People Parts

Comprehensive List of Causes

A TOOL FOR ROOT CAUSE ANALYSIS Solutions
DESCRIPTION OF IMPLEMENTATION & RESEARCH PHASES: ANALYSIS PHASE:
INCIDENT EVIDENCE GATHERING IDENTIFICATION OF CRITICAL FACTORS
Document the type / severity of Gather relevant evidence Organise all evidence
event Positions Paper
Implementation phase = direct evidence (scene and witnesses) Map evidence
Cover the who / what / when / Research phase = indirect evidence (written sources) Identify critical factors
where / how as known at the time
Consider People / Parts / Position / Paper Use CLC to identify all immediate and root causes

POSSIBLE IMMEDIATE 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 & Vehicles 7. Work Exposures to 8. Work Place 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 judgment 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 4-2 Distracted by other concerns 5-2 Defective guards or protective 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 4-3 Inattention to footing and surroundings 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energized electrical systems 8-3 Inadequate ventilation
1-4 Operation of equipment without authority 2-4 Use of defective tools (aware) equipment 4-4 Horseplay 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energized 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 energized equipment 4-5 Acts of violence 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate work place layout
1-6 Overexertion of physical capability materials 3-5 Equipment or materials not secured 4-6 Failure to warn 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 devices 4-7 Use of drugs or alcohol 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 3-7 Removal of guards, warning systems or safety 4-8 Routine activity without thought 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 devices 4-9 Other 5-9 Defective safety devices 6-9 Improperly prepared vehicle 7-9 Clutter or debris locations out of reach or sight
1-10 Shortcuts 3-8 Personal protective equipment not available 5-10 Other 6-10 Other 7-10 Storms or acts of nature conflicting information is presented
1-11 Other 3-9 Other 7-11 Slippery floors or walkways 8-6 Other
7-12 Other

POSSIBLE SYSTEM CAUSES

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

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

Align with Getting HSE Right elements

ELEMENTS OF GETTING HSE RIGHT

Leadership and Accountability Risk Assessment and People, Training and Working with Facilities Design and Operations and Maintenance Management of Information and Customers and Community and Stakeholder Crisis and Emergency Incidents Analysis and Assessment, Assurance
Management Behaviours Contractors and Others Construction Change Documentation Products Awareness Management Prevention and Improvement

Form 3862 Rev 1 Feb 99