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SCAT Systematic Cause Analysis Technique

This document provides an overview of the Systematic Cause Analysis Technique (SCAT) for investigating accidents and incidents. SCAT uses a chart and methodology to thoroughly determine the causes. It identifies immediate, basic, and lack of control causes according to the Loss Causation Model. SCAT benefits include checking investigation effectiveness and reinforcing that accidents rarely have a single cause. The document outlines reasons investigations may miss causes and provides guidance on gaining compliance with standards to prevent future occurrences.

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Indra Wardhana
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
5K views

SCAT Systematic Cause Analysis Technique

This document provides an overview of the Systematic Cause Analysis Technique (SCAT) for investigating accidents and incidents. SCAT uses a chart and methodology to thoroughly determine the causes. It identifies immediate, basic, and lack of control causes according to the Loss Causation Model. SCAT benefits include checking investigation effectiveness and reinforcing that accidents rarely have a single cause. The document outlines reasons investigations may miss causes and provides guidance on gaining compliance with standards to prevent future occurrences.

Uploaded by

Indra Wardhana
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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S.C.A.

T
SESSI 7

ACCIDENT/
INCIDENT
INVESTIGATION

Accident/Incident
Investigation

SCAT
Systematic
Cause
Analysis
Technique

Objectives
 Attendees will understand the process of

accident and / or incident causation.


 Attendees will have a thorough understanding
of the SCAT chart and its methodology of
determining causes.
 Attendees will understand a simple and
practical technique valuable in determining if
an investigation of an accident or incident has
been thorough enough.

Overview
 Introduce a systematic approach to

investigation
 Review Loss Causation Model
 Orient SCAT chart
 Identify causes and control activities
 Determine necessary control actions

SCAT Benefits
 Excellent for checking investigation

effectiveness
 A system for analyzing and evaluating causes
 A system for developing control effectiveness
 Reinforces the Principle of Multiple Causes
 A reminder of causes and control of accidental
losses

Reasons for Inadequate Causal


Identification
1.
2.
3.
4.
5.

Failure to do a good investigation


Failure to take enough time
Failure to use a systematic approach
Forgetting previous training
Improper motivation

Reasons for Inadequate Causal


Identification
6.
7.
8.
9.
10.

Lack of method for checking results


Identifying only obvious causes
Many causes easy to overlook
Some causes difficult to identify
Causes selected haphazardly

Principle of Multiple Causes

Accidents and other


problems are seldom,
if ever, the result of a
single cause.

Loss Causation Model


LACK OF
CONTROL

BASIC
CAUSES

IMMEDIATE
CAUSES

INCIDENT

LOSS

Event

Unintended
Harm
and / or
Damage

Inadequate:
System
System
Standards
Compliance
to System
Standards

Personal
&
Job/
System
Factors

Substandard
Practices,
Acts
&
Conditions

Threshold Limit

Loss Causation Model


LOSS

Unintended
Harm
and / or
Damage

People
Property
Process
Product
Planet
Profit

Loss Causation Model


INCIDENT

EVENT

Events are Normally


Contacts with an Energy
Source or Substance:
Struck Against
Struck By
Caught Between
Contact With

Caught In
Fall To
Fall On
Overstress

Loss Causation Model


Examples:
IMMEDIATE
CAUSES
SUBSTANDARD
ACTS,
PRACTICES,
&
CONDITIONS

Substandard Acts Substandard


& Practices
Conditions
Failure to warn
Failure to secure
Improper lifting
Failure to use PPE
Horseplay
Defective Tools
etc.

Inadequate guards
Inadequate PPE
Congestion
Excessive Exposures
Disorder
Noise
etc.

Loss Causation Model


BASIC
CAUSES
PERSONAL
&
JOB/
SYSTEM
FACTORS

Job /System
Factors

Personal Factors

Inadequate:
Inadequate:
- Leadership
- Capability
- Engineering
- Knowledge
- Purchasing
- Skill
- Tools / Eqpt.
Stress
- Work Standards Improper Motivation
Wear and Tear
Abuse and Misuse

Loss Causation Model


LACK OF
CONTROL
INADEQUATE:

Is there a loss control management


in place?
Are there system standards?

SYSTEM
SYSTEM
STANDARDS
COMPLIANCE
TO SYSTEM
STANDARDS

Are the standards adequate?


Is there compliance to system
standards?
At what level is the compliance?

Loss Causation Model


The Management Work for Loss Control Success:
1. Leadership & Administration
2. Leadership Training
3. Planned Inspections & Maintenance
4. Critical Task Analysis & Procedures
5. Accident / Incident Investigation
6. Task Observation
7. Emergency Preparedness
8. Rules & Work Permits
9. Accident / Incident Analysis
10. Knowledge & Skill Training

11. Personal Protective Equipment


12. Health & Hygiene Control
13. System Evaluation
14. Engineering &Change Management
15. Personal Communications
16. Group Communications
17. General Promotion
18. Hiring & Placement
19. Materials & Services Management
20. Off-the-Job Safety

Systematic Cause Analysis Technique


Description of accident / incident
Evaluation of loss potential
Type of contact or near contact
Immediate / direct causes
Basic / underlying causes
Control action needs

Gaining Compliance with


Standards
 Communicate standards
 Review and update standards
 Reinforce performance to standards
 Reeducate / review for understanding
 Practice progressive discipline

Sources of Loss / Control


Opportunities for

P
E
M
E

People
Equipment
Materials
Environment

Status of Current Control Activities


P: Do we have a system and / or system standards for this activity?
Yes
or
No
If No, check P and begin by developing a system and / or system
standards.
S: Are existing system standards adequate?
Yes
or
No
If No, check S and develop adequate system standards.
C: Is there full compliance with system standards?
Yes
or
No
If No, check C and develop means to ensure compliance.

Factors Determining
Control Actions
1. Risk of further losses?
2. Potential for other types of losses?
3. Investigation quality?
4. Extent of management participation?
5. Funds, time, manpower available?
6. Level of control excellence desired?

Guide to Risk Decisions


1. Potential loss severity if an accident occurs:
A - Major
B - Serious
C - Minor
2. Probability that loss will occur:
A - High
B - Moderate

C - Low

3. Cost of recommended control:


A - High
B - Medium

C - Low

4. Degree of control:
A - Substantial
(67 - 100%)

C - Low
(0 - 33%)

B - Moderate
(34 - 66%)

5. What are the alternatives?


6. Justification: Why were the control(s) suggested?

Selamat Berlatih

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