Comprehensive List of Causes People Parts

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. Following Procedures 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 equipment 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) 3-4 Servicing of energized 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 materials 3-5 Equipment or materials not secured 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 2-6 Operation of equipment at improper speed 3-6 Disabled guards, warning systems or safety devices 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 2-7 Servicing of equipment in operation 3-7 Removal of 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 2-8 Other 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 3-8 Personal protective equipment not available 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 3-9 Other 5-10 Other 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 7-11 Slippery floors or walkways 8-6 Other
7-12 Other

POSSIBLE SYSTEM CAUSES

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

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

ELEMENTS OF GETTING HSE RIGHT

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

Form 3862 Rev 1 Feb 99