Leads to cause by checklist The checklists are an aid to identification and classification of Underlying Causes. There are eleven checklists: DE - Facilities, Equipment, Tools (ergonomic design, layout) HW - Facilities, Equipment, Tools (condition, suitability, availability) PR - Procedures, instructions, work practices EC - Error enforcing conditions HK - Environment, workplace TR - Competence, training, awareness. IG - Conflicting goals, activities CO - Communications, informatior . OR - Organization, responsibi 10. MM - Maintenance, inspection, technical integrity. 11. DF - Rescue, recovery measures (equipment, faci Underlying Causes sorted by BRFS.... SEneraeny> ror! Bookmark not defined. Each checklist contains a number of generic preconditions (Leads To elements) and a corresponding number of generic Underlying Causes (Caused By elements) Application: A pre-printed tabular form may be found useful: Leads To Caused By BRF Different versions of the same | Budget constraints on the central | PR procedure were being used in the | document distribution system field |s8 |s6 Enter the text of a precondition in a Leads To cell. Select an appropriate checklist and identify a generic Leads To description that matches the precondition. Enter the precondition identifier in the smalll box in the leads to cell. Examine the corresponding Caused By list. Look for a match between a Underlying Cause finding and one of the Underlying Causes. Enter the finding in the Caused By cell and classify it according to the generic Underlying Cause it most resembles. Correlation between ‘Precondition BRFs and ‘Plans, Parts, People, Place and, PICWS DE | HW | PR_| EC | HK | TR | IG | CO | OR | MM | DF Plans x x Parts x x x x People X x X Place X x PICWS [ x x X xLeads to cause by checklist 4. DE- Facilities, Equipment, Tools (ergonomic design, layout) DEFINITION: Ergonomically poor design of tools or equipment (user-unfriendly). ‘Leads To’ [ Precondition TTA _| Tools or equipment worked or were used differently from expectations (deviation from earlier use, lack of standardisation, ilogical or contrary to common sense, or other than general use normally dictated, such as red = sate!) T.B__| Tools or equipment were too difficult to use (use not made clear, incorrect actions too difficult to remedy, possible actions not clearly indicated, no ‘designed in’ constraints to ensure desired action was carried Out) 1.6 _ | Tools or equipment did not match human sizes or physical capabilites (strength, height, vision and arm reach) 1.D__| Tools or equipment were not adapted to the perceptual, processing or memory capacity of employees (too complex, too obscure, too bewildering) TLE | Tools or equipment provided insufficient insight into what process was going on or offered an insufficient view of the operation (no meters, obscure compuler-managed process control, biind spots) TTF | Tools or equipment falled to provide sufficient feedback of status afler alteration of settings, issuing a command Cr starting an action or process (e.g. Valve is open’ display. indication of operation in progress) 1.6 _| The working environment was improperly equipped (interaction between tools or equipment, awkward or Cluttered lay-out, dangerous situations) "Caused By’ Underiying Cause RF 7101 | Insufficient design provisions were made for the operating extemal environment (exireme DE temperatures, humdi, particulates et) 7102 | The design made insuficent use of industy slandards slandard guidelines Inco outoldote, | OE HSE crteria not present) 7703 | Insufficient account of process criteria was laken during the design (operational specifications not | DE present, requirements incorrect or incomplete, out-of-date) 7.04 | Insufficient attention was paid to specific ergonomic issues during design (no ergonomic assessment, | DE unfamiliarity with the operational environment) 7105 _| There was insufficient designer-user communication during the design or modification phase co 7.06 | There were financial restrictions or pressure of time during the design or modification (costvelated | IG exclusions or modifications, acceptance testing shortcuts) 7.07 _| There was insufficient introduction of a new or modified design (too lite information provided, HW implementation badly planned, insufficient time allocated for implementation) 7.08 | There were insufficient controls in the design process (design change controls, checks on compliance | DE with standards/guidelines, quality controls) 1.09 | The design philosophy was inappropriate (making no use of effective proven ergonomic design, failing | DE to use experience or information from related industrial branches) 7.10 | Purchase of construction material was insufficienty controlled (diferent rom previously purchased | OE ‘material, materials failing to meet design specifications) 061111 20f 122. Leads to cause by checklist HW - Facilities, Equipment, Tools (condition, suitability, availability) DEFINITION: Poor condition. Suitability or availability of materials: tools, equipment and components. (Specific design of hardware is included here in 2D). ‘Leads To’ Precondition 2A Tools or equipment were partially or wholly defective, no longer in optimal condition (too much rust, too worn, no longer 100% reliable) 2.8 | Too! or equipment maintenance was makeshifl or ‘temporary’ (sub-standard materials, workmanship) 2.€ | Tools or equipment were insufficient or not available (not purchased, not in stock, already in use, 100 late or wrongly supplied, not in use because of maintenance) 2.0 | Tools or equipment were not suitable or only partially suitable for the objective in mind (not fitfor purpose, out-of-date, inferior brand, poorer quality, wrong specifications) "Caused By’ Underlying Cause BRF 2.01 | The supply system for tools or equipment was ineffective (inventory, administration, HW ordering, issuing) 2.02 _| Procedures for operating tools or equipment were inadequate (resulting in wrongful use) PR 2.03 | Specifications and requirements that the tools or equipment should meet were insufficient | DE (functionality, quality, brand, material, size, and other details) 2.04 | The control system for regularly evaluating and updating the specifications of the tools or | HW equipment was inadequate 2.05 | The physical circumstances in which the tools or equipment were used were unsuitable HW, (used outside the specifications laid down in the design, such as use of corroding material in the tropics, the influence of cold, sea water) 2.06 | Tools or equipment were not properly stored or insufficiently cleaned (items were lost, HW damaged or became very dirty) 2.07 | Tools or equipment were wrongfully used (by untrained, inexperienced or unqualified TR Personnel) 2.08 | Maintenance of the tools or equipment was inadequate (planning, execution, registration) _ | MM 2.09 | There were financial constraints or pressure of time during the purchase or improvement of | HW. the tools or equipment (inferior quality, items with too few possibilities, inadequate number, necessary modifications were not performed) 2.10 | The inspection system for the tools or equipment was inadequate (frequency, completeness, | MM precision - items remained too long in circulation) 2.11 | Communications between inspection and maintenance departments was inadequate MM {information about defective material was not notified or was inadequately notified) 2.12 | There were insufficient checks on the tools or equipment being taken from the workplace | HW. (theft) 2.13 | The system for checking that the tools or equipment, both on purchase as well thereafter, | HW. ‘met the specifications and requirements stipulated was inadequate, 2.14 | insufficient follow-up action was made to equipment inspection reporis MM O6IIII 3 of 12