WELCOME

TO TECHNIQUE SESSION IN USING

SCAT S - Systematic
C - Causal
A - Analysis
T - Technique

By, Ir. Fuad ROIYAN

 WHY DO WE NEED TO USE SCAT

We need to know that :

Investigating the causes of one accident is the most

important part of human safety and the loss control
program and to avoid its recurrence.

By, Ir. Fuad ROIYAN

 Why is that ?

* Lesson learned.
* Evaluating the risks of the job.
* Avoiding / preventing from recurrence.
* Avoiding / preventing another problem from
raising.

By, Ir. Fuad ROIYAN

 Investigating the cause of an accident is
the basic step of problem solving.

By, Ir. Fuad ROIYAN

 Steps of traditional problem solving :

* Knowing the problem.

* Getting the facts right.
* Find the source of the problem.
* Develop the problem solving possibilities.
* Select the best problem solving.

By, Ir. Fuad ROIYAN

 We will adopt that traditional steps for the basic
practice of our topic :

HOW TO USE SCAT

Efective steps :
* Knowing the problem.
(Get the picture of what is really
happened.)
* Focus to critical item.

By, Ir. Fuad ROIYAN

 * Develop the analytical cause.
* Get the real/right cause.
* Accident did not happen just like that, there is
always a cause.
* The cause of an accident is rarely the only one,
usually it is more than one.
* To find the causes of an accident we will use SCAT
technique as our guidance.

By, Ir. Fuad ROIYAN

 example (1) :

A car slipped down into the ditch because the

brakes didn’t work.

Critical item : brakes didn’t work

Development : Why didn’t the brakes work?
Possibilities/predictions :
* Something broken (hose/tube leaks, piston or
pump didn’t work, brake lining worn-out, etc.)

* Brake oil/air is empty

* Brake tune-up has not been done properly.

By, Ir. Fuad ROIYAN

 * Switch control is not clear

* Driver did not do the pre-checking before the vehicle

move.

* Driver can not control the vehicle :

Possibilities/predictions :
- Vehicle speed.
- Skill : gear transmission, controlling the steering
wheel, etc.
- Error in operating the switch, etc.

* Road condition :
Slopes downward/sinuous/slippery etc.

By, Ir. Fuad ROIYAN

 Contoh (2)

A worker, while he was working with the

grindstone, hurted his eyes with its gram iron.

Critical item : gram iron flown hitting his eyes.

Development : How could the iron hit the eyes ?
Possibilities/predictions :
* The grindstone had no safety cover, batu gerinda
tidak sesuai dst.
* The Technique & position in using the grindstone
was not correct.
* Worker did not use safety glass
* Worker using safety glass but not properly.
* Working procedure is not adequate, etc.

By, Ir. Fuad ROIYAN

 Getting the datas to support the analysis
* Statement from the worker
* Statement from the witnesses
* Field data, for example :
: material, lay out
: reconstruction (if necessary)

Selection :
Select the items that really match with the case
(combine the predictions, statements and the field
data).
If there’s still any doubts, do it all over again (test)
until the correct item is found.
Ask the help from the expertise if necessary.
After finish, follow the SCAT stages.

By, Ir. Fuad ROIYAN

 SCAT stages : (1)

Define the critical item

Example 1:
Critical item : Brake did not work.
Check SCAT on column Type of Event :

Choose the proper item item (10)

“Equipment Failure”

Item (10) will guide us to see the IC’s column, which

is to find the immediate cause.

By, Ir. Fuad ROIYAN

 SCAT stage :(2)

See on the item (10) is written:

(see : IC’s : 1, 4, 6, 8, 15)

Means :

We are guided to look for the immediate/direct

Causes on the column Immediate/Direct
Causes at item (IC’s : 1, 4, 6, 8, 15).

By, Ir. Fuad ROIYAN

 Attention!

** Immediate/Direct Causes (IC’s) column**

item : (IC’s : 1, 4, 6, 8, 15)

Choose the appropriate item, in this case choose

item : (6).
“Using defective equipment”

At this item (6) we are guided to look for the

Basic Causes column (BC’s) to find the basic
cause.

By, Ir. Fuad ROIYAN

 Tahapan SCAT: (3)

Attention!

** Basic/Underlying Causes Column(BC’s)**

item 6 (see: BC’s : 2,3,4,5,6,7,8,9,10,11,12,13,14,15)

Means :
To look for the basic cause, we are guided
to find it on the Basic/Underlying Causes
Column (BC’s) at items :
(BC’s : 2,3,4,5,6,7,8,9,10,11,12,13,14,15)

By, Ir. Fuad ROIYAN

 Choose the appropriate item :

In this case choose:

item (11.1) : Inadequate preventive maintenance

item (14.3) : Inadequate inspection and/or monitoring

By, Ir. Fuad ROIYAN

 In this case…..
Immediate/Direct Cause is :

IC (6) : Using defective Equipment

Basic/Underlying Cause is :

BC (11.1) : Inadequate preventive maintenance

and
BC (14.3) : Inadequate inspection and/or monitoring

By, Ir. Fuad ROIYAN

 Example : (2)

Critical item : gram iron hit the eyes.

Check SCAT on the column:

** Type of Event : **
Choose the appropriate item item (2)

“Strucked by (hit by moving object)”

At item (2) we are guided to look at the column

IC’s to find the immediate/direct cause.

By, Ir. Fuad ROIYAN

 See column:
“ Type of Event :”
item (2) stated :
( see : IC’s : 1,2,4,5,6,9,10,12,13,14,15,16,20,26 )

Means :
The same with example No.1, to look for Immediate /
Direct Causes) see the Immediate/Direct Causes
column (IC’s), at item :
(IC’s: 1,2,4,5,6,9,10,12,13,14,15,16,20,26 )

By, Ir. Fuad ROIYAN

 Choose the appropriate item in column
“ Immediate/Direct Causes ( IC’s)”

In This Case Choose:

item IC’s (6) : Using Defective Equipment

item IC’s(16) : Failure to follow procedures

By, Ir. Fuad ROIYAN

 Attention!

**In Immediate/Direct Causes Column (IC’s)**

is stated :
item 6 (see.BC’s: 2,3,4,5,6,7,8,9,10,11,12,13,14,15)
item16 (see.BC’s: 1,2,3,4,5,6,7,8,13)

Means :
We are guided to look for the Basic Causes in
BC’s column at the above items.

By, Ir. Fuad ROIYAN

 Choose the appropriate items in the column
“ Basic/Underlying Causes (BC’s)”

In This Case Choose:

Item (11.1) : Inadequate preventive maintenance

Item (14.3) : Inadequate inspection and/or monitoring

By, Ir. Fuad ROIYAN

 Let us practice with the actual
cases in our field.

By, Ir. Fuad ROIYAN

 Systematic Cause Analysis Technique

Determine the potential loss if it is uncontrollable

Determine one Type of Contact

Find all the potential Immediate Causes

Find all the potential Basic Causes

Make recommendation of corrective action that has to be done

By, Ir. Fuad ROIYAN

 REVIEW

LACK OF BASIC IMMEDIATE

INCIDENT LOSS
CONTROL CAUSES CAUSES

INADEQUATE
PROGRAM SUBSTANDARD
PERSONAL
ACT CONTACT PEOPLE
FACTOR
PROGRAM WITH
PROPERTY
STANDARD & ENERGY
JOB PROCESS
OR
FACTOR
COMPLIANCE SUBSTANDARD SUBSTANCE
TO STANDARD CONDITIONS

THE ILCI LOSS CAUSATION MODEL

By, Ir. Fuad ROIYAN

 REVIEW

LACK OF BASIC IMMEDIATE

INCIDENT LOSS
CONTROL CAUSES CAUSES

Loss
LOSS

By, Ir. Fuad ROIYAN

 REVIEW

LACK OF BASIC IMMEDIATE

INCIDENT LOSS
CONTROL CAUSES CAUSES

Event
(Contact w/
energy or
material)

 STRUCK AGAINST  crash/collide with moving/non-moving object

 STRUCK BY  hit/crashed by moving object
 FALL TO  fall from higher place
 FALL ON  fall at the plain ground
 CAUGHT IN  stuck by sharp objects
 CAUGHT ON  caught,trapped b/w two big objects
INCIDENT

 CAUGHT BETWEEN  cut, smashed, crushed

 CONTACT WITH  electricity, chemical, radiation, heat, cold
 OVERSTRESS  too heavy, fast, high, big
 EQUIPMENT FAILURE  machine/ equipment failure
 EVIRONMENTAL RELEASE  Pollution issues

By, Ir. Fuad ROIYAN

 REVIEW

LACK OF BASIC IMMEDIATE

INCIDENT LOSS
CONTROL CAUSES CAUSES

Immediate
Cause

 OPERATING W/O AUTHORISATION  INADEQUATE SAFETY COVER/BORDER

 FAIL TO REMIND  LACK OF APD
 FAIL TO SECURE
 IN ADEQUATE SPEED
 EQUIPMENTS ARE BROKEN

IMMEDIATE CAUSES
 MEMBUAT ALAT PENGAMAN  WORKING AREA TOO SMALL
TIDAK BERFUNGSI  LACK OF ALARM SYSTEM
 USING THE BROKEN EQUIPMENT  FIRE HAZARD
 USING INADEQUATE APD  LACK OF HOUSEKEEPING
 INADEQUATE LOADING
 INADEQUATE PLACEMENT
 NOISE
 INADEQUATE LIFTING  RADIATION
 POSITION NOT SECURE  EXTREM TEMPERATURE
 SERVICING OPERATING EQUIPMENT  INADEQUATE LIGHTING
 FOOLING AROUND  INADEQUATE VVENTILATION
 DRUNK OF AN ALCOHOL/DRUG
 FAIL TO FOLLOW THE PROCEDURE
 NON-SAEE ENVIRONMENT

By, Ir. Fuad ROIYAN

 REVIEW

LACK OF BASIC IMMEDIATE

INCIDENT LOSS
CONTROL CAUSES CAUSES

Basic
Cause

 INADEQUATE PHYSICAL OR  LEADERSHIP/SUPERVISION

PHYSIOLOGICAL ABILITY BASIC CAUSES  ENGINEERING
 INADEQUATE MENTAL ABILITY  PURCHASSING
 PHYSICAL OR PHYCOLOGICAL STRESS  LACK OF EQUIPMENT
 MENTAL STRESS  MAINTENANCE
 LACK OF KNOWLEDGE  WORKING STANDARD
 LACK OF SKILLS  MISUSED
 LACK OF MOTIVATION

By, Ir. Fuad ROIYAN

 LACK OF BASIC IMMEDIATE
INCIDENT LOSS
CONTROL CAUSES CAUSES

lack of
control

INADEQUATE PROGRAM
LACK OF CONTROL

INADEQUATE STANDARDS
INADEQUATE COMPLIANCE
WITH STANDARD

By, Ir. Fuad ROIYAN

 Wound None Type of accident : Severity : Serious
Loss Lamp is broken Property Damage Probalility: Rarely

Type of Contact :
No.8 Contact with electricity (IC’s: 5,6,7,11,12,13,14,15,16,17,18,20,21,23,24,25,27,28)
Immediate Causes : 5, 6, 16, 17
No.5 To cause safety equipment not functioning.
Fuse was jumped
No.6 Using the broken equipment.
Isolation of sitting lamp cable connection is disclose.
No.16 Fail to follow the procedure.
Fuse reparation is inadequate ;
Inadequate in moving / handling the electric equipment.
No.17 Equipment protection / border is inadequate
Jumped Fuse ; Cable connection peeled-off.

By, Ir. Fuad ROIYAN

 No.5 BC’s: 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15
No.6 BC’s: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15
No.16 BC’s: 1, 2, 3, 4, 5, 6, 7, 8, 13
No.17 BC’s: 5, 7, 8, 10, 11, 12, 13, 15
Basic Causes : 5, 8, 9, 11, 13, 14
No.5 Lack of knowledge
Room Boy was not aware of the electrical danger, held the cable / electric equipment
with wet hands.
No.8 Inadequate Leadership / Supervision
Electrical Supervisor did not know that the mechanic jump the fuse.
No.9 Inadequate Engineering
Electric over burden often happen in the building. Need to review the distribution of the
electric burden or add the capacity.
No.11 Inadequate maintenance
Changing the fuse and electric over burden did not receive enough attention
Portable electrical equipment inspection has not been done properly.
No.13 Inadequate working standard
Working standard of repairing / changing the fuse has not been done properly.
No.14 Misuse
Inadequate electric distribution ; Using the broken cable (cable connection was
improper)

By, Ir. Fuad ROIYAN

 RECOMMENDATION :
Remedial Action :
 Inspection to all the electric equipment, capacity and the electric burden usage in
the building to be done immediately.
 Change and repair immediately if the fuse was cut off / jumped.

Further Action :
 Improve the supervision at the Electric Maintenance Department
 Improve the inspection quality.
 Review the overall electric distribution.
 Hold a safety meeting with the topic “The electric danger and the function of a fuse
as a safe-guard tool for electric.”
 Issue last warning letter to the electrical mechanic who jumps the fuse.
 First warning to be given to electrical mechanic supervisor.

By, Ir. Fuad ROIYAN