Comprehensive List of Causes - Webs

1 DESCRIPTION OF INCIDENT Document the type/severity of Cover the who / what / when / where / how as known at theIMPLEMENTATION & RESEARCHEVIDENCE GATHERING Gather relevant Implementation phase = direct evidence (scene and Research phase = indirect evidence (written Consider People / Parts / Position / analysis PHASE:IDENTIFICATION OF CRITICAL Organise all evidence Map evidence Identify critical factors USE CLC to identify all immediate and rootManagement leadership,commitment & accountabilityVision deficiencyHearing deficiencyOther sensorydeficiencyReduced respiratorycapacityOther permanentphysical disabilitiesTemporary disabilitiesInability to sustain bodypositionsRestricted range of bodymovementSubstance sensitivitiesor allergiesInadequate size orstrengthDiminished capacity dueto medicationOtherNot applicable1-11-21-31-41-51-61-71-81-91-1 01. Physical Capability1-111-12 Previous injury orillnessFatigue due to workload due to lack of rest due to sensoryoverloadDiminished performance due to temperatureextremes due to oxygendeficiency due to atmosphericpressure variationBlood sugarinsufficiencyImpainmentdue to drugor alcohol useOtherNot applicable2-12-22-32-42.))

2 Physical Condition Poor judgementMemory failurePoor co-ordination orreaction timeEmotional disturbanceFears or phobiasLow mechanicalaptitudeLow learning aptitudeInfluenced bymedicationOtherNot applicable3-13-23-33-43-53-63-73. Mental State3-83-9 Preoccupation withproblemsFrustrationConfusingdirectio ns/demandsConflictingdirections/demandsM eaningless ordegrading activitiesEmotional overloadExtreme judgementdecisions/demandsExtreme concentration/perception demandsExtreme boredomOtherNot applicable4-14-24-34-44-54-64-74-84. Mental Stress4-94-10 Improper performance isrewarded saves time or effort avoids discomfort gains attentionImproper supervisoryexampleInadequate identificationof critical safebehavioursInadequatereinforcement of criticalsafe behaviours proper performance iscriticised Inappropriate peerpressure inadequateperformance feedback inadequate disciplinaryprocessInappropriateaggressi onImproper use orproduction incentivesSupervisor impliedhasteEmployee perceivedhasteOtherNot applicable5-15-25-35-45-55-65-75.

3 Inadequate knowledgetransfer inability tocomprehend inadequate instructionqualifications inadequate trainingequipment misunderstoodinstructionsInadequate recall oftraining material training not reinforcedon the job inadequate refreshertraining frequencyInadequate trainingeffort inadequate trainingprogram design inadequate traininggoals / objectives inadequate newemployee orientation inadequate initialtraining inadequate means todetermine if qualified forjobNo training provided need for training notidentified training recordsincorrect or out of date new work methodsintroduced withouttraining decision made not totrainOtherNot applicable7-17-27-37-47. Training / Knowledge Transfer7-5 Lack of contractor pre-qualificationsInadequate contractorpre-qualificationsInadequate contractorselectionUse of non-approvedcontractorLack of job oversightInadequate oversightOtherNot applicable9-19-29-39-49-59. Contractor Selection and Oversight9-69-7 Inadequate technicaldesign design input obsolete design input notcorrect design input notavailable design outputinadequate design input feasible design output unclear design output notcorrect design outputinconsistent no independent designreviewInadequate standards,specifications, and/ordesign criteriaInadequate assessmentof potential failureInadequate ergonomicdesignInadequate monitoringof constructionInadequate assessmentof operational readinessInadequate monitoringof initial operationInadequate evaluationand/or documentation ofchangeOtherNot applicable10-110.

4 Engineering / Design10-810-9 Inadequate workplanningInadequate preventativemaintenance assessment of needs lubrication / servicing adjustment / assembly clearing / resurfacingInadequate repair communication ofneeded repair scheduling of work examination of parts parts substitutionExcessive wear and tear inadequate planningfor use extension of servicelife improper loading use by untrainedpeople use for wrong purposeInadequate referencematerials or publicationsInadequate audit /inspection / monitoring no documentation no correctionresponsibility assigned no accountability forcorrective actionInadequate jobplacement appropriate personnelnot identified appropriate personnelnot available appropriate personnelnot providedOtherNot applicable11-111-211-311-411. Work Planning11-8 Incorrect item received inadequatespecifications to vendor inadequatespecifications onrequisition inadequate control onchanges to orders unauthorisedsubstitution inadequate productacceptancerequirements no acceptanceverification performedInadequate research onmaterials / equipmentInadequate mode orroute of shipmentImproper handling ofmaterialsImproper storage ofmaterials or spare partsInadequate materialpackagingMaterial shelf lifeexceededImproper identificationof hazardous materialsImproper salvage and/orwaste disposalInadequate use of safetyand health dataOtherNot applicable12-112-212-312-412-512-612-712 -812.

5 Purchasing, Material Handling and Material Control12-912-1012-11 Inadequate horizontalcommunication betweenpeersInadequate verticalcommunication betweensupervisor and personInadequatecommunication betweendifferent organisationsInadequatecommunication betweenwork groupsInadequatecommunication betweenshiftsInadequatecommunication methodsNo communicationmethod availableIncorrect instructionsInadequatecommunication due tojob turnoverInadequatecommunication of safetyand health data,regulations orguidelinesStandard terminologynot usedVerification / repeat backtechniques not usedMessages too longSpeech interferenceOtherNot applicable15-115-215-315-415-515-615-715 -815-915-1015-1115. Communication15-1215-1315-1415-15 PERSONAL FACTORSD esign & ConstructionRisk Assessment and ManagementOperations & MaintenanceOccupational healthEmployee competency& involvementThird party managementIncident investigation and analysisImpact upon the community& emergency planningMeasurement, audit & reviewInadequate assessmentof required skillsInadequate practice ofskillInfrequent performanceof skillLack of coaching onskillInsufficient review ofinstruction to establishskillOtherNot applicable6-26-36-46-56.

6 Skill Level6-6 6-1 JOB FACTORSC onflicting roles /responsibilities unclear reportingrelationships conflicting reportingrelationships unclear assignment ofresponsibility conflicting assignmentof responsibility improper orinsufficient delegationof authorityInadequate leadership standards ofperformance missing ornot enforced inadequateaccountability inadequate or incorrectperformance feedback inadequate work sitewalk-through inadequate safetypromotionInadequate correction ofprior hazard / incidentInadequate identificationof worksite / job hazardsInadequate managementof change systemInadequate incidentreporting / investigationsystemInadequate or lack ofsafety meetingsInadequate performancemeasurement andassessmentOtherNot applicable8-18. management / Supervision Employee Leadership assessmentof needs and risksInadequate humanfactors / ergonomicsconsiderationsInadequate standards orspecificationsInadequate availabilityInadequate adjustment /repair / maintenanceInadequate salvage andreclamationInadequate removal /replacement ofunsuitable itemsNo equipment recordhistoryInadequate equipmentrecord historyOtherNot applicable13-113-213.

7 Tools and Equipment13-913-10 13-313-413-513-613-713-8 Lack of PSP for the task lack of definedresponsibility for PSP lack of job safetyanalysis inadequate job safetyanalysisInadequate developmentof PSP inadequate co-ordination with process/ equipment design inadequate employeeinvolvement n thedevelopment inadequate definitionof correction actions inadequate format foreasy useInadequateimplementation of PSP,due to deficiencies contradictoryrequirements confusing format more than one actionper step no check-off spacesprovided inaccurate sequence ofsteps confusing instructions technical error /missing steps excessive references potential situations notcoveredInadequate enforcementof PSP inadequate monitoringof work inadequate supervisoryknowledge inadequatereinforcement non-compliant notcorrectedInadequatecommunication of PSP incomplete distributionto work groups inadequate translationto appropriatelanguages incomplete integrationwith training out of date revisionsstill in use Other Not applicable14-114-214.

8 Work Rules / Policies / Standards / Procedures (PSP)14-514-6 14-314-4 ELEMENTS OF PERFORMANCE STANDARDS Align with AMEC Performance Standards elementsCORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTIONPOSSIBLE SYSTEM CAUSESFor each identified critical factor, consider if any of thelisted root cause categories apply. If yes , circle thespecific root cause. If none of the root Causes in thecategory apply, then check the not applicable box at thebottom of the each identified critical factor, consider if any of thelisted root cause categories apply. If yes , circle thespecific root cause. If none of the root Causes in thecategory apply, then check the not applicable box at thebottom of the by individualViolation by groupViolation by supervisorOperation of equipment without authorityImproper position or posture for the taskOverexertion of physical capabilityWork or motion at improper speedImproper liftingImproper loadingShortcutsOther1-11-21-31-41-51-61 -71-81-91-101-111.

9 Following ProceduresACTIONSC omprehensive List of CausesComprehensive List of CausesA TOOL FOR ROOT CAUSE ANALYSISA TOOL FOR ROOT CAUSE ANALYSISPOSSIBLE SYSTEM CAUSESCONDITIONSI mproper use of equipmentImproper use of toolsUse of defective equipment (aware)Use of defective tools (aware)Improper placement of tools, equipment ormaterialsOperation of equipment at improper speedServicing of equipment in operationOther2-12-22-32-42-52-62-72-82. Use of Tools or EquipmentLack of knowledge of hazards presentPersonal protective equipment not usedImproper use of proper personal protectiveequipmentServicing of energised equipmentEquipment of materials not securedDisabled guards, warning systems or safetydevicesRemoval of guards, warning systems or safetydevicesPersonal protective equipment not availableOther3-13-23-33-43-53-63-73-83- 93. Use of Protective MethodsImproper decision making or lack ofjudgementDistracted by other concernsInattention to footing and surroundingsHorseplayActs of violenceFailure to warnUse of drugs or alcoholRoutine activity without thoughtOther4-14-24-34-44-54-64-74-84-94 .

10 Inattention / Lack of AwarenessInadequate guards or protective devicesDefective guards or proactive devicesInadequate personal protective equipmentDefective personal protective equipmentInadequate warning systemsDefective warning systemsInadequate isolation of process or equipmentInadequate safety devicesDefective safety devicesOther5-15-25-35-45-55-65-75-85-95 -105. Protective SystemsDefective equipmentInadequate equipmentImproperly prepared equipmentDefective toolsInadequate toolsImproperly prepared toolsDefective vehicleInadequate vehicle for the purposeImproperly prepared vehicleOther6-16-26-36-46-56-66-76-86-96 -106. Tools, Equipment and VehiclesFire or explosionNoiseEnergised electrical systemsEnergised systems, other than electricalRadiationTemperature extremesHazardous chemicalsMechanical hazardsClutter or debrisStorms or acts of natureSlippery floors or walkwaysOther7-17-27-37-47-57-67-77-87-9 7-107-117-127. Work Exposures toCongestion or restricted motionInadequate or excessive illuminationInadequate ventilationUnprotected heightInadequate workplace layoutcontrols less than adequate displays less than adequate labels less than adequate locations out of reach or sight conflicting information is presentedOther8-18-28-38-48-58-68.