People Parts

Comprehensive List of Causes

A TOOL FOR ROOT CAUSE ANALYSIS
Solutions
DESCRIPTION OF IMPLEMENTATION & RESEARCH PHASES: ANALYSIS PHASE:
INCIDENT EVIDENCE GATHERING IDENTIFICATION OF CRITICAL FACTORS

• Document the type / severity of • Gather relevant evidence • Organise all evidence
event • Implementation phase = direct evidence (scene and witnesses) • Map evidence Positions Paper
• Cover the who / what / when / • Research phase = indirect evidence (written sources) • Identify critical factors
where / how as known at the time
• Consider People / Parts / Position / Paper • Use CLC to identify all immediate and root causes

POSSIBLE IMMEDIATE CAUSES

ACTIONS CONDITIONS
1. FollowingProcedures 2. Use of Tools or Equipment 3. Use of Protective Methods 4. Inattention / Lack of Awareness 5. Protective Systems 6. Tools, Equipment & Vehicles 7. Work Exposures to 8. Work Place Environment / Layout
1-1 Violation by individual 2-1 Improper use of equipment 3-1 Lack of knowledge of hazards present 4-1 Improper decision making or lack of judgment 5-1 Inadequate guards or protective devices 6-1 Defective equipment 7-1 Fire or explosion 8-1 Congestion or restricted motion
1-2 Violation by group 2-2 Improper use of tools 3-2 Personal protective equipment not used 4-2 Distracted by other concerns 5-2 Defective guards or protective devices 6-2 Inadequate equipment 7-2 Noise 8-2 Inadequate or excessive illumination
1-3 Violation by supervisor 2-3 Use of defective equipment (aware) 3-3 Improper use of proper personal protective 4-3 Inattention to footing and surroundings 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energized electrical systems 8-3 Inadequate ventilation
1-4 Operation of equipment without authority 2-4 Use of defective tools (aware) equipment 4-4 Horseplay 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energized systems, other than electrical 8-4 Unprotected height
1-5 Improper position or posture for the task 2-5 Improper placement of tools, equipment or 3-4 Servicing of energized equipment 4-5 Acts of violence 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate work place layout
1-6 Overexertion of physical capability materials 3-5 Equipment or materials not secured 4-6 Failure to warn 5-6 Defective warning systems 6-6 Improperly prepared tools 7-6 Temperature extremes • controls less than adequate
1-7 Work or motion at improper speed 2-6 Operation of equipment at improper speed 3-6 Disabled guards, warning systems or safety 4-7 Use of drugs or alcohol 5-7 Inadequate isolation of process or equipment 6-7 Defective vehicle 7-7 Hazardous chemicals • displays less than adequate
1-8 Improper lifting 2-7 Servicing of equipment in operation devices 4-8 Routine activity without thought 5-8 Inadequate safety devices 6-8 Inadequate vehicle for the purpose 7-8 Mechanical hazards • labels less than adequate
1-9 Improper loading 2-8 Other 3-7 Removal of guards, warning systems or safety 4-9 Other 5-9 Defective safety devices 6-9 Improperly prepared vehicle 7-9 Clutter or debris • locations out of reach or sight
1-10 Shortcuts devices 5-10 Other 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 3-8 Personal protective equipment not available 7-11 Slippery floors or walkways 8-6 Other
3-9 Other 7-12 Other

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS

1. Physical Capability 2. Physical 3. Mental State 4. Mental Stress 5. Behavior 6. Skill Level 7. Training / Knowledge 8. Management / 9. Contractor 10. Engineering / 11. Work Planning 12. Purchasing, Material 13. Tools & Equipment 14. Work Rules / Policies / 15. Communication
1-1 Vision deficiency Condition 3-1 Poor judgment 4-1 Preoccupation with 5-1 Improper performance 6-1 Inadequate Transfer Supervision / Employee Selection & Design 11--1
11 Inadequate work Handling & Material 13--1 Inadequate
13 Standards / Procedures (PSP) 15--1
15 Inadequate horizontal
1-2 Hearing deficiency 2-1 Previous injury or 3-2 Memory failure problems is rewarded assessment of 7-1 Inadequate knowledge Leadership Oversight 10--1 Inadequate technical
10 planning Control assessment of needs 14--1
14 Lack of PSP for the task communication
1-3 Other sensory illness 3-3 Poor coordination 4-2 Frustration • saves time or effort required skills transfer 8-1 Conflicting roles / 9-1 Lack of contractor design 11--2
11 Inadequate preventive 12--1
12 Incorrect item and risks •lack of defined responsibility between peers
deficiency 2-2 Fatigue or reaction time 4-3 Confusing • avoids discomfort 6-2 Inadequate • inability to responsibilities pre-qualifications • design input maintenance received 13--2 Inadequate human
13 for PSP 15--2
15 Inadequate vertical
1-4 Reduced respiratory • due to 3-4 Emotional directions / • gains attention practice of skill comprehend • unclear reporting 9-2 Inadequate obsolete • assessment of •inadequate factors / ergonomics •lack of job safety analysis communication
capacity workload disturbance demands 5-2 Improper supervisory 6-3 Infrequent • inadequate relationships contractor pre- • design input not needs specifications to considerations •inadequate job safety between supervisor
1-5 Other permanent • due to lack of 3-5 Fears or phobias 4-4 Conflicting example performance of instructor • conflicting reporting qualifications correct • lubrication / vendor 13--3 Inadequate standards
13 analysis and person
physical disabilities rest 3-6 Low mechanical directions / 5-3 Inadequate skill qualifications relationship 9-3 Inadequate • design input not servicing •inadequate or specifications 14--2
14 Inadequate development of PSP 15--3
15 Inadequate
1-6 Temporary • due to aptitude demands identification of critical 6-4 Lack of coaching • inadequate training • unclear assignment of contractor selection available • adjustment / specifications on 13--4 Inadequate availability
13 •inadequate coordination with communication
disabilities sensory 3-7 Low learning 4-5 Meaningless or safe behaviors on skill equipment responsibility 9-4 Use of non -approved • design output assembly requisition 13--5 Inadequate adjustment
13 process / equipment design between different
1-7 Inability to sustain overload aptitude degrading activities 5-4 Inadequate 6-5 Insufficient review • misunderstood • conflicting assignment contractor inadequate • cleaning / •inadequate control / repair / •inadequate employee organizations
body positions 2-3 Diminished 3-8 Influenced by 4-6 Emotional overload reinforcement of of instruction to instructions of responsibility 9-5 Lack of job oversight • design input resurfacing on changes to maintenance involvement in the 15--4
15 Inadequate
1-8 Restricted range of performance medication 4-7 Extreme judgment / critical safe behaviors establish skill 7-2 Inadequate recall of • improper or 9-6 Inadequate oversight infeasible 11--3
11 Inadequate repair orders 13--6 Inadequate salvage
13 development communication
body movement • due to 3-9 Other decision demands • proper 6-6 Other training material insufficient delegation 9-7 Other • design output • communication of •unauthorized and reclamation •inadequate definition of between work groups
1-9 Substance temperature 4-8 Extreme performance is • training not of authority unclear needed repair substitution 13--7 Inadequate removal /
13 corrective actions 15--5
15 Inadequate
sensitivities or extremes o Not Applicable concentration / criticized o Not Applicable reinforced on the job 8-2 Inadequate leadership o Not Applicable • design output not • scheduling of work •inadequate product replacement of •inadequate format for easy communication
allergies • due to oxygen perception • inappropriate peer • inadequate refresher • standards of correct • examination of acceptance unsuitable items use between shifts
1-10 Inadequate size or deficiency demands pressure training frequency performance missing • design output parts requirements 13--8 No equipment record
13 14--3
14 Inadequate implementation of 15--6
15 Inadequate
strength • due to 4-9 Extreme boredom • inadequate 7-3 Inadequate training or not enforced inconsistent • parts substitution •no acceptance history PSP, due to deficiencies communication
1-11 Diminished capacity atmospheric performance effort • inadequate • no independent 11--4
11 Excessive wear and verification 13--9 Inadequate equipment
13 •contradictory requirements methods
4-10 Other
due to medication pressure feedback • inadequate training accountability design review tear performed record history •confusing format 15--7
15 No communication
variation o Not Applicable • inadequate program design • inadequate or 10--2 Inadequate
10 • inadequate 12--2
12 Inadequate research •more than one action per method available
1-12 Other 13-10 Other
2-4 Blood sugar disciplinary process • inadequate training incorrect performance standards, planning for use on materials / step 15-8
15- Incorrect instructions
o Not Applicable insufficiency 5-5 Inappropriate goals / objectives feedback specifications, and / • extension of service equipment •no check- off spaces provided 15--9
15 Inadequate
o Not Applicable
2-5 Impairment due aggression • inadequate new • inadequate work site or design criteria life 12--3
12 Inadequate mode or •inaccurate sequence of steps communication due to
to drug or alcohol 5-6 Improper use of employee walk-through 10--3 Inadequate
10 • improper loading route of shipment •confusing instructions job turnover
use production incentives orientation • inadequate safety assessment of • use by untrained 12--4
12 Improper handling of •technical error / missing 15--10
15 Inadequate
5-7 Supervisor implied • inadequate initial promotion potential failure people materials steps communication of
2-6 Other
haste training 8-3 Inadequate correction of 10--4 Inadequate
10 • use for wrong 12--5
12 Improper storage of •excessive references safety and health
o Not Applicable 5-8 Employee perceived • inadequate means prior hazard / incident ergonomic design purpose materials or spare •potential situations not data, regulations or
haste to determine if 8-4 Inadequate identification 10--5 Inadequate
10 11--5
11 Inadequate reference parts covered guidelines
5-9 Other qualified for job of worksite / job hazards monitoring of materials or publications 12--6
12 Inadequate material 14--4
14 Inadequate enforcement of PSP 15--11
15 Standard terminology
7-4 No training provided 8-5 Inadequate management construction 11--6
11 Inadequate audit / packaging •inadequate monitoring of not used
o Not Applicable • need for training not of change system 10--6 Inadequate
10 inspection / monitoring 12--7
12 Material shelf life work 15--12
15 Verification /
identified 8-6 Inadequate incident assessment of • no documentation exceeded •inadequate supervisory repeat back
• training records reporting / investigation operational • no correction 12--8
12 Improper identification knowledge techniques not used
incorrect or out of system readiness responsibility of hazardous •inadequate reinforcement 15-13
15- Messages too long
date 8-7 Inadequate or lack of 10--7 Inadequate
10 assigned materials •non-compliance not 15--14
15 Speech interference
• new work methods safety meetings monitoring of initial • no accountability 12--9
12 Improper salvage corrected
15-15 Other
introduced without 8-8 Inadequate performance operation for corrective action and / or waste 14--5
14 Inadequate communication of
training measurement & 10--8 Inadequate
10 11--7
11 Inadequate job disposal PSP o Not Applicable\
• decision made not to assessment evaluation and / or placement 12--10
12 Inadequate use of •incomplete distribution to
train 8-9 Other documentation of • appropriate safety and health data work groups
7-5 Other change personnel not 12-11 Other •inadequate translation to
o Not Applicable identified appropriate languages
o Not Applicable 10-9 Other o Not Applicable
• appropriate •incomplete integration with
o Not Applicable personnel not training
available •out of date revisions still in
For each identified critical factor, consider if any of the listed root
• appropriate use
cause categories apply. If 'yes,' circle the specific root cause.
personnel not 14-6 Other
If none of the root causes in the category apply, then check the
provided o Not Applicable
'not applicable' box at the bottom of the column.
11-8 Other
o Not Applicable

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

• Align with ‘Getting HSE Right’ elements

ELEMENTS OF GETTING HSE RIGHT

Leadership and Risk Assessment and People, Training and Working with Facilities Design and Operations and Management of Information and Customers and Community and Crisis and Emergency Incidents Analysis and Assessment, Assurance
Accountability Management Behaviours Contractors and Others Construction Maintenance Change Documentation Products Stakeholder Awareness Management Prevention and Improvement