uses A TOO TOOL FOR ROOT CAUSE ANA ANALYSIS DESCRIPTION IMPLEMENTATION & OF INCIDENT RESEARCH EVIDENCE ANALYSIS PHASE: GATHERING IDENTIFICATION OF • Document the type/severity of CRITICAL • Gather relevant • Organise all evidence • Cover the who / what / when / where / how as known at • Implementation phase = direct evidence (scene and • Map evidence the • Research phase = indirect evidence (written • Identify critical factors • Consider People / Parts / Position / • USE CLC to identify all immediate and root
POSSIBLE SYSTEM CAUSES
ACTIONS CONDITIONS 1. Following Procedures 2. Use of Tools or Equipment 3. Use of Protective Methods 4. Inattention / Lack of Awareness 5. Protective Systems 6. Tools, Equipment and Vehicles 7. Work Exposures to 8. Workplace 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 5-1 Inadequate guards or protective devices 6-1 Defective equipment 7-1 Fire or 8-1 Congestion or restricted motion 1-2 Violation by group 2-2 Improper use of tools 3-2 Personal protective equipment not used judgement 5-2 Defective guards or proactive devices 6-2 Inadequate equipment 7-2 explosion 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 4-2 Distracted by other concerns 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energised electrical systems 8-3 Inadequate ventilation 1-4 Operation of equipment without authority 2-4 Use of defective tools (aware) equipment 4-3 Inattention to footing and surroundings 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energised 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 energised equipment 4-4 Horseplay 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate workplace layout 1-6 Overexertion of physical capability materials 3-5 Equipment of materials not secured 4-5 Acts of violence 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 4-6 Failure to warn 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 4-7 Use of drugs or alcohol 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 4-8 Routine activity without thought 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 4-9 Other 5-10 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented 1-11 Other 3-8 Personal protective equipment not available Other 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. Behaviour 6. Skill Level 7. Training / Knowledge 8. Management / Supervision 9. Contractor Selection 10. Engineering / 11. Work Planning 12. Purchasing, Material 13. Tools and Equipment 14. Work Rules / Policies / 15. Communication Condition Transfer Employee Leadership and Oversight Design Handling and Material Control Standards / Procedures (PSP) 1-1 Vision deficiency 2-1 Previous injury or 3-1 Poor judgement 4-1 Preoccupation with 5-1 Improper performance is 6-1 Inadequate assessment 7-1 Inadequate knowledge 8-1 Conflicting roles / 9-1 Lack of contractor pre- 10-1 Inadequate 11-1 Inadequate work 12-1 Incorrect item received 13-1 Inadequate 14-1 Lack of PSP for the task Inadequate horizontal 1-2 Hearing deficiency illness 3-2 Memory failure problems rewarded of required skills transfer responsibilities qualifications technical design • inadequate assessment of needs • lack of defined communication between planning 1-3 Other sensory Fatigue 3-3 Poor co-ordination or 4-2 Frustration • saves time or effort Inadequate practice of • inability to • unclear reporting 9-2 Inadequate contractor • design input obsolete 11-2 Inadequate preventative specifications to and risks responsibility for PSP peers 6-2 deficiency • due to workload reaction time 4-3 Confusing • avoids discomfort skill comprehend relationships pre-qualifications • design input not maintenance vendor 13-2 Inadequate human • lack of job Inadequate vertical 1-4 Reduced respiratory • due to lack of rest 3-4 Emotional disturbance directions/demands • gains attention Infrequent performance • inadequate • conflicting reporting 9-3 Inadequate contractor correct factors / ergonomics safety analysis communication between 6-3 • assessment of needs • inadequate capacity • due to sensory 3-5 Fears or phobias 4-4 Conflicting 5-2 Improper supervisory of skill instruction relationships selection • design input not • lubrication / servicing specifications on considerations • inadequate job safety supervisor and person 1-5 Other permanent overload 3-6 Low mechanical directions/demands example Lack of coaching on qualifications • unclear assignment of 9-4 Use of non-approved available requisition 13-3 Inadequate standards analysis Inadequate 6-4 • adjustment / assembly physical disabilities 2-2 Diminished performance aptitude 4-5 Meaningless or 5-3 Inadequate identification skill • inadequate responsibility contractor • design output • clearing / resurfacing • inadequate control on or specifications 14-2 Inadequate communication between 1-6 Temporary disabilities • due to temperature 3-7 Low learning aptitude degrading activities of critical safe Insufficient review of training equipment • conflicting assignment 9-5 Lack of job oversight inadequate 11-3 Inadequate repair changes to orders 13-4 Inadequate availability development of PSP different organisations 6-5 1-7 Inability to sustain body extremes 3-8 Influenced by 4-6 Emotional overload behaviours instruction to • misunderstood of responsibility 9-6 Inadequate oversight • design input feasible • communication of • unauthorised 13-5 Inadequate adjustment • inadequate co- Inadequate positions • due to oxygen medication 4-7 Extreme judgement 5-4 Inadequate establish skill 7-2 instructions • improper or 9-7 Other • design output unclear needed repair substitution / repair / maintenance ordination with communication between 1-8 Restricted range of body deficiency 3-9 Other decisions/demands reinforcement of critical 6-6 Other Inadequate recall of insufficient delegation D Not applicable • design output not • scheduling of work • inadequate 13-6 Inadequate salvage and process work groups movement • due to atmospheric D Not applicable 4-8 Extreme concentration/ safe behaviours D Not applicable training material 8-2 of authority correct • examination of parts product acceptance reclamation / equipment design Inadequate 1-9 Substance pressure variation perception demands • proper performance is • training not reinforced Inadequate leadership • design output • parts substitution requirements 13-7 Inadequate removal / • inadequate communication between sensitivities or 2-3 Blood sugar 4-9 Extreme boredom criticised on the job • standards of inconsistent 11-4 Excessive wear and tear • no acceptance replacement of employee involvement shifts allergies • inadequate refresher verification performed unsuitable n the development items 1-10 Inadequate size or insufficiency 4-10 •Inappropriate peer training performance missing or • no independent design • inadequate planning 12-2 Inadequate research on 13-8 No equipment record • inadequate definition Inadequate Other frequency strength 2-4 Impainment due to drug D Not pressure 7-3 Inadequate training not enforced review for use materials / equipment history of correction actions communication methods 1-11 Diminished capacity due or alcohol use applicable • inadequate effort • inadequate 10-2 Inadequate • extension of service 12-3 Inadequate mode or 13-9 Inadequate • inadequate format for No communication to medication Other performance feedback • inadequate accountability standards, life route of shipment equipment record easy use method available 1-12 Other D Not applicable • inadequate disciplinary training program • inadequate or incorrect specifications, and/or • improper loading 12-4 Improper handling of history 14-3 Inadequate Incorrect instructions design design criteria 13-10 Other D Not process • inadequate performance feedback 10-3 Inadequate assessment • use by untrained materials D Not implementation of PSP, Inadequate applicable 5-5 Inappropriate training goals / • inadequate work site of potential failure people 12-5 Improper storage of applicable due to deficiencies communication due to aggression objectives walk-through 10-4 Inadequate ergonomic • use for wrong purpose materials or spare parts • contradictory job turnover 5-6 Improper use or • inadequate new • inadequate design 11-5 Inadequate reference 12-6 Inadequate material requirements Inadequate production employee orientation 8-3 safety promotion 10-5 Inadequate monitoring materials or publications packaging • confusing format communication of safety 5-7 incentives • inadequate initial Inadequate correction of of construction 11-6 Inadequate audit / 12-7 Material shelf life • more than one action and health data, Supervisor implied training prior hazard / incident 10.6 Inadequate assessment inspection / monitoring exceeded per step regulations or 8-4 5.8 haste • inadequate means to Inadequate identification of operational readiness • no documentation 12-8 Improper identification • no check-off spaces guidelines Employee perceived determine if qualified for 8-5 of worksite / job hazards Inadequate monitoring of hazardous materials provided Standard terminology 10-7 • no correction 5.9 haste 7-4 job Inadequate management of initial operation responsibility assigned 12-9 Improper salvage and/or • inaccurate sequence not used D Other No training provided of change system 10-8 Inadequate evaluation • no accountability for waste disposal of steps 15-12 Verification / repeat back 8-6 Not applicable • need for training not Inadequate incident and/or documentation of corrective action 12-10 Inadequate use of • confusing instructions techniques not used identified reporting / investigation change safety • technical error / 15-13 Messages too long 11-7 Inadequate job • training records 8-7 system 10-9 Other and health data missing steps 15-14 Speech interference placement incorrect or out of date 12-11 Other • new work methods Inadequate or lack of D Not applicable • appropriate personnel D Not • excessive references 15-15 Other introduced without 8-8 safety meetings not identified applicable • potential situations not D Not applicable training Inadequate performance • appropriate personnel covered • decision made not to measurement and not available 14-4 Inadequate train 8-9 assessment • appropriate personnel enforcement of PSP 7-5 Other D Other not provided • inadequate D Not applicable Not applicable 11-8 Other monitoring of work D Not • inadequate supervisory applicable knowledge • inadequate reinforcement • non-compliant not corrected 14-5 Inadequate communication of PSP • incomplete distribution to work groups • inadequate translation For each identified critical factor, consider if any of the to appropriate For each listed identified root cause critical factor, categories apply. consider If “yes”, if any the circle of the languages listed root specific root cause cause.categories If none ofapply. the rootIf causes “yes”, circle the in the • incomplete integration category apply, then check the “not applicable” boxthe specific root cause. If none of the root causes in at with training thecategory bottom apply, of the then check the “not applicable” box at the column. • out of date revisions bottom of the column. still in use 14-6 • Other D • Not applicable
CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION
• Align with AMEC Performance Standards elements
ELEMENTS OF PERFORMANCE STANDARDS
Management leadership, Employee competency Impact upon the community commitment & accountability Risk Assessment and Management Design & Construction Operations & Maintenance Occupational health Third party management Incident investigation and analysis Measurement, audit & review & involvement & emergency planning