PEOPLE (ACTS)

The “People (Acts)” causal factors involve either the actions of a person or actions which were required but not carried out
or were incorrectly performed. There are four main categories, with an additional level of detail under each.

PROCESS (CONDITIONS) CLASSIFICATIONS

Process (Conditions) classifications usually involve some type of physical hazard or organisational aspect out with the control
of the individual. There are five major classification categories, with an additional level of detail under each of the major
categories.
 PEOPLE (ACTS)

The “People (Acts)” causal factors involve either the actions of a person or actions which were required but not carried out
or were incorrectly performed. There are four main categories, with an additional level of detail under each.
Following Procedures:
Violation intentional (by individual or group)
Violation unintentional (by individual or group)
Improper position (in the line of fire)
Overexertion or improper position/posture for task
Work or motion at improper speed
Improper lifting or loading
Use of Tools, Equipment, Materials and Products:
Improper use/position of tools/equipment/materials/products
Servicing of energized equipment/inadequate energy isolation
Use of Protective Methods:
Failure to warn of hazard
Inadequate use of safety systems
Personal Protective Equipment not used or used improperly
Equipment or materials not secured
Disabled or removed guards, warning systems or safety devices
Inattention/Lack of Awareness:
Improper decision making or lack of judgement
Lack of attention/distracted by other concerns/stress
Acts of violence
Use of drugs or alcohol
Fatigue

PROCESS (CONDITIONS) CLASSIFICATIONS

Process (Conditions) classifications usually involve some type of physical hazard or organisational aspect out with the control
of the individual. There are five major classification categories, with an additional level of detail under each of the major
categories.
Protective Systems
Inadequate/defective guards or protective barriers
Inadequate/defective Personal Protective Equipment
Inadequate/defective warning systems/safety devices
Inadequate security provisions or systems
Tools, Equipment, Materials, Products:
Inadequate design/specification/management of change
Inadequate/defective tools/equipment/materials/products
Inadequate maintenance/inspection/testing
Work Place Hazards:
Congestion, clutter or restricted motion
Inadequate surfaces, floors, walkways or roads
Hazardous atmosphere (explosive/toxic/asphyxiant)
Storms or acts of nature
Organisational:
Inadequate training/competence
Inadequate work standards/procedures
Inadequate hazard identification or risk assessment
Inadequate communication
Inadequate supervision
Poor leadership/organisational culture
Failure to report/learn from events
FATAL INCIDENTS / FATALITIES

CausalFactor
PROCESS (CONDITIONS) : Organisational : Inadequate supervision
PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
PROCESS (CONDITIONS) : Organisational : Inadequate communication
PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stress
PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspection/te
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety devices
PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used improperly
PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools/equip
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equipment
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective Personal Protective Equipment
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specification/man
PROCESS (CONDITIONS) : Work Place Hazards : Storms or acts of nature
PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety devi
PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
PEOPLE (ACTS) : Following Procedures : Work or motion at improper speed
PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
PEOPLE (ACTS) : Inattention/Lack of Awareness : Acts of violence
PEOPLE (ACTS) : Inattention/Lack of Awareness : Fatigue
PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Servicing of energized equipment/inadequate energy isola
PEOPLE (ACTS) : Following Procedures : Overexertion or improper position/posture for task
Grand Total
 year Data
2011 2010
Sum of incidents Sum of fatalities Sum of incidents Sum of fatalities
18 21
16 18
15 15
11 16
10 12
9 9
9 9
9 9
8 11
8 8
7 7
7 7
6 9
6 9
6 10
6 6
5 10
5 10
5 8
5 7
4 4
4 5
4 7
4 4
4 7
2 5
2 5
2 2
2 2
1 5
1 1
1 1
1 1
pment/inadequate energy isolation
203 260 242
18 20
14 16
30 33
7 8
13 13
16 17
12 12
12 13
7 8
10 11
5 5
1 1
4 5
5 6
1 1
9 11
4 4
10 11
2 2
2 2
9 10
6 6
12 15
5 6
2 3
2 2
8 8
6 8
1 1
3 4
3 3
3 4
269
HIGH POTENTIAL EVENTS

Sum of HiPoEvents
CausalFactor
PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
PROCESS (CONDITIONS) : Organisational : Inadequate supervision
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specification/management
PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools/equipment/mat
PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety devices
PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
PROCESS (CONDITIONS) : Organisational : Inadequate communication
PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equipment/materia
PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspection/testing
PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stress
PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
PEOPLE (ACTS) : Inattention/Lack of Awareness : Fatigue
PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety devices
PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used improperly
PEOPLE (ACTS) : Following Procedures : Work or motion at improper speed
PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Servicing of energized equipment/inadequate en
PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
PROCESS (CONDITIONS) : Work Place Hazards : Storms or acts of nature
PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective Personal Protective Equipment
PEOPLE (ACTS) : Following Procedures : Overexertion or improper position/posture for task
PEOPLE (ACTS) : Inattention/Lack of Awareness : Acts of violence
Grand Total
year
2011 2010
24 47
21 23
20 37
18 31
18 13
17 9
15 27
15 13
15 22
15 19
13 9
13 16
12 2
12 21
9 15
9 10
9 3
9 5
8 15
6 9
5 6
4 4
3 1
3 9
3 3
3 6
3 3
3 1
3 6
2 5
2
2 4
1 3
1 3
1
317 400
year CausalFactor
2011 PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
2011 PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
2011 PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
2011 PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
2011 PEOPLE (ACTS) : Following Procedures : Work or motion at improper speed
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Acts of violence
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Fatigue
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stre
2011 PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety
2011 PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
2011 PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
2011 PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
2011 PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used impro
2011 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools
2011 PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
2011 PROCESS (CONDITIONS) : Organisational : Inadequate communication
2011 PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
2011 PROCESS (CONDITIONS) : Organisational : Inadequate supervision
2011 PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
2011 PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
2011 PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective Personal Protective Equipment
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety device
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specificati
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspect
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equ
2011 PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
2011 PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
2011 PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
2011 PROCESS (CONDITIONS) : Work Place Hazards : Storms or acts of nature
2010 PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
2010 PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
2010 PEOPLE (ACTS) : Following Procedures : Overexertion or improper position/posture for task
2010 PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
2010 PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Acts of violence
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stre
2010 PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety
2010 PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
2010 PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
2010 PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
2010 PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used impro
2010 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools
2010 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Servicing of energized equipmen
2010 PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
2010 PROCESS (CONDITIONS) : Organisational : Inadequate communication
2010 PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
2010 PROCESS (CONDITIONS) : Organisational : Inadequate supervision
2010 PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
2010 PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
2010 PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety device
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specificati
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspect
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equ
2010 PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
2010 PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
2010 PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
2010 PROCESS (CONDITIONS) : Work Place Hazards : Storms or acts of nature
incidents fatalities
2 2
9 9
4 4
9 9
2 2
1 5
1 1
16 18
7 7
2 5
4 7
8 11
4 7
6 10
6 6
1 1
9 9
15 15
18 21
10 12
8 8
4 5
2 5
11 16
5 10
6 9
5 8
6 9
5 10
4 4
1 1
7 7
5 7
8 8
16 17
3 4
12 15
12 12
6 8
14 16
5 5
2 3
6 6
7 8
 5 6
1 1
9 11
3 3
3 4
12 13
30 33
18 20
13 13
10 11
9 10
2 2
7 8
5 6
10 11
4 5
4 4
2 2
1 1
1 1
2 2
year CausalFactor
2011 PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
2011 PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
2011 PEOPLE (ACTS) : Following Procedures : Overexertion or improper position/posture for task
2011 PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
2011 PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
2011 PEOPLE (ACTS) : Following Procedures : Work or motion at improper speed
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Acts of violence
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Fatigue
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
2011 PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stre
2011 PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety
2011 PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
2011 PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
2011 PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
2011 PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used impro
2011 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools
2011 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Servicing of energized equipmen
2011 PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
2011 PROCESS (CONDITIONS) : Organisational : Inadequate communication
2011 PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
2011 PROCESS (CONDITIONS) : Organisational : Inadequate supervision
2011 PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
2011 PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
2011 PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective Personal Protective Equipment
2011 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety device
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specificati
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspect
2011 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equ
2011 PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
2011 PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
2011 PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
2011 PROCESS (CONDITIONS) : Work Place Hazards : Storms or acts of nature
2010 PEOPLE (ACTS) : Following Procedures : Improper lifting or loading
2010 PEOPLE (ACTS) : Following Procedures : Improper position (in the line of fire)
2010 PEOPLE (ACTS) : Following Procedures : Overexertion or improper position/posture for task
2010 PEOPLE (ACTS) : Following Procedures : Violation intentional (by individual or group)
2010 PEOPLE (ACTS) : Following Procedures : Violation unintentional (by individual or group)
2010 PEOPLE (ACTS) : Following Procedures : Work or motion at improper speed
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Fatigue
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Improper decision making or lack of judgment
2010 PEOPLE (ACTS) : Inattention/Lack of Awareness : Lack of attention/distracted by other concerns/stre
2010 PEOPLE (ACTS) : Use of Protective Methods : Disabled or removed guards, warning systems or safety
2010 PEOPLE (ACTS) : Use of Protective Methods : Equipment or materials not secured
2010 PEOPLE (ACTS) : Use of Protective Methods : Failure to warn of hazard
2010 PEOPLE (ACTS) : Use of Protective Methods : Inadequate use of safety systems
2010 PEOPLE (ACTS) : Use of Protective Methods : Personal Protective Equipment not used or used impro
2010 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Improper use/position of tools
2010 PEOPLE (ACTS) : Use of Tools, Equipment, Materials and Products : Servicing of energized equipmen
2010 PROCESS (CONDITIONS) : Organisational : Failure to report/learn from events
2010 PROCESS (CONDITIONS) : Organisational : Inadequate communication
2010 PROCESS (CONDITIONS) : Organisational : Inadequate hazard identification or risk assessment
2010 PROCESS (CONDITIONS) : Organisational : Inadequate supervision
2010 PROCESS (CONDITIONS) : Organisational : Inadequate training/competence
2010 PROCESS (CONDITIONS) : Organisational : Inadequate work standards/procedures
2010 PROCESS (CONDITIONS) : Organisational : Poor leadership/organisational culture
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate security provisions or systems
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective guards or protective barriers
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective Personal Protective Equipment
2010 PROCESS (CONDITIONS) : Protective Systems : Inadequate/defective warning systems/safety device
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate design/specificati
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate maintenance/inspect
2010 PROCESS (CONDITIONS) : Tools, Equipment, Materials & Products : Inadequate/defective tools/equ
2010 PROCESS (CONDITIONS) : Work Place Hazards : Congestion, clutter or restricted motion
2010 PROCESS (CONDITIONS) : Work Place Hazards : Hazardous atmosphere (explosive/toxic/asphyxiant)
2010 PROCESS (CONDITIONS) : Work Place Hazards : Inadequate surfaces, floors, walkways or roads
HiPoEvents
9
3
1
6
15
3
1
4
21
8
3
9
13
12
3
17
3
2
15
24
18
15
20
9
3
9
1
15
18
12
13
3
5
2
2
5
9
3
9
27
3
4
23
15
 1
3
9
2
6
9
6
4
19
47
31
22
37
15
1
10
3
13
13
21
16
3
6
5