Comprehensive

Comprehensive List of Cause

uses
A TOO
TOOL FOR ROOT CAUSE ANA
ANALYSIS
DESCRIPTION IMPLEMENTATION &
OF INCIDENT RESEARCH EVIDENCE ANALYSIS PHASE:
GATHERING IDENTIFICATION OF
• Document the type/severity of CRITICAL
• Gather relevant • Organise all evidence
• Cover the who / what / when / where / how as known at • Implementation phase = direct evidence (scene and • Map evidence
the • Research phase = indirect evidence (written • Identify critical factors
• Consider People / Parts / Position / • USE CLC to identify all immediate and root

POSSIBLE SYSTEM 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 and Vehicles 7. Work Exposures to 8. Workplace 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 5-1 Inadequate guards or protective devices 6-1 Defective equipment 7-1 Fire or 8-1 Congestion or restricted motion
1-2
Violation by group 2-2 Improper use of tools 3-2 Personal protective equipment not used judgement 5-2 Defective guards or proactive devices 6-2 Inadequate equipment 7-2 explosion 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 4-2 Distracted by other concerns 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energised electrical systems 8-3 Inadequate ventilation
1-4
Operation of equipment without authority 2-4 Use of defective tools (aware) equipment 4-3 Inattention to footing and surroundings 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energised 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 3-4 Servicing of energised equipment 4-4 Horseplay 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate workplace layout
1-6
Overexertion of physical capability materials 3-5 Equipment of materials not secured 4-5 Acts of violence 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 2-6 Operation of equipment at improper speed 3-6 Disabled guards, warning systems or safety 4-6 Failure to warn 5-7 Inadequate isolation of process or equipment 6-7 Defective vehicle 7-7 Hazardous chemicals • displays less than adequate
1-8
Improper lifting 2-7 Servicing of equipment in operation devices 4-7 Use of drugs or alcohol 5-8 Inadequate safety devices 6-8 Inadequate vehicle for the purpose 7-8 Mechanical hazards • labels less than adequate
1-9
Improper loading 2-8 Other 3-7 Removal of guards, warning systems or safety 4-8 Routine activity without thought 5-9 Defective safety devices 6-9 Improperly prepared vehicle 7-9 Clutter or debris • locations out of reach or sight
1-10 Shortcuts devices 4-9 Other 5-10 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 3-8 Personal protective equipment not available Other 7-11 Slippery floors or walkways 8-6 Other
3-9 Other 7-12 Other

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS
1. Physical
Capability 2. Physical 3. Mental State 4. Mental Stress 5. Behaviour 6. Skill Level 7. Training / Knowledge 8. Management / Supervision 9. Contractor Selection 10. Engineering / 11. Work Planning 12. Purchasing, Material 13. Tools and Equipment 14. Work Rules / Policies / 15. Communication
Condition Transfer Employee Leadership and Oversight Design Handling and Material Control Standards / Procedures (PSP)
1-1 Vision deficiency 2-1 Previous injury or 3-1 Poor judgement 4-1 Preoccupation with 5-1 Improper performance is 6-1 Inadequate assessment 7-1 Inadequate knowledge 8-1 Conflicting roles / 9-1 Lack of contractor pre- 10-1 Inadequate 11-1 Inadequate work 12-1 Incorrect item received 13-1 Inadequate 14-1 Lack of PSP for the task Inadequate horizontal
1-2 Hearing deficiency illness 3-2 Memory failure problems rewarded of required skills transfer responsibilities qualifications technical design • inadequate assessment of needs • lack of defined communication between
planning
1-3 Other sensory Fatigue 3-3 Poor co-ordination or 4-2 Frustration • saves time or effort Inadequate practice of • inability to • unclear reporting 9-2 Inadequate contractor • design input obsolete 11-2 Inadequate preventative specifications to and risks responsibility for PSP peers
6-2
deficiency • due to workload reaction time 4-3 Confusing • avoids discomfort skill comprehend relationships pre-qualifications • design input not maintenance vendor 13-2 Inadequate human • lack of job Inadequate vertical
1-4 Reduced respiratory • due to lack of rest 3-4 Emotional disturbance directions/demands • gains attention Infrequent performance • inadequate • conflicting reporting 9-3 Inadequate contractor correct factors / ergonomics safety analysis communication between
6-3 • assessment of needs • inadequate
capacity • due to sensory 3-5 Fears or phobias 4-4 Conflicting 5-2 Improper supervisory of skill instruction relationships selection • design input not • lubrication / servicing specifications on considerations • inadequate job safety supervisor and person
1-5 Other permanent overload 3-6 Low mechanical directions/demands example Lack of coaching on qualifications • unclear assignment of 9-4 Use of non-approved available requisition 13-3 Inadequate standards analysis Inadequate
6-4 • adjustment / assembly
physical disabilities 2-2 Diminished performance aptitude 4-5 Meaningless or 5-3 Inadequate identification skill • inadequate responsibility contractor • design output • clearing / resurfacing • inadequate control on or specifications 14-2 Inadequate communication between
1-6 Temporary disabilities • due to temperature 3-7 Low learning aptitude degrading activities of critical safe Insufficient review of training equipment • conflicting assignment 9-5 Lack of job oversight inadequate 11-3 Inadequate repair changes to orders 13-4 Inadequate availability development of PSP different organisations
6-5
1-7 Inability to sustain body extremes 3-8 Influenced by 4-6 Emotional overload behaviours instruction to • misunderstood of responsibility 9-6 Inadequate oversight • design input feasible • communication of • unauthorised 13-5 Inadequate adjustment • inadequate co- Inadequate
positions • due to oxygen medication 4-7 Extreme judgement 5-4 Inadequate establish skill 7-2 instructions • improper or 9-7 Other • design output unclear needed repair substitution / repair / maintenance ordination with communication between
1-8 Restricted range of body deficiency 3-9 Other decisions/demands reinforcement of critical 6-6 Other Inadequate recall of insufficient delegation D Not applicable • design output not • scheduling of work • inadequate 13-6 Inadequate salvage and process work groups
movement • due to atmospheric D Not applicable 4-8 Extreme concentration/ safe behaviours D Not applicable training material 8-2 of authority correct • examination of parts product acceptance reclamation / equipment design Inadequate
1-9 Substance pressure variation perception demands • proper performance is • training not reinforced Inadequate leadership • design output • parts substitution requirements 13-7 Inadequate removal / • inadequate communication between
sensitivities or 2-3 Blood sugar 4-9 Extreme boredom criticised on the job • standards of inconsistent 11-4 Excessive wear and tear • no acceptance replacement of employee involvement shifts
allergies • inadequate refresher verification performed unsuitable n the development
items
1-10 Inadequate size or insufficiency 4-10 •Inappropriate peer training performance missing or • no independent design • inadequate planning 12-2 Inadequate research on 13-8 No equipment record • inadequate definition Inadequate
Other frequency
strength 2-4 Impainment due to drug D Not pressure 7-3 Inadequate training not enforced review for use materials / equipment history of correction actions communication methods
1-11 Diminished capacity due or alcohol use applicable • inadequate effort • inadequate 10-2 Inadequate • extension of service 12-3 Inadequate mode or 13-9 Inadequate • inadequate format for No communication
to medication Other performance feedback • inadequate accountability standards, life route of shipment equipment record easy use method available
1-12 Other D Not applicable • inadequate disciplinary training program • inadequate or incorrect specifications, and/or • improper loading 12-4 Improper handling of history 14-3 Inadequate Incorrect instructions
design design criteria 13-10 Other
D Not process • inadequate performance feedback 10-3 Inadequate assessment • use by untrained materials D Not implementation of PSP, Inadequate
applicable 5-5 Inappropriate training goals / • inadequate work site of potential failure people 12-5 Improper storage of applicable due to deficiencies communication due to
aggression objectives walk-through 10-4 Inadequate ergonomic • use for wrong purpose materials or spare parts • contradictory job turnover
5-6 Improper use or • inadequate new • inadequate design 11-5 Inadequate reference 12-6 Inadequate material requirements Inadequate
production employee orientation 8-3 safety promotion 10-5 Inadequate monitoring materials or publications packaging • confusing format communication of safety
5-7 incentives • inadequate initial Inadequate correction of of construction 11-6 Inadequate audit / 12-7 Material shelf life • more than one action and health data,
Supervisor implied training prior hazard / incident 10.6 Inadequate assessment inspection / monitoring exceeded per step regulations or
8-4
5.8 haste • inadequate means to Inadequate identification of operational readiness • no documentation 12-8 Improper identification • no check-off spaces guidelines
Employee perceived determine if qualified for 8-5 of worksite / job hazards Inadequate monitoring of hazardous materials provided Standard terminology
10-7 • no correction
5.9 haste 7-4 job Inadequate management of initial operation responsibility assigned 12-9 Improper salvage and/or • inaccurate sequence not used
D Other No training provided of change system 10-8 Inadequate evaluation • no accountability for waste disposal of steps 15-12 Verification / repeat back
8-6
Not applicable • need for training not Inadequate incident and/or documentation of corrective action 12-10 Inadequate use of • confusing instructions techniques not used
identified reporting / investigation change safety • technical error / 15-13 Messages too long
11-7 Inadequate job
• training records 8-7 system 10-9 Other and health data missing steps 15-14 Speech interference
placement
incorrect or out of date 12-11 Other
• new work methods Inadequate or lack of D Not applicable • appropriate personnel D Not • excessive references 15-15 Other
introduced without 8-8 safety meetings not identified applicable • potential situations not D Not applicable
training Inadequate performance • appropriate personnel covered
• decision made not to measurement and not available 14-4 Inadequate
train 8-9 assessment • appropriate personnel enforcement of PSP
7-5 Other D Other not provided • inadequate
D Not applicable Not applicable 11-8 Other monitoring of work
D Not • inadequate supervisory
applicable knowledge
• inadequate
reinforcement
• non-compliant not
corrected
14-5 Inadequate
communication of PSP
• incomplete distribution
to work groups
• inadequate translation
For each identified critical factor, consider if any of the to appropriate
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column. • out of date revisions
bottom of the column. still in use
14-6 • Other
D • Not applicable

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

• Align with AMEC Performance Standards elements

ELEMENTS OF PERFORMANCE STANDARDS

 Management leadership,
Employee competency Impact upon the community
commitment & accountability Risk Assessment and Management Design & Construction Operations & Maintenance Occupational health Third party management Incident investigation and analysis Measurement, audit & review
& involvement & emergency planning