Doc. No.
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INCIDENT CAUSES CHECKLIST
APPARENT CAUSES 
   
SUBSTANDARD ACTIONS
   [] 1.Operating equipment without authority
   [] 2. Failure to secure
   [] 3.Failure to warn
   [] 4.Operating at improper speed
   [] 5.Making safety device inoperable
   [] 6.Using defective equipment
   [] 7.Using equipment improperly
   [] 8.Failure to properly use PPE
   [] 9.Improper loading/placement/lifting
   [] 10.Improper position for task
   [] 11.Servicing equipment in operation
  [] 12. Horse play
LATENT CAUSES
PERSONAL FACTORS
  [] 1.Inadequate capability
[] 2.Lack of knowledge/training
  [] 3.Lack of skill
  [] 4.Stress
  [] 5.Improper motivation
  [] 6.Fatigue
  [] 7.Mental absence
    
Rev.: 00
Date :
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SUBSTANDARD CONDITIONS  
[] 1.Inadequate guard or barriers  
[] 2.Improper protective equipment  
[] 3.Defective tools, equipment  
[] 4.Conjection or restricted action  
[] 5.Inadequate warning system  
[] 6.Fire & explosion hazards  
[] 7.Poor housekeeping  
[] 8.Environmental conditions  
[] 9.Noise/Radiation exposures  
[] 10.Inadequte ventilation  
[] 11.High or low temperatures  
[] 12.Inadequate illumination  
JOB FACTORS  
[] 1.Inadequate leadership supervision  
[] 2.Inadequate engineering  
[] 3.Inadequate purchasing  
[] 4.Inadequate tools/equipment  
[] 5.Inadequate maintenance  
[] 6.Inadequate work standards  
[] 7.Wear & tear  
[] 8.Abuse or misuse