21. Tools and plant/equipment





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21.1 Wrong tools or plant/equipment provided:the tools and equipment provided werethought to be right, but proved to be the wrong

tools or equipment, because the riskassociated with their use was incorrectlyassessed.

Incorrect risk assessment is either a trainingor behavioral issue & investigation willdetermine which it is. If training, a

recommendation should address theadditional training. If behavioral, an A-B-Canalysis should help.

21.2 Correct tools or plant/equipment notavailable: the needed tools or equipment werenot available at the job site, either becausethey were never supplied, or wereinaccessible.

Procedural issue. A properrecommendation will address how theproper gear will be provided in the future. Ifpeople knowingly used the wrong tools orequipment, see Column 2.

21.3 No inspection: the tools and equipment

were not inspected prior to use, and a defectwas not identified before use.

If a procedure is in place & the people have

adequate training & skill, the failure toinspect is a behavioral issue. If aninspection was done & the defect was notdetected, this may be training issue.

21.4 Incorrect adjustment/repair/ maintenance:the proper tools and equipment wereavailable, but had not been correctlymaintained or repaired when last serviced.

Either a training or behavioral issue,depending whether the person performingthe service knew what was required toservice the tools or equip. Properrecommendation will address either thetraining deficiency or the undesiredbehaviour.

21.5 Removal or replacement of unsuitableitems not effective: items that were no longerserviceable remained in use.

Either a training or behavioral issue,depending whether the person couldrecognize that the tool or equipment was nolonger serviceable. A properrecommendation will address either thetraining deficiency or the undesiredbehaviour.

21.6 No preventative maintenance program:

the tools or equipment involved in the incidentwere not covered by a preventativemaintenance program, and becameunserviceable.

This is a procedural issue & a proper

recommendation will address the need toestablish a routine maintenance plan forthis tool or equipment.

21.7 Testing of plant, tools or equip notperformed Tools/equip were not properlytested or evaluated for fitness for use. Thiscan include failure to inspect plant equip formechanical integrity or evaluate the electricalintegrity of a power tool.

This can be a procedural issue or aviolation depending on whether the properexpectations were in place.






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22. Standards/Practices/Procedures (SPP)

Note: SPP covers any written document which instructs people what the expectations are inperforming work. These can be very general, like a Golden Rule, or very specific, like a startup procedure for a unique process.

22.1 Lack of SPP for the task: there were nowritten SPP covering the work beingperformed at the time of the incident, due tosuch factors as the failure to assignresponsibility for the development of SPP, orthe failure to recognize the need for standardinstructions for this task.

If the need was not recognized, this is anissue with risk assessment & additionaltraining may be necessary. If the need wasidentified, then the failure to develop SPP isa behavioral issue. An A-B-C analysis mightbe helpful. A proper recommendation willaddress these issues.

22.2 Development of SPP not effective: therewere some SPP in place, but the SPP thatwere developed did not fully meet needs of thework, due to such factors as inadequate co-ordination with design efforts, havingunknowledgeable people developing the SPP,not identifying the proper steps to take inproblem situations or a poor format that madeSPP difficult to use.

At the surface, this is a procedural issueand a recommendation needs to addresswhat needs to be done to improve the SPP. A deeper issue is why the procedure wasnot right, which may be a training orbehavioral issue. Your investigation willneed to determine why and then address itwith a proper recommendation.

22.3 Communication of SPP not effective:there was an appropriate SPP in place, but ithad not been properly communicated, due tosuch factors as incomplete distribution,language difficulties, incomplete integrationwith training efforts or out of date SPP still inuse.

This is a procedural issue and yourinvestigation will need to determine what isneeded to make the communicationsufficiently effective, accurate and reliable.

22.4 Implementation of SPP not effective:there were SPP in place, but theimplementations of the SPP were not

complete, due to such factors as contradictoryrequirements, confusing formats, inaccuratesequence of steps, technical errors,incomplete instructions, etc.

At the surface, this is a procedural issue & arecommendation needs to address whatneeds to be done to improve the SPP. A

deeper issue is why the procedure was notfully implemented, which may be a trainingor behavioral issue. Your investigation willneed to determine why & then address itwith a proper recommendation.

22.5 Enforcement of SPP not effective: wellcrafted SPP were in place, but their use wasnot properly enforced to the extent necessary,due to such factors as inadequate monitoringof the work being done, or inadequate

supervisory knowledge of what was to bedone.

A behavioral issue, both for the employeesusing the SPP and the supervisorsresponsible for the work. An A-B-C analysismight be helpful in understanding theundesired behavior.





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23. Communication

Note: Can be written or verbal.

23.1 Horizontal communication between peersnot effective: the people involved in theincident did not communicate importantinformation between peers and colleagues.

This is a behavioral issue & you will need tounderstand why the information was notcommunicated. An A-B-C analysis might behelpful. The recommendation will need toaddress how this behavior will beencouraged in the future.

23.2 Vertical communication betweensupervisor and person not effective: theperson & supervisor involved in the incidentdid not communicate important information.This missing communication can be in eitherdirection.

See above.

23.3 Communication between differentorganizations not effective: individuals in twodifferent organizations did not communicateimportant information. For example:

operations & maintenance, supplier &purchaser, host employer & contractor, orengineers & operators.

See above.

23.4 Communication between work groups noteffective: individuals in two different workgroups, working on the same task, did notcommunicate important information.

See above.

23.5 Communication between shifts noteffective: the people involved in making the

handover from one shift to the next did notfully communicate all necessary informationabout current work activities.

See above.

23.6 Communication not received: theindividuals involved in the incident attemptedto communicate, but the information did notreach the intended person. Examples couldinclude a note that got lost, an email that wasmisdirected or a phone message not retrieved.

This is likely a procedural issue and yourinvestigation will need to determine why thecommunication was not received. A properrecommendation will address howcommunications will be made more reliable.

23.7 Incorrect information: the person involvedin the incident was given information, but that

This is likely a knowledge issue, especiallyif the person did not recognize the





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information proved to be incorrect. information was incorrect. Yourinvestigation will need to determine why theincorrect information was communicated &a proper recommendation will address

training needs.

23.8 Information not understood: the peopleinvolved in the incident did communicate withone another, but the information conveyedwas not understood.

The investigation will need to determinewhy the information was not understood. Aproper recommendation will address howthe communication will be improved – forexample – verification techniques, simplerlanguage, written versus verbal.

23.9 Other: must define. The use of „other‟ without comment orexplanation has no value to your

investigation.




An Overview

Documents

Inident Investigation Root Cause Analysis