Phenomena 4M Why-Why Analysis Check Education Engineering Enforcement Environment

. Excavation Why 1 Why 2 Why 3 Why 4 Why 5

for trench MAN:
cutting for
JCB operator was not He was not Supervisor did Supervisor was NG To institute a Supervisor is
Cable laying
knowing about the aware about not informed not present at system for must during
was done by
cable the electrical about the the site. proper job mechanized
JCB. During
cable cable supervision excavation
excavation
(written
one HT cable
procedure on
out sheath got
job supervision,
damaged. handing over
during change
of supervisor)

MACHINE:
Cable was not Cable route NG Cable route to
detected in GIS drawing was be incorporated
clearance. not there for in the existing
the location in GIS
GIS.

METHOD:
GIS clearance was GIS was filled Officer was NG Training to all
available but in the wrong not aware of officers engaged
notapproved in format. two different in the Trench
systematic way. formats of GIS clearance.
clearance
Approvers did NG Communication
not notice the to the
location of the approvers to be
job. made.
MANAGEMENT:
No supervisor was Supervisor NG Supervisor is
present at site during who was must during
mechanized knowing that mechanized
excavation cable was excavation
present was
absent
Another Communicatio NG Roles &
supervisor n gap Responsibility
who was between the training is to be
supposed to supervisors provided.
be present was
not knowing
about the
cable