Comprehensive List of Causes

A TOOL FOR ROOT CAUSE ANALYSIS

DESCRIPTION OF INCIDENT IMPLEMENTATION & RESEARCH PHASES: ANALYSIS PHASE:
EVIDENCE GATHERING IDENTIFICATION OF CRITICAL FACTORS
Document the type / severity of event Gather relevant evidence Organize all evidence
Cover the who / what / when / how as Implementation phase = direct evidence (scene and witnesses) Map evidence
known at the time Research phase = indirect evidence (written sources) Identify critical factors
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. Innatention / 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 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 judgment 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 4-2 Distracted by other concerns 5-3 Inadequate personal protective 6-3 Improperly prepared equipment 7-3 Energized electrical system 8-3 Inadequate ventilation
1-4 Operation equipment without authority 2-4 Use of defective tools (aware) protective equipment 4-3 Inattention to footing and surroundings equipment 6-4 Defective tools 7-4 Energized system, other than electrical 8-4 Unprotected height
1-5 Improper position or posture for the task 2-5 Improper placement of tools, equipment 3-4 Servicing of energized equipment 4-4 Horseplay 5-4 Defective personal protective 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate work place layout
1-6 Overexertion of physical capability or material 3-5 Equipment or material not secured 4-5 Acts of violence equipment 6-6 Improperly prepared tools 7-6 Temperature extremes - controls less than adequate
1-7 Work or motion at improper speed 2-6 Operation equipment at improper speed 3-6 Disabled guards, warning systems or 4-6 Failure to warn 5-5 Inadequate warning systems 6-7 Defective vehicle 7-7 Hazardous chemicals - displays less than adequate
1-8 Improper lifting 2-7 Servicing equipment in operation safety devices 4-7 Use of drugs or alcohol 5-6 Defective warning systems 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 4-8 Routine activity without thought 5-7 Inadequate isolation of process or 6-9 Improperly prepared vehicle 7-9 Clutter or debris - locations out of reach or sight
1-10 Shortcuts safety devices 4-9 Other equipment 6-10 Other 7-10 Storms or acts of nature - conflicting information is presented
1-11 Other 3-8 Personal protective equipment not 5-8 Inadequate safety devices 7-11 Slippery floors or walkways 8-6 Other
available 5-9 Defective safety devices 7-12 Other
3-9 Other 5-10 Other

POSSIBLE BASIC/ROOT CAUSES

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

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

AREA FOR IMPROVEMENT

Setting Up Leadership, Competence, Emergency Performance Accident/Incident,

HSE Risk HSE Legal and Other Management of Communication & Control of Evaluation of Non-Conformity,
Objectives, Targets & Organization & Training & Documentation Operational Control Preparedness & Monitoring and Corrective and Control of Record Audit Management Review
Management Requirements Change Consultation Documents Compliance
Programs Resources Awareness Response Measurements Preventive Action