CATEGORIES OF CAUSES

TYPES OF IMMEDIATE CAUSES

Substandard Practices Substandard Conditions
In general, a substandard condition is a
In general, a substandard practice is a
hazard i.e. the state of something that can
hazardous action; someone:
cause harm.
> is doing something (in a manner) that
they are not supposed to do, or

> is not doing something (in a manner) that

they are supposed to do.

TYPES OF BASIC CAUSES

Engineering & Design Factors:
Inadequate evaluation of change and/or
documentation of change and/or
communication of change (inadequate
management of change in any aspect)
Inadequate assessment of operational
readiness / completeness of construction /
ready for use / fit for use
Job Factors: Personal Factors:
Inadequate communication - internal /
between roles and/or departments; external / Perceived inadequate mental / psychological
between the organization and other state, or capacity / capability to do the work
organizations / the community
Inadequate administrative controls /
Inadequate physical / physiological state /
inadequate identification of roles and
capability to do the work
responsibilities in administrative controls

Inadequate engineering / technical standards, Inadequate maintenance / inadequate

Physical or physiological stress
specifications and/or design criteria operation / inadequate construction

Inadequate integration of external engineering Inadequate reporting of, investigation of, or

/ technical standards, specifications and/or follow-up into loss events and near miss Perceived mental or psychological stress
design criteria events
Inadequate monitoring of construction /
Inadequate training Improper risk taking / improper motivation
installation / assembly / fabrication
Inadequate monitoring of initial / on-going
Error-inducing conditions Lack of knowledge / lack of skill
operation / maintenance
Inadequate technical design of engineering
Organizational factors
controls
Inadequate inherently safe design Incompatible / conflicting goals
Inadequate assessment of loss exposures / inadequate verification / improvement of work
risks / hazards practices

Inadequate ergonomic design Inadequate equipment and tools for the job

LATENT CAUSES
Categories of Latent Causes:
APEGA RM System Elements
P S C
1) Management Leadership, Commitment,
and Accountability
2) Risk Assessment and Management of
Risks
3) Community Awareness and Emergency
Preparedness
4) Management of Change
5) Incident Reporting, Investigation, Analysis
and Actions
6) Program Evaluation and Continuous
Improvement
7) Design, Construction, and Start-up
8) Operations and Maintenance
9) Employee Competency and Training
10) Contractor Competency and Integration

11) Operations and Facilities Information and

Documentation
where:
P = inadequate program
S = inadequate performance standards
C = inadequate compliance with performance standards
Categories of Causes:
Impacts on PEAP
People
First Aid
Medical Treatment
Restricted Work
Fatality
Lost Time
Environment
spill / release <25 kg, no
adverse impact
spill / release >25 kg, no
adverse impact
spill / release >25 kg,
adverse impact
regulatory exceedance
off-plant adverse impact
Assets
Minor <$5,000
Serious $5,000-$50,000
Major $50,000-$500,000
Catastrophic >$500,000
Productivity /
Business Interruption *
Minor <$5,000
Serious $5,000-$50,000
Major $50,000-$500,000
Catastrophic >$500,000
* measured as conversion
cost of lost production plus
any wasted / lost materials
This ENGG404 model is based on a model developed by Bird Jr., F.E. and Germain, G.L. (1992). Practical Loss Control Leadership. Loss Control Management. Det Norske Veritas Inc.
Adapted by ESRM Program at The U of Alberta, including the APEGA Model for Management System Elements.
Incident Type Immediate Causes Type Basic Causes Type Latent Causes (weakness in RME) LC Categories
Body Motion: Substandard Practices Engineering & Design Factors: APEGA RM System Elements P S C
Inadequate evaluation of change and/or documentation of
In general, a substandard practice is a 1) Management Leadership, Commitment, and
Struck against change and/or communication of change (inadequate
hazardous action; someone: Accountability
management of change in any aspect)
> is doing something (in a manner) that Inadequate assessment of operational readiness /
Struck by 2) Risk Assessment and Management of Risks
they are not supposed to do, or completeness of construction / ready for use / fit for use
> is not doing something (in a manner)
that they are supposed to do. Inadequate engineering / technical standards, specifications 3) Community Awareness and Emergency
Fall to lower level
and/or design criteria Preparedness
Use of Safeguards / Control Measures /
Inadequate integration of external engineering / technical
Fall on same level Protective Defenses 4) Management of Change
standards, specifications and/or design criteria
(assumes in place)
Use of Tools or Equipment Inadequate monitoring of construction / installation / 5) Incident Reporting, Investigation, Analysis and
Caught in
(good equipment available) assembly / fabrication Actions
Following Procedures General: Inadequate monitoring of initial / on-going operation /
Caught on 6) Program Evaluation and Continuous Improvement
(assumes sound & exist) maintenance
Following Procedures Specific:
Caught between Inadequate technical design of engineering controls 7) Design, Construction, and Start-up
(assumes sound & exist)
Inattention / Lack of Awareness
Overexertion Inadequate inherently safe design 8) Operations and Maintenance
(not focused)
PPE Not Used / Used Incorrectly / Not
Overstress Inadequate assessment of loss exposures / risks / hazards 9) Employee Competency and Training
Suitable for Hazard
Inadequate ergonomic design 10) Contractor Competency and Integration
11) Operations and Facilities Information and
Substandard Conditions Job Factors:
Documentation
In general, a substandard condition is a
inadequate verification / improvement of work practices Categories of Latent Causes:
hazard
i.e. the state of something that can cause
Contact with: Inadequate equipment and tools for the job P = inadequate program
harm.
Condition (inadequate, defective, or
Inadequate maintenance / inadequate operation /
Environmental Heat missing / lack) of safeguards / control S = inadequate performance standards
inadequate construction
measures / protective devices
Condition (inadequate, defective, or
Inadequate reporting of, investigation of, or follow-up into
Environmental Cold missing / lack) of tools, hardware, C = inadequate compliance with performance standards
loss events and near miss events
equipment, supplies, materials
Inadequate administrative controls / inadequate
Hot surface PPE is Deficient / Damaged / Degraded identification of roles and responsibilities in administrative
controls Note: "standards" means the same thing as "administrative controls"
Inadequate communication - internal / between roles and/or Can be internal (corporate, institutional)
Cold surface process hazards departments; external / between the organization and other
organizations / the community
Fire workplace hazards Inadequate training Can be external (government codes, industry standards)
Electricity occupational hazards Error-inducing conditions Examples: policies, procedures, work processes,
schedules, checklists, plans, specifications, and the like.
Chemical - corrosive exposure to process hazards Organizational factors
Chemical - toxic Software bugs / malware Incompatible / conflicting goals
Noise Personal Factors:
Inadequate physical / physiological state / capability to do
Pressure
the work
Perceived inadequate mental / psychological state, or
Radiation
capacity / capability to do the work
Physical or physiological stress
Note: The grey areas are noted only to demonstrate that these
Perceived mental or psychological stress tables can be used for comprehensive collection of date. For our
purposes, we will not appy the grey areas.
Improper risk taking / improper motivation
Lack of knowledge / lack of skill