Comprehensive List of Causes

A TOOL FOR ROOT CAUSE ANALYSIS

DESCRIPTION OF IMPLEMENTATION & RESEARCH ANALYSIS PHASE:
INCIDENT EVIDENCE GATHERING IDENTIFICATION OF CRITICAL
• Gather relevant • Organise all evidence
• Document the type/severity of • Implementation phase = direct evidence (scene and • Map evidence
• Cover the who / what / when / where / how as known at 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 explosion 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 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 Other 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 3-8 Personal protective equipment not available 7-11 Slippery floors or walkways 8-6 Other
3-9 Other 7-12 Other

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS
1. Physical 2. Physical 3. Mental State 4. Mental Stress 5. Behaviour 6. Skill Level 7. Training / Knowledge 8. Management / Supervision 9. Contractor Selection 10. Engineering / Design 11. Work Planning 12. Purchasing, Material 13. Tools and Equipment 14. Work Rules / Policies / 15. Communication
Capability Condition Transfer Employee Leadership and Oversight 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 technical 11-1 Inadequate work 12-1 Incorrect item received 13-1 Inadequate assessment 14-1 Lack of PSP for the task 15-1 Inadequate horizontal
1-2 Hearing deficiency illness 3-2 Memory failure problems rewarded of required skills transfer responsibilities qualifications design planning • inadequate of needs and risks • lack of defined communication between
1-3 Other sensory Fatigue 3-3 Poor co-ordination or 4-2 Frustration • saves time or effort 6-2 Inadequate practice of • inability to • unclear reporting 9-2 Inadequate contractor • design input obsolete 11-2 Inadequate preventative specifications to vendor 13-2 Inadequate human responsibility for PSP peers
deficiency • due to workload reaction time 4-3 Confusing • avoids discomfort skill comprehend relationships pre-qualifications • design input not maintenance • inadequate factors / ergonomics • lack of job safety 15-2 Inadequate vertical
1-4 Reduced respiratory • due to lack of rest 3-4 Emotional disturbance directions/demands • gains attention 6-3 Infrequent performance • inadequate instruction • conflicting reporting 9-3 Inadequate contractor correct • assessment of needs specifications on considerations analysis communication between
capacity • due to sensory 3-5 Fears or phobias 4-4 Conflicting 5-2 Improper supervisory of skill qualifications relationships selection • design input not • lubrication / servicing requisition 13-3 Inadequate standards or • inadequate job safety supervisor and person
1-5 Other permanent overload 3-6 Low mechanical directions/demands example 6-4 Lack of coaching on • inadequate training • unclear assignment of 9-4 Use of non-approved available • adjustment / assembly • inadequate control on specifications analysis 15-3 Inadequate
physical disabilities 2-2 Diminished performance aptitude 4-5 Meaningless or 5-3 Inadequate identification skill equipment responsibility contractor • design output • clearing / resurfacing changes to orders 13-4 Inadequate availability 14-2 Inadequate development communication between
1-6 Temporary disabilities • due to temperature 3-7 Low learning aptitude degrading activities of critical safe 6-5 Insufficient review of • misunderstood • conflicting assignment 9-5 Lack of job oversight inadequate 11-3 Inadequate repair • unauthorised 13-5 Inadequate adjustment / of PSP different organisations
1-7 Inability to sustain body extremes 3-8 Influenced by 4-6 Emotional overload behaviours instruction to establish instructions of responsibility 9-6 Inadequate oversight • design input feasible • communication of substitution repair / maintenance • inadequate co- 15-4 Inadequate
positions • due to oxygen medication 4-7 Extreme judgement 5-4 Inadequate skill 7-2 Inadequate recall of • improper or 9-7 Other • design output unclear needed repair • inadequate product 13-6 Inadequate salvage and ordination with process communication between
1-8 Restricted range of body deficiency 3-9 Other decisions/demands reinforcement of critical 6-6 Other training material insufficient delegation ‰ Not applicable • design output not • scheduling of work acceptance reclamation / equipment design work groups
movement • due to atmospheric ‰ Not applicable 4-8 Extreme concentration/ safe behaviours ‰ Not applicable • training not reinforced 8-2 of authority correct • examination of parts requirements 13-7 Inadequate removal / • inadequate employee 15-5 Inadequate
1-9 Substance sensitivities pressure variation perception demands • proper performance is on the job Inadequate leadership • design output • parts substitution • no acceptance replacement of involvement n the communication between
or allergies 2-3 Blood sugar 4-9 Extreme boredom criticised • inadequate refresher • standards of inconsistent 11-4 Excessive wear and tear verification performed unsuitable items development shifts
1-10 Inadequate size or insufficiency 4-10 Other •Inappropriate peer training frequency performance missing or • no independent design • inadequate planning 12-2 Inadequate research on 13-8 No equipment record • inadequate definition 15-6 Inadequate
strength 2-4 Impainment due to drug ‰ Not applicable 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 • inadequate effort • inadequate 10-2 Inadequate standards, • extension of service 12-3 Inadequate mode or 13-9 Inadequate equipment • inadequate format for 15-7 No communication
to medication Other performance feedback • inadequate training accountability specifications, and/or life route of shipment record history easy use method available
1-12 Other ‰ Not applicable • inadequate disciplinary program design • inadequate or incorrect design criteria • improper loading 12-4 Improper handling of 13-10 Other 14-3 Inadequate 15-8 Incorrect instructions
‰ Not applicable process • inadequate training performance feedback 10-3 Inadequate assessment • use by untrained materials ‰ Not applicable implementation of PSP, 15-9 Inadequate
5-5 Inappropriate goals / objectives • inadequate work site of potential failure people 12-5 Improper storage of due to deficiencies communication due to
aggression • inadequate new walk-through 10-4 Inadequate ergonomic • use for wrong purpose materials or spare parts • contradictory job turnover
5-6 Improper use or employee orientation • inadequate safety design 11-5 Inadequate reference 12-6 Inadequate material requirements 15-10 Inadequate
production incentives • inadequate initial 8-3 promotion 10-5 Inadequate monitoring materials or publications packaging • confusing format communication of safety
5-7 Supervisor implied training Inadequate correction of of construction 11-6 Inadequate audit / 12-7 Material shelf life • more than one action and health data,
haste • inadequate means to 8-4 prior hazard / incident 10.6 Inadequate assessment inspection / monitoring exceeded per step regulations or
5.8 Employee perceived determine if qualified for Inadequate identification of operational readiness • no documentation 12-8 Improper identification • no check-off spaces guidelines
haste job 8-5 of worksite / job hazards 10-7 Inadequate monitoring • no correction of hazardous materials provided 15-11 Standard terminology
5.9 Other 7-4 No training provided Inadequate management of initial operation responsibility assigned 12-9 Improper salvage and/or • inaccurate sequence of not used
‰ Not applicable • need for training not 8-6 of change system 10-8 Inadequate evaluation • no accountability for waste disposal steps 15-12 Verification / repeat back
identified Inadequate incident and/or documentation of corrective action 12-10 Inadequate use of safety • confusing instructions techniques not used
• training records reporting / investigation change 11-7 Inadequate job and health data • technical error / 15-13 Messages too long
incorrect or out of date 8-7 system 10-9 Other placement 12-11 Other missing steps 15-14 Speech interference
• new work methods Inadequate or lack of ‰ Not applicable • appropriate personnel ‰ Not applicable • excessive references 15-15 Other
introduced without 8-8 safety meetings not identified • potential situations not ‰ Not applicable
training Inadequate performance • appropriate personnel covered
• decision made not to measurement and not available 14-4 Inadequate enforcement
train 8-9 assessment • appropriate personnel of PSP
7-5 Other ‰ Other not provided • inadequate monitoring
‰ Not applicable Not applicable 11-8 Other of work
‰ Not applicable • inadequate supervisory
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
For each identified critical factor, consider if any of the
listed root cause categories apply. If “yes”, circle the languages
listed root cause categories apply. If “yes”, circle the
specific root cause. If none of the root causes in the • incomplete integration
specific root cause. If none of the root causes in the
category apply, then check the “not applicable” box at the with training
category apply, then check the “not applicable” box at the
bottom of the column. • out of date revisions
bottom of the column.
still in use
14-6 • Other
‰ • Not applicable

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

Management leadership,
commitment & accountability
• Align with AMEC Performance Standards elements
ELEMENTS OF PERFORMANCE STANDARDS
Employee competency Impact upon the community
Risk Assessment and Management Design & Construction Operations & Maintenance Occupational health Third party management Incident investigation and analysis Measurement, audit & review
& involvement & emergency planning