ROOT CAUSE ANALYSIS TECHNIQUE

REPORT THE INCIDENT

STEP 1

Determine the Type of Incident (What Happened?)

1.6 1.7
1.1 1.2 1.3 1.4 1.5 1.8 1.9 1.10 1.11
Human Resources Industry Specific
Accident Crime Environmental Impact Equipment Failure Financial Occurrence Incident Natural Event Non-Conformance Product Interruption Resource Wastage

1 Collision 1 Fraud 1 Esthetical 1 Component 1 Exchange Rates 1 Disputes 1 Trucking and 1 Earthquake 1 Legal 1 Raw Material 1 Logistical
2 Explosion 2 Hijacking 2 Impact 2 Structural 2 Interest Rate 2 Go Slow / Work Tramming 2 Flooding 2 Quality 2 Supply Failure 2 Other
3 Fire 3 Industrial 3 Pollution 3 Other 3 Fluctuation to Rules 2 Seismic Event 3 Hurricane / 3 Other 3 Utility Failure
4 Hazardous 4 Espionage 4 Spillage 4 Market Changes 3 Social Demands 3 Process Deviation Cyclone 4 Other
Substance Release 5 Erosion 5 Commodity 4 Strikes 4 Other 4 Lightning
5 Sabotage /
5 Occupational Vandalism 6 Emission Prices 5 Other 5 Wind
6 Other 6 Theft 7 Other 6 Stock Prices 6 Other
7 Violent Crime 7 Other
8 Other
 ROOT CAUSE ANALYSIS TECHNIQUE
STEP 2
LOSSES

Identify all Consequences / Losses Resulting from the Incident / Event (What were the Consequences)

1. Damages 5. Asset Loss 9. Financial Loss 12. Loss of Market Loss

2. Illness 6. Civil Loss 10. Image / Reputation Loss 13. Other

3. Injury 7. Criminal Liability 11. Substandard Quality

4. Production Loss 8. Vicarious Liability Product / Service

 ROOT CAUSE ANALYSIS TECHNIQUE

STEP 3
INCIDENT / EVENT

For each incident that was due to exposure to / contact with a source of energy or with a substance, identify the way in which the contact occurred as well as the agency
(primary item / substance inflicting the injury, damage etc.)

3.1 3.2 3.3

Type of Contact General Agency Occupational Hygiene Agency
1 Caught between or under 7 Fall on Same Level (slip and 1 Aircraft 10 Fall of Ground 18 Material / Goods 25 Power Tools 29 Sharp Edge 1 Biological 10 Noise
(crushed or amputated) fall, trip over) 11 Fire 19 Machinery 30 Surface 2 Chemical 11 Psychological
2 Animals / Insects / 26 Pressure Positive /
2 Caught In (pinch and nip People 12 Fixed Walkway 20 Metal - Cold Negative 31 Transport 3 Cold 12 Radiation
8 Handling (lifting, pushing,
points) pulling) 3 Building / Structure 13 Hand Tools 21 Metal - Hot 27 Projectile 4 Dust 13 Smoke
32 Trucking /
3 Contact On (snagged, hung) 4 Compressed Air 14 Installation 22 Motor Vehicles 28 Rolling Stock Tramming 5 Ergonomical 14 Vapors
9 Over Stress (over exertion, 5 Container 15 Locomotive 33 Trackless Machines 6 Fumes 15 Vibration
overload, overexposure, 23 Natural
4 Contact With (electricity, ergonomic) 6 Expired Product 16 Ladder / Stairs Phenomenon 34 Vessels 7 Gasses 16 Other
heat, cold, radiation,
chemical, noise) 10 Stuck Against (running or 7 Equipment 17 Lifting Equipment 24 Obstruction 35 Other 8 Heat
5 Drowning (inundation) bumping into) 8 Electricity 9 Illumination
6 Fall from Elevation to 11 Struck By (hit by moving 9 Explosive devise
Lower Level object)
12 Other
 ROOT CAUSE ANALYSIS TECHNIQUE
STEP 4

For each incident that was due to exposure to / contact with a source of energy or with a substance, identify the way in which the contact occurred as well as the agency
(primary item / substance inflicting the injury, damage etc.)

IDENTIFY RISK / LOSS POTENTIAL USING RISK ASSESSMENT MATRIX

CONSEQUENCE / SEVERITY
1 - 10K 10 - 100k 100k - 1m 1 - 10m >10m
Minor Injury Temporary Permanent Fatality Multiple
LIKELIHOOD OF RECURRENCE Disability Disability Fatalities
OF EVENT
Low Minor Moderate Major Critical
5 4 3 2 1
1 or more times per Almost RISK LEVEL INVESTIGATION REQUIREMENTS
Moderate High Extreme Extreme Extreme
week Certain
LOW RISK PRELIMINARY INVESTIGATION SUPERVISOR
Occurs once per
Likely Moderate High High Extreme Extreme
month
MODERATE RISK CAUSAL INVESTIGATION LINE MANGER
Occurs once per year Possible Low Moderate High Extreme Extreme
HIGH RISK RCAT INVESTIGATION MIDDLE / SENIOR MANAGEMENT
Occurs once every 10
Unlikely Low Low Moderate High Extreme
years
EXTREME RISK RCAT INVESTIGATION SENIOR MANAGEMENT / MD
Occurs once in a life
Rare Low Low Low Moderate High
time / 100 years

GATHER INCIDENT INFORMATION / EVIDENCE (FACTS)

"WHO" - PEOPLE EVIDENCE
• Witnesses are not limited to eyewitnesses
• Witnesses may be fearful or ill at ease
• Do not lead the witness or force answers
• Do not argue with or refute the witness
"WHERE" - POSITION EVIDENCE
• Accuracy of information is critical
• Record locations of all principal elements
• Use drawings, mapping, photography, video as needed
• Keep accurate photo logs
"WHAT" - PARTS EVIDENCE
• Some overlap with position evidence
• Chain of custody considerations
• Can be liquids or gasses, not just solids
• Must be protected to avoid contamination or further
damage
• Undamaged parts may tell as much as damaged parts
• Some physical evidence will require scientific
interpretation

"WRITTEN" - PAPER EVIDENCE "HOW" - PROCESS EVIDENCE

• Potentially the most durable evidence
• Can directly reveal underlying causes
• Indentify process (production) conditions
• Indentify where normal parameters were not met
• Identify Abnormalities
• Identify the physical environment, and especially sudden changes to that environment, is factors that need to be identified. The situation at
the time of the accident is what is important, not what the "usual" conditions were.

SUB STANDARD ACTS / "AT RISK" BEHAVIOR
IDENTIFY THE POSSIBLE INDIVIDUAL OR TEAM ACTIONS THAT CONTRIBUTED TO THE INCIDENT
1 2
Following Procedures /
Practices / Rules /
Standards
1 Deviation by Individual
2 Deviation by Group
3 Deviation by Supervisor
4 Operation of equipment
without authority
5 Improper position or
posture for task
6 Overexertion of physical
capability
7 Work or motion at
improper speed
8 Improper lifting
9 Improper loading
10 Shortcuts
11 Other
Use of Tools or
Use of Protective Methods
Equipment
1 Improper use of
equipment
2 Improper use of tools
3 Use of defective
equipment (aware)
4 Use of defective tools
(aware)
5 Improper placement of
tools, equipment or
materials
6 Operation of equipment
at improper speed
7 Servicing of equipment
in operation
8 Other
Was this immediate cause identified in a risk assessment? YES NO
ROOT CAUSE ANALYSIS TECHNIQUE
STEP 5
IMMEDIATE
CAUSES
SUB STANDARD CONDITION / "AT RISK" CONDITION
IDENTIFY THE IMMEDIATE CAUSES
IDENTIFY THE POSSIBLE CONDITION THAT CONTRIBUTED TO THE INCIDENT
3 4 5 6 7 8
Inattention / Lack of Transportation, Work Place Environment /
Protective System Work Exposures To
Awareness Equipment & Tools Layout
1 Lack of knowledge of 1 Improper decision 1 Inadequate guards or 1 Defective vehicles, 1 Fire or explosion 1 Congestion or restricted
hazards present making or lack of protective devices vessels, aircraft and motion
judgement rolling stock 2 Noise
2 PPE not used 2 Defective guards or 3 Energized electrical 2 Inadequate or excessive
protective devices system illumination
3 Improper use of PPE 2 Distracted by other 2 Inadequate vehicles,
4 Servicing of energized activities 3 Inadequate PPE vessels, aircraft and 4 Energized systems, other 3 Inadequate ventilation
equipment rolling stock than electrical
3 Inattention to footing 4 Defective PPE 4 Unprotected height
5 Equipment or materials and surroundings 5 Inadequate warning 3 Improperly prepared 5 Radiation 5 Inadequate work place
not secured systems vehicles, aircrafts and layout
4 Horseplay 6 Defective warning rolling stock 6 Temperature extremes
6 Disabled guards, warning 5 Acts of violence systems 7 Hazardous Chemicals • Demarcation
systems or safety devices inadequate
6 Failure to warn / make 7 Inadequate isolation of 4 Defective equipment 8 Mechanical hazards
7 Removal of guards, safe process or equipment 5 Inadequate equipment 9 Clutter or debris • Controls inadequate
warning systems or for the purpose
safety devices 7 Use of drugs or alcohol 8 Inadequate safety 10 Storms or acts of nature • Displays inadequate
8 Routine activity without devices 6 Improperly prepared 11 Slippery floors or • Labels inadequate
thought equipment walkways • Locations out of reach
8 PPE not available 9 Defective safety devices
or sight
9 Other 9 Other 10 Other 7 Defective tools 12 Other
8 Inadequate tools • Conflicting information
is presented
9 Improperly prepared
tools 6 Other
10 Other
Baseline Risk Assessment
Issued Based Risk Assessment
Continuous Risk Assessment
 ROOT CAUSE ANALYSIS TECHNIQUE
WHO STEP 6
ROOT CAUSES WHAT?
?

IDENTIFY THE ROOT (BASIC) CAUSES

WORKPLACE FACTORS Continued on next page

HUMAN FACTORS WHY? WORKPLACE FACTORS

IDENTIFY THE POSSIBLE HUMAN FACTORS THAT CONTRIBUTED TO THE IMMEDIATE Why was the sub-standard Why did the sub-standard IDENTIFY THE POSSIBLE WORKPLACE FACTORS THAT CONTRIBUTED TO THE
CAUSE act committed? hazardous condition exist? IMMEDIATE CAUSE

1 2
Inadequate Physical
Capability
1 Vision deficiency
2 Hearing deficiency
3 Other sensory deficiency
4 Reduced respiratory capacity
5 Other permanent physical
disabilities
6 Temporary disability
7 Inability to sustain body
positions
8 Restricted range of body
movement
9 Substance sensitivities or
allergies
10 Inadequate size or strength
11 Diminished capacity due to
medication
12
Diminished capacity due to
inadequate intake of
substance
13 Other
Inadequate Physical
Condition
1 Previous injury or illness
2 Fatigue
• due to workload
• due to lack of rest
• due to sensory overload
3 Diminished performance
• due to temperature
extremes
• due to oxygen deficiency
• due to atmospheric
pressure variation
4 Blood sugar insufficiency
5 Impairment due to drug or
alcohol use
6 Other
3 4
Inadequate Mental
State
1 Poor judgement
2 Memory Failure
3 Poor coordination or
reaction time
4 Emotional disturbance
5 Fears or phobias
6 Low mechanical aptitude
7 Low learning aptitude
8 Influenced by medication
9 Other
5 6
Mental Stress Behaviour Inadequate Skill
Level
1 Preoccupation with 1 Improper performance is 1 Inadequate assessment of
problems rewarding required skills
2 Frustration • saves time or effort 2 Inadequate practice of skill
3 Confusing directions / • avoids discomfort 3 Infrequent performance of
demands • gains attention skill
4 Conflicting directions / 2 Improper supervisory 4 Lack of coaching on skill
demands example 5 Insufficient review of
5 Meaningless or degrading 3 Inadequate identification of instruction to establish skill
activities critical safe behaviours 6 Other
6 Emotional Overload 4 Inadequate reinforcement of
7 Extreme judgement / critical safe behaviours
decision making
• proper performance is
8 Extreme concentration / criticized
perception demands • inappropriate peer pressure
9 Extreme boredom • inadequate performance
10 Other feedback
5 Inappropriate aggression
6 Improper use of production
incentives
7 Supervisor implied haste
8 Employee perceived haste
9 Habit / personal preference
10 Vandalism
11 Other

7 8
Inadequate Training /
Knowledge Transfer
1 Inadequate knowledge transfer
• inability to comprehend
• inadequate instructor
qualifications
• inadequate training equipment
• misunderstood instructions
2 Inadequate recall of training
material
• training not reinforced on the job
• inadequate refresher training
frequency
3 Inadequate training effort
• inadequate training program
design
• inadequate training goals /
objectives
• inadequate new employee
orientation
• inadequate initial training
• inadequate means to determine if
qualified for job
4 No training provided
• need for training not identified
• training records incorrect or out of
date
• new work methods introduced
without training
5 Other
Inadequate Management /
Supervision / Employee
Leadership
1 Conflicting roles / responsibilities
• unclear reporting relationships
• conflicting reporting relationships
• unclear assignment of
responsibility
• conflicting assignment of
responsibilities
• improper or insufficient
delegation of authority
2 Inadequate Leadership
• standard of performance missing
or not enforced
• inadequate accountability
• inadequate or incorrect
performance feedback
• inadequate work site walk-through 5 Inadequate ergonomic design
• inadequate safety promotion
3 Inadequate correction of prior
hazard / incident
4 Inadequate identification of
worksite / job hazards
5 Inadequate management of change
system
6 Inadequate incident reporting /
investigation systems
7 Inadequate or lack of safety
meetings
8 Inadequate performance
measurement and assessment
9 Other
9 • non-compliance not corrected
Inadequate Contractor Selection
& Oversight
1 Lack of contactor pre-qualifications
2 Inadequate contractor pre-
qualifications
3 Inadequate contractor selection
4 Use of non-approved contractor
5 Lack of job oversight
6 Inadequate oversight / supervision
7 Other
ROOT CAUSE ANALYSIS TECHNIQUE
IDENTIFY THE POSSIBLE WORKPLACE FACTORS THAT CONTRIBUTED TO THE IMMEDIATE CAUSE
10
Inadequate Engineering / Design Inadequate Work Planning /
Maintenance
1 Inadequate technical design
• design input obsolete
• design input not correct
• design input not available
• design output inadequate
• design input infeasible
• design output unclear
• design output not correct
• design output inconsistent
• no independent design review
2 No / inadequate Risk Assessment
3 Inadequate standards,
specifications, and/or design criteria
4 Inadequate assessment of potential
failure
6 Inadequate monitoring of
construction
7 Inadequate assessment of
operational readiness
8 Inadequate monitoring of initial
operation
9 Inadequate evaluation and/or
documentation of damage
10 Other
STEP 6
ROOT CAUSES
WORKPLACE FACTORS
11
1 Inadequate work planning
2 Inadequate preventive maintenance
• assessment of needs
• lubrication / servicing
• adjustment / assembly
• cleaning / resurfacing
3 Inadequate repair
• communication of needed repair
• scheduling of work
• examination of parts
• parts substitution
4 Excessive wear and tear
• inadequate planning for use
• extension of service life
• improper loading
• use by untrained people
• use for wrong purpose
5 Inadequate reference materials or
publications
6 Inadequate audit / inspection /
monitoring
• no documentation
• no correction responsibility
assigned
• no accountability for corrective
action
7 Inadequate job placement
• appropriate personnel not
identified
• appropriate personnel not
available
• appropriate personnel not
provided
8 Other
12
Inadequate Purchasing,
Inadequate work rules / policies
Material handling and material / standards / procedures (PSP)
control
1 Incorrect item received
• inadequate specifications to
vendor
• inadequate specifications on
requisition
• inadequate control on changes to
orders
• unauthorized substitution
• inadequate product acceptance
requirements
• no acceptance verification
performed
2 Inadequate research on materials /
equipment
3 Inadequate mode or route of
shipment
4 Improper handling of materials
5 improper storage of materials or
spare parts
6 Inadequate material packaging
7 Material shelf life exceeded
8 Improper identification of
hazardous materials
9 Improper salvage and / or waste
disposal
10 Inadequate use of safety and health
data
13
Inadequate Tools & Equipment
1 Inadequate assessment of needs
and risks
2 Inadequate human factors /
ergonomics consideration
3 Inadequate standards
4 Inadequate availability
5 Inadequate adjustment / repair /
maintenance
6 Inadequate salvage and reclamation
7 Inadequate removal / replacement
of unsuitable items
8 No equipment record history
9 Inadequate equipment record
history
10 Other
14
1 Lack of PSP for the task
• lack of defined responsibility for
PSP
• lack of critical task / job safety
analysis
• inadequate critical task / job
safety analysis
2 Inadequate development of PSP
• inadequate coordination with
process / equipment design
• inadequate employee
involvement in the development
• inadequate definition of
corrective actions
•inadequate format for easy use
3 Inadequate implementation of PSP,
due to deficiencies
• contradictory requirements
• confusing format
• more than one action per step
• no check-off spaces provided
• inaccurate sequence of steps
• confusing instructions
• technical error / missing steps
• excessive references
• potential situations not covered
4 Inadequate enforcement of PSP
• inadequate monitoring of work
• inadequate supervisory knowledge
• inadequate reinforcement
5 Inadequate communication of PSP
• incomplete distribution to work
groups
• inadequate translation to
appropriate languages
• incomplete integration with
training
• out of date revisions still in use
6 Inadequate task observation of PSP
7 Other
15
Inadequate Communication
1 Inadequate horizontal
communication between peers
2 Inadequate vertical communication
between supervisors and person
3 Inadequate communication
between different organizations
4 Inadequate communication
between work groups
5 Inadequate communication
between shifts
6 Inadequate communication methods
7 No communication method
8 available
Incorrect instructions
9 Inadequate communication due to
job turnover
10 Inadequate communication of
safety and health data, regulations
or guidelines
11 Standard terminology not used
12 Verification / repeat back
techniques not used
13 Messages too long
14 Speech interference
15 Cultural / ethnic communication
barriers
16 Other
 ROOT CAUSE ANALYSIS TECHNIQUE
STEP 7
INADEQUATE
SYSTEM CONTROL

IDENTIFY THE SYSTEM DEFICIENCIES THAT CONTRIBUTED TO THE EXISTENCE OF ROOT CAUSES

1 2 4 6 8 9 11 13

PLANNING & LEADERSHIP COMPETENCY, TRAINING & OPERATIONAL MANAGEMENT WORK PROCESSES AND OCCUPATIONAL HEALTH PERSONAL PROTECTIVE EMERGENCY PREPAREDNESS CORRECTIVE & PREVENTIVE
COMMUNICATIONS & DESIGN OPERATING PERMITS SYSTEMS EQUIPMENT ACTION SYSTEMS

1 Planning & Implementing
2 Resourcing
3 Management Commitment
4 Document & Data Control
5 Committees & Employee
Involvement
6 External Regulations &
Standards
7 External Relations
8 Management Reviews
1 Employee Orientations /
Awareness
2 Competency & Training needs
identified
3 Training program content &
delivery
4 Training program effectiveness
5 One-on-one communication
6 Group SHERQ Meetings
7 Program Promotions
1 Planning for product realisation 1 Organization permits and high 1 Occupational health 1 PPE Requirements 1 Emergency preparedness 1 Corrective & preventive action
2 Process related to interested risk work controls administration 2 PPE Availability administration process
parties 2 Externally required permits 2 Hazard recognition and 3 PPE Compliance 2 Emergency response plans 2 Corrective & preventive action
3 Design and development 3 Organisation SHERQ rule evaluation 3 Emergency response team communication
4 Production and service function program 3 Hazard control 4 Emergency equipment 3 Control of Non-Conforming
4 Occupational hygiene 5 Mutual Aid products
monitoring
5 Occupation medicine
6 Records

3 5 7 10 12
MANAGEMENT OF INCIDENT / NON-CONFORMITY MEASUREMENT, MONITORING
OPERATIONAL RISK AND PURCHASING SYSTEMS INSPECTIONS REPORTING, INVESTIGATION &
CHANGE ANALYSIS & AUDITS

1 Identifying operational risk
2 Operation analysis
3 Significant task identification &
analysis
4 Management of change
5 Task & operation controls
1 Equipment, materials and 1 Planned general inspections 1 Incident / Non-Conformity 1 Routine process measurements
suppliers 2 Specialised SHERQ equipment investigation process 2 System Audits
2 Contractors inspections 2 Middle & senior management
3 Mobile and material handling participation
equipment 3 Incident / Non-Conformity
4 Engineering maintenance analysis
systems 4 Record Keeping
5 Statutory compliance
6 Housekeeping inspections

REVIEW STATUS OF CURRENT / SYSTEM CONTROL ACTIVITIES

S: Are there system standards for this activity?

Yes or No
If No: Check and begin by developing system standards

STD: Are existing standards adequate?

Yes or No
If No: Check and develop adequate standards

C: Is there full compliance with standards?

Yes or No
If No: Check and develop means to ensure compliance