SYSTEMATIC CAUSE ANALYSIS TECHNIQUE (TASC)

DESCRIPTION OF THE ACCIDENT /

INCIDENT
EVALUATION OF LOSS POTENTIAL FROM THE ACCIDENT / INCIDENT
^ SEVERITY OF LOSS POTENTIAL ^ PROBABILITY OF RECURRENCE ^ EXPOSURE FREQUENCY
(A) Serious – Loss of life, permanent disability. Loss of process, higher cost. (TO) High - Probability of loss recurrence (TO) High - Many people exposed
many times daily.
(B) Seri a – Loss of time due to injury, not disability. Process interruption, significant cost. (b) Serious - Probability of recurrence of loss (b) Moderate - Moderate number of people exposed several times daily.
(C) Minor – Minor injury without loss of time. Partial interruption of the process, lower cost. (C) Minor - Probability of loss recurrence (C) Low - Few people exposed in less than a day.

1 Struck into (running toward or tripping over) (See IQ: 1, 2, 4, 5,
. 12, 13, 14, 15, 16, 17, 1 8, 19, 26)
2 Hit by (Moving Object) (See IQ: 1, 2, 4, 5, 6, 9, 10, 12, 13, 14,
. 15, 16, 20, 26)
3 Fall to a lower level (See IQ: 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17,
. 22)
TYPE OF CONTACT
4 Fall on the same level (slip and fall, overturn) (See IQ: 4, 9, 13, 14, 7 Trapped between or under (crushed or amputated) (See IQ: 9 Overvoltage, overexertion, overload, ergonomics (See CI: 8, 9, 10,
. 15, 16, 19, 22, 26) . 1, 2, 5, 6, 9, 11, 12, 13, 14, 15, 16, 22, 28) . 11, 13, 14, 15)
5 Caught by (Sharp or cutting points) (See IQ: 5, 6, 11, 13, 1 4, 15, 8 Contact with (electricity, heat, cold, radiation, caustic 1 Equipment failure (See IC: 4, 6, 8, 15, 19, 23)
. 16, 18) . substances, toxic substances, biological substances, noise) 0 Spill/leak into the environment (See IC: 1, 2, 3, 4, 5, 6, 8, 9, 12, 15,
6 Caught in (caught, hung) (See IQ: 5, 6, 11, 12, 13, 14, 1 5, 16, 18) (see IQ: 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21 , 23, 24, . 18, 19, 20, 22, 25, 27, 28
. 25, 27, 28) 1
1
IMMEDIATE / DIRECT CAUSES (IC) .

■1. Operating
SUBSTANDARD PRACTICES / ACTS
equipment without authorization (See CB: 2, 4, 5, 7, 8, 12, 13, 15)
8. Improper loading (See CB:1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13,
15)
15. Improper use of equipment (See CB:1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12,
13, 15)
22. Danger of explosion or fire (See CB: 5, 6, 7, 8, 9, 10, 11, 12,
13,15)
2. Lack of warnings (See CB: 1, 2, 3, 4, 5, 6, 7, 8, 9, 12 , 13, 15) 9. Improper storage (See CB:1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) 16. Failure to follow procedures (See CB: 1, 2, 3, 4, 5, 7, 8, 13) 23. Disorder; poor cleaning (See CB: 5, 6, 7, 8, 9, 10, 11,12, 13,15)
3. Failure to secure (See CB: 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) Improper lifting (See CB: 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) Noise exposures (See CB: 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
Operating at inappropriate speed (See CB: 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 15) 10. ■ SUBSTANDARD CONDITIONS
Inadequate protections and barriers (See CB: 5, 7, 8, 9, 10, 11,
24. Radiation exposures (See CB: 5, 6, 7, 8, 9, 10, 11, 12, 13,
25.
4. Make safety instruments inoperable (See CB: 2, 3, 4, 5, 6, 17. 12, 13, 15)
5. 11. 14)
Improper task position (See CB: 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) 18. Inadequate or improper PPE (See CB: 5, 7, 8, 9, 10, 12, 13) 26. Exposures to extreme temperatures (See CB: 1, 2, 3, 8, 9, 11,
7, 8, 9, 12, 13, 15) 12. Perform maintenance on equipment in operation (See CB: 2, 3, 4, 5, 6, 19. Defective tool, equipment or material (See CB: 8, 9, 10, 11, 12, 13, 14, 12)
6.
Use of defective equipment ((See CB: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 7, 8, 9, 12, 13, 15) 15) 27. Inadequate lighting (See CB: 8, 9, 10, 11, 12, 13)
14, 15) 13. Jokes (See CB: 2, 3, 4, 5, 7, 8, 13, 15) 20. Limited space to move around (See CB: 8, 9, 10, 13) 28. Inadequate ventilation (See CB: 8, 9, 10, 11, 12, 13)
7. Inappropriate use of PPE (See CB: 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 15)
14. Under the influence of alcohol/or other drugs (See CB: 2, 3, 4, 5, 7, 21. Inadequate warning system (See CB: 8, 9, 10, 11, 12,13, 29. Hazardous environmental conditions (See CB: 8, 9, 10, 11, 12,
8, 13, 15) 14, 15) 13)
BASIC CAUSES / ROOT (CB)
PERSONAL 3 Insufficient blood sugar. 7 Inadequate discipline. 9.7 Inadequate initial monitoring or operation. 13. INADEQUATE WORK STANDARDS
FACTORS
1 INADEQUATE 3.11
. Drugs. . Inappropriate peer pressure. 9.8 Inadequate evaluation of change. (See NS: 1,2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, 15, 16, 19)
PHYSICAL/PHYSIOLOGICAL ABILITY 4 MENTAL
1 OR PSYCHOLOGICAL 9 Inappropriate example of supervision. 1
. . INADEQUATE ACQUISITIONS 13.1 Inadequate development of standards for:
(See NS: 6, 9,weight,
12, 15,size,
18) strength, reach, . TENSION
0 . Poor performance feedback. 0
1 Height, (See NS: 1, 3, 4, 6, 9, 12, 13, 14, 15,19) 13.1.1 Inventory and evaluation of exposures and
. etc. (See Emotional
4 NS: 1, 4, 5,overload.
6, 10, 11, 12, 15, 7 Poor reinforcement of appropriate 10.1 Poor order specifications and needs.
1 Inappropriate. .16, 18, Fatigue
20) due to load or speed of . behavior. Inappropriate production orders. 13.1.2 Coordination in the design of the process.
. limited body movement. 1 mental task. Extreme demands for 1 incentives. 10.2 Inadequate investigation of material/equipment. 13.1.3 Employee involvement.
4 opinion/decision.
WORK
0
FACTORS
2 Limited ability to maintain body 10.3 Inadequate specifications to sellers. 13.1.4 Standards, procedures, rules.
1 positions. . Routine, monotony of unimportant 8..INADEQUATE LEADERSHIP AND/OR 10.4 Inappropriate boarding mode or route. 13.2 Inadequate communication of standards for:
. Sensitivity to substances or allergies. 2 jobs. Extreme demands on 7
SUPERVISION 10.5 Poor receiving inspection. 13.2.1 Publications.
3
4 Sensitivity to sensory extremes 4 concentration/perception. .8 (See NS: 1,or2,conflictive
Unclear 3, 4, 6, 8,hierarchical
9, 10, 12, 13, 15, 10.6 Inappropriate communication of information 13.2.2 Distribution.
1 (temperature, sound, etc.). . “Senseless” or “degrading” 16,.1 17, 18) relationships. Health and security. 13.2.3 Lack of translation into appropriate
. Visual deficiency. 3
6 activities. 1 Unclear or conflicting assignment of 10.7 Improper handling of materials. languages.
13.2.4 Training.
5
6 Hearing impairment. 4 Confusing directives and orders. .8 responsibility. 10.8 Improper storage of materials. 13.2.5 Reinforcement with symbols, codes,
1 Other deficiencies (touch, taste, smell, . Conflicting requests. .7 Insufficient or inappropriate delegation. 10.9 Improper transportation of materials. symbols
color and work aids.
. balance). 4
7 Worry about problems. .
2
3 Provide inappropriate policies, procedures, 10.10 Poor Material Identification 13.3 Inadequate maintenance of standards for:
7 Temporary disabilities.
Respiratory inability. 5 4 LACK Frustration.
OF KNOWLEDGE 1
8 practices or guidelines for action. dangerous. 13.3.1 Workflow Tracking
2 INADEQUATE
1 MENTAL/PSYCHOLOGICAL
Other permanent physical disabilities. . .(See Mental NS: 2, 4,
illness.
5, 6, 7, 8, 9, 10, 11, 12, 13, .2 Give contradictory objectives, goals, 10.11 Improper disposal of waste and 13.3.2 Update
. CAPACITY
(See
. ANC: 6, 9, 5
8
2 15, 16, 18, .
4
5 standards. Inadequate programming or waste. 13.3.3 Monitoring the use of standards /
82 15,Fears
10, 18) and phobias. 4
0 Lack of experience. 7
8 planning of work. Poor instruction/guidance 10.12 Inadequate selection of contractors. procedures/rules.
). Poor orientation. . and/or preparation. Inappropriate reference 11. INADEQUATE 1 Inadequate compliance
1. Emotional MAINTENANCE
9 Inadequate initial training. 1
8
6 documents, instructions and advisory 1 3 EXCESSIVE monitoring.WEAR
.1 disturbances. (See NS: 1, 3, 4, 6, 9, 10,
4
5 Inadequate training update. 3
.8 publications. 4 . AND USE
92 Mental illness. 13, 15, 19)1 Needs
. Misunderstood directives. .9
8 Poor identification and evaluation of loss . 4 (See
1 NS: 3, 4, 6, 9,
Inadequate 10,
planning of use.
1. Intelligence level. 11.1 Inadequate
1 prevention:
assessment.
6 1 INABILITY .7 exposures. 13,
4 14,Improper15) extension of useful life.
.2 Inability to
. Lubrication and
. 0
5 ( See NS: 2, 4, 5, 6, 7, 9, 10, .
1
8 Inadequate knowledge of . Poor inspection and/or control.
12 understand.
1 service.
.4
6 13, 15,Poor
16) initial instruction. 1
.0 supervisory/administrative work. 1 Inappropriate workload or usage
0. Bad judgment. 11.2. Improper Adjustment/asse
.2 Insufficient practice. 4
8
1 Inadequate assignment of the worker to the 1 demands.
13 Bad coordination. repair: mbly.
5
1 Rare execution. .1 demands of the task. 1 Communication of 4
1 Poor maintenance.
2.10
. 2 Little
Slowlearning
reaction.attitude.
.1 Lack of preparation/advice. 1 Poor performance measurement and 1 Cleaning
needs. or .
4 Use by unqualified/trained persons.
2.11
1. Memory
Poor mechanical
loss.
3
6 Inadequate review of 9 2 INADEQUATE evaluation PoorENGINEERING
or incorrect performance .1 polishing.
Work planning. .2 Use for improper purposes.
3 PHYSICAL
14 aptitude.
OR
7 .5 INADEQUATE MOTIVATION
instructions. . 8 (See NS: 1, 3, 4, 9, 12, 14)
feedback .
2 Unit verification. 1 ABUSE
1
5 OR MISTREATMENT
. PHYSIOLOGICAL
2 TENSION
. .(See NS: 1, 2, 4, 5, 6, 8, 10, 11, 13,
2 .
9 Inadequate assessment of loss exposures. 12. INADEQUATE
1
. TOOLS AND
Replacement of 5 (See
4 NS: 1, 3, 4, 6, 8, 9, 10, 11, 13, 14, 15,
1
3
(See
. Injury4,or6,illness.
ANC: 9, 11, 12, 13, EQUIPMENT
7
.4 14, 17, 18)
Rewarding (tolerance) of inadequate .1 Poor consideration of ergonomic/human .
1 parts. . 16,
. 17, Inappropriate
1
4 19) or
.5 18,Fatigue
15, 20) due to load or task (See 1
5
.6 performance. 3
1
9 factors. 1 2NS: 1, needs
Poor 3, 4, 6,and
7, 9,risk
11,assessment.
12, 14, 15, 5
.3 impermissible
1 I conduct:
1
2 duration. 19) 2
1
.
7 Punishment for adequate performance. . Poor specification standards and/or design 1 Inadequate human/ergonomic .6
1 15.1.2
5 Unintentional
n
3
. Fatigue due to lack of rest.
5
.3 Lack of incentives. 9
2 criteria. . .1 factors considerations. 1
4 Permitted
. t
.6 Fatigue due to sensory
.
2 Excessive frustration. . ■ Inadequate construction control 1 . Inadequate standards or
2 5
.
4 Inappropriate
1 Ie
2 overload.
6
7 Inappropriate aggression. 3
9 Inadequate evaluation of operational 1
2 .1 specifications. .4 Conduct:
15.2.2
.
5 n
3
. Exposure to health risks.
. Inappropriate attempt to save time or . conditions. .2 . Inadequate availability.
2 2
7 Unintention
.1 t
.7 Exposure to extreme
4
3 effort. 4 Inadequate controls. .
3 3 Poor adjustment/repair/maintenance.
1 al
2 i
e
3
2 temperatures. Lack of
.
7 Inappropriate attempt to avoid 9 2
1 1 Salvage and inadequate claim. . o
n
3
. oxygen.
.6 discomfort. . 2 1
. Improper removal and replacement 1 tn
.8 Variation of atmospheric
.
4 Inappropriate attempt to attract 5
6 . . of substandard items.
2 ia
4
2 pressure. Restricted
5
7 attention. 4 .1 l
o
3
. movements.
. 1 .
3 n
 SYSTEM NEEDS (NS)
1. LEADERSHIP AND MANAGEMENT 5. ACCIDENT/ INCIDENT INVESTIGATION 10. TRAINING OF KNOWLEDGE AND 17 GENERAL PROMOTION
Q Ye c SKILLS . PSC
1.1 General Policy. 5.1 Accident/Incident Investigation System.
Q Ye c 17.1 Loss Control Bulletin Boards.
s
1.2 Loss Control Coordinator. 5.2 Participation of Operational Management. s Q Ye c 17.2 Use of Accident/Incident Statistics.
1.3 Participation of Senior and Middle Management 10.1 Administration. s
5.3 Accidents/Serious Incidents and High Potential. 17.3 Promotion of Critical Issues.
1.4 Standards for Loss Control Performance. 10.2 Analysis of Training Needs
5.4 Corrective and Follow-up Actions. 17.4 Awards and Recognition for Individuals.
1.5 Participation in Loss Control Activities. 10.3 Instructor Qualifications.
5.5 Investigation and reporting of Incidents (Near- 17.5 Control Information Publications
1.6 Management Meetings. 10.4 Training Systems.
Accidents). Losses.
1.7 Loss Control Reference Manual. 10.5 Evaluation of the Training and Monitoring
5.6 Maintenance of Accident/Incident reports. 17.6 Awards and Recognitions for Groups.
1.8 Internal Audits Performed. System.
17.7 Promotion of the System of Order and Cleanliness.
1.9 Individual Loss Control Responsibility. 17.8 External Promotions.
1.10 Annual Loss Control Objectives. 11. PERSONAL PROTECTIVE EQUIPMENT
Q Ye c 17.9 Records of Promotion Activities.
1.11 Joint Health and Safety Committees and/or Health 6. TASK OBSERVATION 11.1 Administration. s
and Safety Representatives.
Q Ye c 11.2 Personal Protective Equipment Records. 18. RECRUITMENT AND PLACEMENT
1.12 Refusal to Work Due to Loss Control Hazards. 6.1 Administration. PSC
11.3 Compliance with Standards.
1.13 Reference Library. 6.2 Partial/Selective Observation of tasks s 18.1 Capacity Requirements.
1.14 Documents control. 6.3 Complete Observation of Tasks. INDUSTRIAL HEALTH AND HYGIENE CONTROL 18.2 Medical exam.
1.15 Regulations, Codes and Standards. 6.4 Observation of Critical Tasks. 18.3 General Orientation/Induction.
1.16 External Communications. 6.5 Assurance System. Q Ye c 18.4 Review of Pre-Employment/Pre-Placement Qualifications.
12.1 Administration.
6.6 Analysis of Task Observations Report. 12.2 Identification and evaluation of Health Risks. s
2. LEADERSHIP TRAINING
12.3 Control of Health Risks.
7. EMERGENCY PREPARATION 12.4 Occupational Health Control and Industrial 19. MANAGEMENT OF MATERIALS AND SERVICES
2.1 Analysis of Training Needs.
Q Ye c Hygiene. PSC
2.2 Loss Control Leadership Orientation/Induction. 7.1 Administration. s 12.5 Information and Training. 19.1 Administration.
2.3 Initial Formal Training for Senior Management. 7.2 Emergency Reaction Analysis. 12.6 Health Care Systems. 19.2 Contractor Selection.
2.4 Review, Update and Advanced Formal Training of Q Ye c 7.3 Emergency plan. 12.7 Professional Assistance. 19.3 Contractor Administration.
Senior Management. s 7.4 External Emergencies. 12.8 Communications.
2.5 Initial Formal Training for Loss Control 7.5 Power Source Controls. SAFETY OUTSIDE OF WORK
12.9 Records 20. PSC
Leadership. 7.6 Protection and rescue system.
2.6 Review, Update and Advanced Formal Training 7.7 Emergency Equipment. 20.1 Identification and Analysis of Problems.
SYSTEM EVALUATION 20.2 Safety Education outside of Work.
for Loss Control Leadership. 7.8 System of Acquired Experiences.
2.7 Formal Training of the Loss Control Coordinator. 7.9 First aid. 13.1 Evaluation of Loss Control Records. Q Ye c
2.8 Training Records. 7.10 Mutual Aid and Organized External Assistance. 13.2 Regular System Evaluation. s
7.11 Planning after the Event. 13.3 Evaluation of Compliance with Loss Control
3. PLANNED INSPECTIONS AND MAINTENANCE 7.12 Communication in Case of Emergency. System Standards.
7.13 Communiqués to the Community. 13.4 Perception Surveys.
3.1 Planned General Inspections.
13.5 Registry mantenance.
3.2 Tracking system. 8. WORK RULES AND PERMITS .
3.3 Analysis of the Inspection Report.
Q Ye c ENGINEERING AND CHANGE MANAGEMENT LEGEND OF NEEDS
3.4 Critical Parts/Items. 8.1 General Loss Control Rules.
3.5 Preventive Maintenance. 8.2 Rules for Special Works. 14.1 Administration.
3.6 Inspections of Special Systems. 8.3 Permit System for Specialized Work. 14.2 Risk Identification and Hazard Assessment. Q - It is not part of our system
3.7 Equipment Pre-Use Inspections.
3.8 Alternate System for reporting Substandard Q Ye c
8.4
8.5
Operating Permit Systems.
Learning and Review of Rules.
14.3 Project Review and Change Management. S - Inadequate standards
14.4 Operation Control and Work Processes.
Conditions. s 8.6 Compliance and Recognition of the Rules. C - Inadequate compliance with our
3.9 Compliance Requirements. 8.7 Use of Instruction Signs and Color Code. PERSONAL COMMUNICATIONS standards
4. CRITICAL TASK ANALYSIS AND PROCEDURES 9. ANALYSIS OF ACCIDENTS/ INCIDENTS 15.1 Training in Personal Communication
Q Ye c Techniques.
4.1 Administration. 9.1 Consequence Measurements.
s 15.2 Orientation/Job Induction.
4.2 Critical Task Inventory. 9.2 Cause and Control Analysis. 15.3 Task Instruction.
4.3 Objectives for the Analysis and Procedures of 9.3 Identification and Analysis of Damage to 15.4 Planned Personal Contacts.
Critical Tasks. Property/Process.
4.4 Analysis and Procedures of Critical Tasks. 9.4 Incident Analysis (Near-Accidents)
4.5 Identification and Control of Potential Losses. 9.5 Problem Solving Teams.

Q Ye c 16. GROUP COMMUNICATIONS

s
16.1 Group Meetings.
16.2 Registry mantenance.
16.3 Administration Participation.