Hazop (incident investigation & root cause analysis )

Incident Investigation & Root Cause Analysis

H|S|E|Q – Trainers, Consultants and Risk Management Advisors

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1.0 Incident Investigation – An Introduction

1.1 Fundamental Defininitions / Terminology.

Incident:

Work related events in which an injury or ill health (Regardless of severity) or fatality occurred or could have occurred.

Accident:

An event that results in harm to persons or property.

Near Miss Incident:

An unplanned, uncontrolled event that can cause or has the potential to cause injury to personnel or damage to equipment.

Unsafe Act / Practice / Behavior:

Any human action(s) that could result in a near miss, incident or injury

Unsafe Condition

Any situation in a workplace that, if left uncorrected, could result in a near-miss or incident.

Minor First Aid Injury:

An accident that results in an injury for which no medical care beyond first aid is required.

Recordable Injury/Illness:

An on-the-job injury/illness that results in required medical attention beyond first aid, initial doctors‟ visit, including stitches, loss of consciousness, use of prescription drugs, and/or work restriction.

Lost Time Accident /Lost time illness:

A work-related injury/illness that results in a loss of at least one full scheduled workday or shift.

1.2 Incident Reporting

Statutory and Regulatory Requirements

Nature and type of incidents to be reported are classified into three main categories:

Operational:

Electricity – generation, transmission, distribution

Desalinated water – production, transmission

Health and Safety:

Fatality

Major Injury

Ill-health and

Dangerous Occurrences

Environmental

Air, Water, Land



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NOMAC Requirements

All employees and contractors are required to report any of the following to their immediate supervisor:

Incidents resulting in injury or illness of any magnitude, including those injuries requiring the administration of minor first-aid measures

Motor vehicle accident that involves a company vehicle or a rented or a personal vehicle on a company business

Incidents resulting in production interruption and property or equipment damage of any magnitude

Incidents resulting in environmental damage of any magnitude

Incidents resulting in a security consequence of any magnitude

Incidents resulting in customer related non productive time or company financial loss

A near-miss incident due to an unsafe act / practices and/or conditions at a workplace.

The supervisor will fill up the Initial Incident Reporting form to his departmental Managers with a copy to PGM / PM and Site HSE Engineer/Officer.

1.3 Incident Analysis

An analysis shall be conducted as soon as reasonably practical following the event. All accidents and incidents shall be analyzed regardless of whether or not there are injuries or equipment damage. The seriousness or severity potential should dictate the level to which an incident is analyzed.

More seriousness or high potential severity incidents shall be investigated more thoroughly.

1.4 Incident Investigation

Incident investigation is a systematic effort to record all relevant facts and evidence related to how and why an incident happened. Since unsafe act / practices / behaviours and conditions cause incidents, we must determine where the HSE programs failed to control unsafe acts / practices or conditions.

Effective incident investigation will accomplish this through a fact-finding process as opposed to fault-finding or apportioning blame process. This fact-finding process shall determine all issues that led to the incidents, both the basic and the root causes. Then it should demonstrate how control can be re-established by management and employees.

Incident investigations team must be formed under the chairmanship of a senior management member to establish and carry out the following:

Determine Who, What, When, Where and How?

Identify causes – both basic and root causes

Determine the plan or management system failure

Develop and assign corrective and preventive action items

Track action items to completion

Communicate lessons learned to all company staff as appropriate to prevent recurrence throughout the company plants



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Incident Report

Analysis of Incident

Incident Investigation

Investigation Report

Trend Analysis & Corrective

Actions

End

1.5 Incident Reporting and Investigation Process

The following schematic diagram outlines the significant steps of the process and their usual sequence.

1.6 The Typical Accident Investigation.

The typical accident investigation starts when the investigator is informed of the accident, usually in terms of the harm or loss that occurred. With this as the starting point, the investigator begins to look backwards for causes or causal factors to explain how and why the harm or loss occurred. When the investigator arrives at an accident scene, he surveys the situation and makes an initial and overall assessment. Then the investigator starts a search for the facts or the situation or the information that will enable the investigator to find the cause of the accident or its causal factors.

There are several sources of accident “facts” or data, such as people, physical objects, surroundings, the condition, location and relative position of various persons and objects, etc. The data and facts thus gathered are assimilated, sifted, organized and then analyzed by the investigator. These analyses may permit the investigator to develop one or more possible accident scenarios about how and why the harm or loss occurred.

The typical investigation is ended when the investigator finds what could be termed “the cause” of the accident. These conclusions are generally in the form of a set of statements about the sequential events that led to the final harm or loss and a cause statement.

Finally, based on the facts, the description of the events leading to the harm or loss and the conclusions drawn, the investigator recommends actions whose implementation should prevent the accident the next time.



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1.7 Accident Investigation – Key Facts Checklist

Should determine:

What happened

How it happened

Why it happened

What should be done to avoid recurrence

The objective is to identify the causal factors and recommend corrective actions. The investigation report should offer adequate, but not excessive, recommendations for corrective actions.

Check list for identifying key facts:

1. Nature of Injury.

Foreign body Cut

Bruises Strain & sprain

Fracture Burns

Amputation Puncture wound

Hernia Dermatitis

Abrasions Others

2. Part of Body.

Head &neck (scalp, eyes, ears, mouth, teeth, neck, face, skull, etc.)

Upper extremities (shoulders, arms, elbows, forearms, wrists, hands, fingers, thumbs, palms, etc.)

Body, back, chest, abdomen, groin, etc.

Lower extremities (hips, thighs, legs, knees, ankles, feet, toes, etc.)

3. Accident Type.

Stuck against rough / sharp object

Struck by flying objects

Struck by sliding, falling or other moving objects

Caught in or in between

Falls (on same level or to different level)

Over exertion

Slip, Burns

Contact with temperature extremes

Inhalation, absorption, ingestion, poisoning

Electric shock



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4. Hazardous Condition.

Improperly / inadequately guarded or unguarded

Defective tools, equipment, substances

Unsafe design or construction

Hazardous arrangement / layout / congested area

Improper illumination / ventilation

Improper dress / PPE

Poor housekeeping

5. Agency of Accident.

Machines Vehicles

Hand tools Sheet stock / scrap

Conveyors & elevators Hoists / cranes

Floors & surfaces Chemicals

Electrical apparatus Fire

High pressure / temperature releases Stairs/ladders/platforms/ scaffoldings

6. Unsafe Acts.

Operating without authority

Operating at off-design conditions

Making safety devices inoperative

Failure to warn / secure

Using defective equipment / materials/ tools / vehicles

Failure to use proper personal protective equipment

Poor housekeeping

Unsafe loading / placing / mixing

Horseplay

Unsafe lifting / carrying

Taking an unsafe position

Adjusting / cleaning machinery in motion

7. Contributing Factors.

Disregard of instructions

Bodily defects

Lack of knowledge or skill

Act of other than injured



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2.0 Incident Investigation – The Four Step Process

Investigation is a four-step process comprising the following necessary stages:

Control the Scene (Initial Response)

Gather Data (Implementation & Research)

Analyze Data (Analysis)

Write Report (Correction)

These steps in accident investigation are simple: the accident investigators gather information, analyze it, draw conclusions, and make recommendations. Although the procedures are straightforward, each step can have its pitfalls. As mentioned earlier, an open mind is necessary in accident investigation: preconceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be drawn until all the information is gathered.

2.1 Initial Response

The first response must be to:

Take all steps necessary to provide emergency rescue and medical help for the injured.

Take those actions that will prevent or minimize the risk of further accidents, injury or property damage.

These immediate actions may include:

Securing, barricading or isolating the scene

Collecting transient or perishable evidence

Determining the extent of damage to equipment, material or building facilities

Restoring the operating functions

An effective initial response includes the following essential steps

1. Take Control

2. Ensure First Aid

3. Control Secondary Accidents

4. Identify Sources of Evidence

5. Preserve Evidence

6. Determine Loss Potential

7. Notify Managers

The above steps do not have to be in the same sequence. The actual sequence will be determined by the nature of the incident and the circumstances surrounding it.

A proper & positive initial response results in the following benefits:



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Valuable opportunity to reduce the extent of loss

Preserve valuable information necessary to learn what actually happened

Key to getting the investigation on the right track

2.2 Gathering Data

The next step of the investigation process is gathering data. There are four major categories of data or sources of evidence. These are referred to as the “four Ps”:

Positions

People

Parts

Paper

Positions

This is the most fragile of all evidence as it can be easily moved / altered. It includes, among other things:

Hand notes,

Sketches, maps & measurements

Photographs

As little time as possible should be lost between the moment of an accident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera, film, camera flash, tape measure, etc.) should be immediately available so that no time is wasted.

The physical environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the accident is what is important, not what the "usual" conditions were. For example, accident investigators may want to know:

What were the weather conditions?

Was poor housekeeping a problem?

Was it too hot or too cold?

Was noise a problem?

Was there adequate light?

Were toxic or hazardous gases, dusts, or fumes present?

Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as:

positions of injured workers

equipment being used

materials being used



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safety devices in use

position of appropriate guards

position of controls of machinery

damage to equipment

housekeeping of area

weather conditions

lighting levels

noise levels

You may want to take photographs before anything is moved, both of the general area and specific items. Later careful study of these may reveal conditions or observations missed previously. Sketches of the accident scene based on measurements taken may also help in subsequent analysis and will clarify any written reports. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the accident scene should be prepared.

People

In some situations witnesses may be your primary source of information because you may be called upon to investigate an accident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.

Witnesses should be interviewed as soon as practicable after the accident. If witnesses have an opportunity to discuss the event among themselves, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts.

Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene of the accident where it is easier to establish the positions of each person involved and to obtain a description of the events. On the other hand, it may be preferable to carry out interviews in the quiet of an office where there will be fewer distractions. The decision may depend in part on the nature of the accident and the mental state of the witnesses.

This category of evidence includes:

Direct Witnesses

– Injured / Co-workers

– Others in area

Indirect Witnesses

– Contractors

– Maintenance Personnel

– Equipment Designers

– Spares Purchasers



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The major technique or method for obtaining information from people is through interviews. All witnesses should be interviewed, because it may require several witnesses‟ versions to determine or reconstruct the entire series of events. Confirmation of observations by various witnesses is very important.

Developing a scenario is a good idea if certain questions are unanswered, particularly questions that have to do with the exact physical relationship between the employee and his or her environment. Typical questions during interviews may include:

Was a safe work procedure used?

Had conditions changed to make the normal procedure unsafe?

Were the appropriate tools and materials available?

Were they used?

Were safety devices working properly?

Was lockout used when necessary?

For most of these questions, an important follow-up question is "If not, why not?"

The physical and mental condition of those individuals directly involved in the event may be explored. The purpose for investigating the accident is not to establish blame against someone but the personal characteristics still need to be considered. Some factors will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done?

Had they been adequately trained?

Can they physically do the work?

What was the status of their health?

Were they tired?

Were they under stress (work or personal)?

Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation.

Answers to any of the preceding types of questions logically lead to further questions such as:

Were rules communicated to and understood by all employees?

Were written procedures available?

Were they being enforced?

Was there adequate supervision?

Were workers trained to do the work?

Had hazards been previously identified?

Had procedures been developed to overcome them?

Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?

Were regular safety inspections carried out?



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Interviewing

Interviewing is an art that cannot be given justice in a brief document such as this, but a few do's and don'ts can be mentioned. The purpose of the interview is to establish an understanding with the witness and to obtain his own words describing the event:

DO...

put the witness, who is probably upset, at ease

emphasize the real reason for investigation, to determine what happened and why

let the witness talk, listen

confirm that you have the statement correct

try to sense any underlying feelings of the witness

make short notes only during the interview

DO NOT...

intimidate the witness

interrupt

prompt

ask leading questions

show your own emotions

make lengthy notes while the witness is talking

Ask open-ended questions that cannot be answered by simply "yes" or "no". The actual questions you ask the witness will naturally vary with each accident, but there are some general questions that should be asked each time:

Where were you at the time of the accident?

What were you doing at the time?

What did you see, hear?

What were the environmental conditions (weather, light, noise, etc.) at the time?

What was (were) the injured worker(s) doing at the time?

In your opinion, what caused the accident?

How might similar accidents be prevented in the future?

If you were not at the scene at the time, asking questions is a straightforward approach to establishing what happened. Obviously, care must be taken to assess the credibility of any statements made in the interviews. Answers to a first few questions will generally show how well the witness could actually observe what happened.

Generally, people aren't used to being interviewed. After a traumatic experience, a witness may not be able to recall the details. But, witnesses should be interviewed as soon as possible. People react differently. Don't be surprised if a witness who was close to the incident has an entirely different story from someone who saw it at a distance. Witnesses may remember more clues after the shock has worn off, so be open to follow-up sessions. Some witnesses may offer biased testimony if they feel a need to influence the findings. Witnesses may omit entire sequences of events if they don't realize their importance. Finally, eyesight, hearing, reaction time, and the general condition of each witness may affect his or her ability to observe.



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Good interviewing skills are developed with experience. The most experienced team member should lead the interviews. It may be helpful to have someone with a legal background on the interview team. Use the checklist below to help with your interviews.

After the interviews, the team should analyze each witness' statement, and may want to re-interview some witnesses to confirm or clarify key points. Even with inconsistencies in the statements, the investigation team should assemble all of the available testimony into a logical order. Consider the statements along with data from the incident site in your report.

Have you appointed a speaker for the team?

Have you obtained preliminary statements as soon as possible from all witnesses?

Has each witness located his or her position on a map of the site (including the direction of view)?

Is the interview conducted at a convenient time and place?

Have you told the witnesses that the investigation's purpose is accident prevention?

Have you introduced the team and tried to make the witness comfortable?

Do you record each witness' identity and qualifications?

Are your questions worded carefully, and do you ensure the witness understands each question?

Do you ask open-ended questions requiring more than a "yes" or "no" reply?

Do you let the witness speak freely while you listen?

Do you take notes without distracting the witness and use a tape recorder only with the witness' consent?

Do you record the witness' exact words?

Do you let the witness use sketches and diagrams?

Do you confirm direct observation and identify opinion or hearsay?

Are you polite and careful not to lead the witness or to argue?

Do you supply each witness with a copy of his or her statement?

• Gather just the facts… make no judgments or statements

• Conduct interviews one on one

• Be friendly but professional

• Interview all supervisors

• Use sketches & diagrams to help witness.

• Let each witness speak freely & take notes without distracting witness (avoid use of tape recorder).

• Emphasize areas of direct observation & label hearsay accordingly.

• Provide feedback but don‟t lead the witness or put the person on defensive or give a “true-false” test.

• Look out for corroborations & inconsistencies.

• End with a positive note & keep the line open



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Interviewing Process

Parts

The third category of evidence is parts and includes physical evidence such as:

Tools, equipment, parts, materials & PPE

Worn or failed equipment parts

Improper tools & equipment

Incorrect use of tools & equipment

Process liquid/solid samples; before & after

To seek out possible causes resulting from the equipment and materials used, investigators might ask:

Was there an equipment failure?

What caused it to fail?

Was the machinery poorly designed?

Were hazardous substances involved?

Were they clearly identified?

Was a less hazardous alternative substance possible and available?

Was the raw material substandard in some way?

Should personal protective equipment (PPE) have been used?

Was the PPE used?

Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist.

Paper

This is the last category of evidence and includes:

Maintenance logs & schedules

Employee training records

Work procedures & practices, codes & regulations



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Checklists, work orders, work permits, etc.

Building plans, layouts, Flow diagrams, P&Ids

Safety Inspections, audits, observations, etc.

Similar investigation reports

Employee medical history & health records

Job / shift schedules, overtime records

Parts / equipment / materials inspection & certification

Equipment / instruments calibration records

Design specifications & materials of construction

MSDS / Chemical analysis report

Risk assessments & HAZOP

Contractor prequalification & contract terms & conditions

Environmental monitoring / emission reports

These are seldom at the scene of the incident & hence, are often neglected. Consequently, it is often an overlooked source of information, All available and relevant information must be extracted and recorded from documents such as technical data sheets, maintenance reports, past accident reports, formalized safe-work procedures, and training reports. Any pertinent information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar accidents.

Summarizing the information gathered

Where and when did the adverse event happen?

Who was injured/suffered ill health or was otherwise involved with the adverse event?

How did the adverse event happen? (Note any equipment involved).

What activities were being carried out at the time?

Was there anything unusual or different about the working conditions?

Were there adequate safe working procedures and were they followed?

What injuries or ill health effects, if any, were caused?

If there was an injury, how did it occur and what caused it?

Was the risk known? If so, why wasn‟t it controlled? If not, why not?

Did the organization and arrangement of the work influence the adverse event?

Was maintenance and cleaning sufficient? If not, explain why not.

Were the people involved competent and suitable?

Did the workplace layout influence the adverse event?

Did the nature or shape of the materials influence the adverse event?

Did difficulties using the plant and equipment influence the adverse event?

Was the safety equipment sufficient?

Did other conditions influence the adverse event?



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2.3 Collecting & Sifting Evidence (Analysis)

Facts must be separated from opinions, direct evidence from circumstantial evidence and eyewitness statements from hearsay testimony. Your investigation should be exhaustive. Look for all relevant facts, not just the obvious. Usually an accident has several causal factors, yet some investigators will stop after discovering the first one. Study the accident scene carefully.

Divide the data collected into following categories:

Hard Evidence.

Data that usually cannot be disputed, e.g., time & place of accident, logs & other written reports & the position of physical evidence (providing investigators can establish that it has not been moved).

Witness Statement.

Statements from persons who saw the accident happen & from those who came upon the scene immediately afterwards

Circumstantial Evidence.

The logical interpretation of facts that leads to a single, but un-proven conclusion.

Critical Factors

• Negative events or undesirable conditions that influence the course of events

• Major contributions to the incident

• Events or conditions, which if eliminated, would have either prevented the occurrence or reduced its severity

An investigator who believes that incidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine briefly some underlying factors in a chain of events that ends in an accident.

The important point is that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:

Was the worker distracted? If yes, why was the worker distracted?

Was a safe work procedure being followed? If not, why not?

Were safety devices in order? If not, why not?

Was the worker trained? If not, why not?

An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent "carelessness".



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2.4 The Written Report (Correction)

The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar accidents. Resist the temptation to make only general recommendations to save time and effort.

For example, you have determined that a blind corner contributed to an accident. Rather than just recommending "eliminate blind corners" it would be better to suggest:

install mirrors at the northwest corner of building X (specific to this accident)

install mirrors at blind corners where required throughout the worksite (general)

Never make recommendations about disciplining persons who may have been at fault. This would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future accident investigations.

In the unlikely event that you have not been able to conclusively determine the causes of an accident, you probably still have uncovered safety weaknesses in the operation. It is appropriate that recommendations be made to correct these deficiencies.

If your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings such as:

If a limited space is provided for an answer, the tendency will be to answer in that space despite recommendations to "use back of form if necessary."

If a checklist of causes is included, possible causes not listed may be overlooked.

Headings such as "unsafe condition" will usually elicit a single response even when more than one unsafe condition exists.

Differentiating between "primary cause" and "contributing factors" can be misleading. All accident causes are important and warrant consideration for possible corrective action.

Your previously prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the accident that you have so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.

If doubt exists about any particular part, say so. The reasons for your conclusions should be stated and followed by your recommendations. Weed out extra material that is not required for a full understanding of the accident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good accident report is quality, not quantity.

What should be done if the investigation reveals "human error"?

A difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough worksite accident investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual.

Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation. Furthermore, it will also allow future accidents to happen from similar causes because they have not been addressed.



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Corrective Actions

Temporary actions (immediate)

generally address the unsafe acts & conditions

Permanent actions (long-term)

generally address personal & job factors

Aimed at:

Reducing likelihood of occurrence

Reducing severity of consequences

Corrective Actions – General Principles

Recommendations must be based on key contributory factors and underlying causes.

Must be appropriate and adequate

Recommendation(s) must be communicated clearly.

Must be S.M.A.R.T. (smart, measurable, achievable, realistic, time bound

Strict time table must be established.

Follow up must be conducted.

What are the existing barriers in place to prevent this incident?

Why didn‟t the existing barriers work

Fix or improve existing barriers before creating new ones.

Make sure each cause you identify is covered by a corrective action.

Ensure that the corrective actions meet the following criteria

Report Forms and Formats

Statutory and Regulatory Reports

All incidents shall be reported by the PGM / PM or his representative to the project company in accordance with the following:

a) The ECRA “Initial Incident Reporting Form” should be submitted by the Project Company or owner to the office of Vice Governor Regulatory Affairs within two business days of the occurrence of an Incident.



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Structure of Initial Incident Reporting Form Contents:

1. General information

Name of licensee / Company,

Incident reference,

Location of incident-area, unit, equipment,

Date and time of incident – start, finish.

2. Contact details

Name of person making notification,

Contact details- telephone number, e-mail, etc.,

Date and time of notification to Authority.

3. Incident classification

Operational – electricity, desalinated water,

Health & safety – fatality, major injury, III- health,

Dangerous occurrence,

Environmental – air, water, land.

4. Incident description

Sequence of events – description of events leading to incident,

Consequences – impact on operations, people or environment,

Causation – immediate causes, nature of defect, failures, etc.,

Remedial actions – present status, actions taken to rectify situation.

5. Other information

Any other relevant information – police presence, media interest, etc.

b) The ECRA “Incident Investigation Report” should be submitted by the project company or owner to the office of Vice Governor Regulatory Affairs within 20 business days of the occurrence of an Incident or any other shorter period as decided by the ECRA.

Structure of Incident Investigation Report Contents

1. Executive summary

A brief description of the incident

the consequential losses (people, assets, demand and / or Generation affected (MW)

Environment and licensee reputation and major recommendations.

2. Introduction

A brief description of why the report is being prepared and legal obligations for undertaking the investigation.

3. Incident description

Detailed description of scene – location, people involved, etc.,

Sequence of events



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Impact of the event – people, environment and property

Emergency procedures – actions taken, agencies involved

Work activities – identified and controlled

4. Investigation and observations

Investigation procedure – background information

Documentation review

Interviews and discussions

Site visits

Equipment analysis and review

5. Analysis and conclusions

Summary of key findings

Immediate causes

Root causes

6. Recommendations and action plan

Immediate actions – short term

Follow – up actions – long term

Action plan – tracking, times and responsibilities

7. Appendices

Documentation – examples but not limited to;

Letters, emails, faxes, minutes of meetings, contracts, etc.

Log sheets, work permits, etc.

HSE plans, risk assessments, method statements, etc.

Surveys, inspections, etc.

Excerpts from procedures, manuals, instructions, etc.

Testing and inspection certificates, etc.

Charts, maps, illustrations, sketch, etc.

Photos with narrative

c) The ECRA “Final Close-out Report” should be submitted to the office of Vice Governor Regulatory Affairs within the period agreed with the Authority.

As a minimum, the final close-out report shall contain:

1. a summary of the incident;

2. a review of the main and contributory causes;

3. a review of key issues identified and preventative action taken and

4. a table listing original recommendations, action parties and action taken to close-out each point.

5. Basic information regarding equipments to the incident occurring.



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NOMAC Reports

The site first aider or doctor shall fill the First Aid Treatment form (NC/QHSE/SP-006/FM-001) for Injury incidents requiring first aid treatment.

The immediate supervisor shall fill the Initial Incident Report form (NC/QHSE/SP-006/FM-002) within 24 hours of the incident occurrence.

Any employee observing a Near Miss, unsafe act or condition shall fill the Near Miss Reporting form (NC/QHSE/SP-006/FM-003) and drop the form in designated Near Miss stations/ boxes. These forms shall be collected by the site HSEE/O.

All final written investigation reports shall be completed and approved within 3 weeks (15 working days) of the incident occurrence by the incident investigation team leader.



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3.0 Root Cause Analysis

System Defects > Root Causes > Immediate Causes > Contact > Incident

Possible Immediate Causes

ACTIONS:

Not following procedures

Improper use of tools or equipment

Inadequate use of protective methods

Inattention / lack of awareness

CONDITIONS:

Inadequate protective systems

Inadequate tools, equipment & vehicles

Work exposures

Workplace environment / layout

Examples of unsafe acts:

– Unauthorized operation of equipment

– Running - Horse Play

– Not following procedures

– By-passing safety devices

– Not using protective equipment

– Under influence of drugs or alcohol

– Taking short-cuts

Do not use examples such as carelessness or not using common sense. (These are neither visible not measurable)

Examples of unsafe conditions:

– Ergonomic Hazards

– Environmental hazards

– Inadequate housekeeping

– Blocked walkways

– Improper or damaged PPE

– Inadequate machine guarding

Root or System Causes

The most basic causes that can reasonably be identified, that management has control to fix, and for which effective corrective actions for preventing recurrence can be generated.

Possible Basic (System) Causes

PERSONAL FACTORS:

Physical capability

Physical condition



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Mental state

Mental Stress

Behavior

Skill level

JOB FACTORS:

Training / knowledge transfer

Management leadership/employee leadership

Contractor selection & oversight

Engineering / design

Work planning

Purchasing, mtrl. handling & mtrl. control

Tools & equipment

Work rules/policies/standards/procedures(PSP)

Communication

Examples of personal factors:

– Lack of knowledge & Lack of skill

– Lack of physical capability

– Lack of mental capability

– Physical stress

– Mental stress

– Improper motivation

Examples of job factors:

– Inadequate leadership

– Inadequate engineering

– Inadequate purchasing

– Inadequate maintenance

– Inadequate tools & inadequate equipment

– Inadequate work standards

There are several techniques available for carrying out Root Cause Analysis – each having its own advantages and disadvantages and specific areas of application. We will use the Comprehensive List of Causes (CLC) as our primary technique using the CLC Chart and the Glossary to the Chart given at the end of this manual.

However, we will also have an overview of the other common techniques used for conducting a root cause analysis. Some of the significant techniques include:

Documentation Review Legislation Review 5 Why Fish Bone



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Event & Condition Mapping Human Error Analysis Change Analysis

The main classes of accident models are (based on Kjellén, 2000):

Causal-sequence models Process models Energy model Logical tree models Human information-processing models SHE management models

Some of the Core Analytical Techniques include:

• Event & Causal Factor Charting & Analysis (ECFA) • Barrier Analysis • Change Analysis • Causal Factor Analysis

Some of the more Complex Analytical Techniques include:

• Fault Tree Analysis • MORT (Management Oversight Risk Tree) • PET (Project Evaluation Tree Analysis) • Tripod Beta • Tap-RooT

These techniques are generally used for complex accidents with multiple system failures.

In addition to these, certain Specific Analytical Techniques include:

• Human Factor Analysis • Failure Modes & Effect Analysis • Software Hazards Analysis • Materials & Structure Analysis • Atmospheric Dispersion Analysis



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DOE’s core analytical techniques5

Events and causal factors charting (ECFC)

Events and causal factors charting is a graphical display of the accident‟s chronology and is used primarily for compiling and organizing evidence to portray the sequence of the accident‟s events.

The events and causal factor chart is easy to develop and provides a clear depiction of the data. Keeping the chart up-to-date helps insure that the investigation proceeds smoothly, that gaps in information are identified, and that the investigators have a clear representation of accident chronology for use in evidence collection and witness interviewing.

Events and causal factors charting is useful in identifying multiple causes and graphically depicting the triggering conditions and events necessary and sufficient for an accident to occur.

Events and causal factors analysis is the application of analysis to determine causal factors by identifying significant events and conditions that led to the accident. As the results from other analytical techniques are completed, they are incorporated into the events and causal factors chart. “Assumed” events and conditions may also be incorporated in the chart.

The following figure gives an overview over symbols used in an event and causal factor chart and some guidelines for preparing such a chart.

The Figure below shows a simplified event and causal factors chart in general.



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Barrier analysis

Barrier analysis is used to identify hazards associated with an accident and the barriers that should have been in place to prevent it. A barrier is any means used to control, prevent, or impede the hazard from reaching the target.

Barrier analysis addresses:

• Barriers that were in place and how they performed

• Barriers that were in place but not used

• Barriers that were not in place but were required

• The barrier(s) that, if present or strengthened, would prevent the same or similar accidents from occurring in the future.

The following Figure shows types of barriers that may be in place to protect workers from hazards.

Physical barriers are usually easy to identify, but management system barriers may be less obvious (e.g. exposure limits). The investigator must understand each barrier‟s intended function and location, and how it failed to prevent the accident. There exists different ways in which defences or barriers may be categorized, i.e. active or passive barriers (see e.g. Kjellén, 2000), hard or soft defences (see e.g. Reason, 1997), but this topic will not be discussed any further in this report.



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To analyze management barriers, investigators may need to obtain information about barriers at three organizational levels responsible for the work; the activity, facility and institutional levels. For example, at the activity level, the investigator will need information about the work planning and control processes that governed the work activity, as well as the relevant safety management systems. The investigator may also need information about safety management systems at the facility level. The third type of information would be information about the institutional-level safety management direction and oversight provided by senior line management organizations.

The basic steps of a barrier analysis are:

Step 1 Identify the hazard and the target. Record them at the top of the worksheet

Step 2 Identify each barrier. Record in column one.

Step 3 Identify how the barrier performed (What was the barrier‟s purpose? Was the barrier in place or not in place? Did the barrier fail? Was the barrier used if it was in place?) Record in column two.

Step 4 Identify and consider probable causes of the barrier failure. Record in column three.

Step 5 Evaluate the consequences of the failure in this accident. Record in column four.

The investigator should use barrier analysis to ensure that all failed, unused, or uninstalled barriers are identified and that their impact on the accident is understood. The analysis should be documented in a barrier analysis worksheet.

Change analysis

Change is anything that disturbs the “balance” of a system operating as planned. Change is often the source of deviations in system operations.

Change analysis examines planned or unplanned changes that caused undesired outcomes. In an accident investigation, this technique is used to examine an accident by analysing the difference between what has occurred before or was expected and the actual sequence of events.

The investigator performing the change analysis identifies specific differences between the accident–free situation and the accident scenario. These differences are evaluated to determine whether the differences caused or contributed to the accident.

The change analysis process is described in the following Figure.

When conducting a change analysis, investigators identify changes as well as the results of those changes. The distinction is important, because identifying only the results of change may not prompt investigators to identify all causal factors of an accident. When conducting a change analysis, it is important to have a baseline situation that the accident sequence may be compared to.



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The table below shows a simple change analysis worksheet.

The investigators should first categorize the changes according to the questions shown in the left column of the worksheet, i.e., determine if the change pertained to, for example, a difference in:

• What events, conditions, activities, or equipment were present in the accident situation that were not present in the baseline (accident-free, prior, or ideal) situation (or vice versa)

• When an event or condition occurred or was detected in the accident situation versus the baseline situation

• Where an event or condition occurred in the accident situation versus where an event or condition occurred in the baseline situation

• Who was involved in planning, reviewing, authorizing, performing, and supervising the work activity in the accident versus the accident-free situation.

• How the work was managed and controlled in the accident versus the accident-free situation.

To complete the remainder of the worksheet, first describe each event or condition of interest in the second column. Then describe the related event or condition that occurred (or should have occurred) in the baseline situation in the third column. The difference between the event and conditions in the accident and the baseline situations should be briefly described in the fourth column. In the last column, discuss the effect that each change had on the accident.



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The differences or changes identified can generally be described as causal factors and should be noted on the events and causal factors chart and used in the root cause analysis.

A potential weakness of change analysis is that it does not consider the compounding effects of incremental change (for example, a change that was instituted several years earlier coupled with a more recent change). To overcome this weakness, investigators may choose more than one baseline situation against which to compare the accident scenario.

Events and causal factors analysis

The events and causal factors chart may also be used to determine the causal factors of an accident, as illustrated in the Figure below. This process is an important first step in later determining the root causes of an accident. Events and causal factors analysis requires deductive reasoning to determine which events and/or conditions that contributed to the accident.

Before starting to analyse the events and conditions noted on the chart, an investigator must first ensure that the chart contains adequate detail.

Examine the first event that immediately precedes the accident. Evaluate its significance in the accident sequence by asking:

“If this event had not occurred, would the accident have occurred?”

If the answer is yes, then the event is not significant. Proceed to the next event in the chart, working backwards from the accident. If the answer is no, then determine whether the event represented normal activities with the expected consequences. If the event was intended and had the expected outcomes, then it is not significant. However, if the event deviated from what was intended or had unwanted consequences, then it is a significant event.

Carefully examine the events and conditions associated with each significant event by asking a series of questions about this event chain, such as:

• Why did this event happen?

• What events and conditions led to the occurrence of the event?

• What went wrong that allowed the event to occur?

• Why did these conditions exist?



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• How did these conditions originate?

• Who had the responsibility for the conditions?

• Are there any relationships between what went wrong in this event chain and other events or conditions in the accident sequence?

• Is the significant event linked to other events or conditions that may indicate a more general or larger deficiency?

The significant events, and the events and conditions that allowed the significant events to occur, are the accident‟s causal factors.

Root cause analysis

Root cause analysis is any analysis that identifies underlying deficiencies in a safety management system that, if corrected, would prevent the same and similar accidents from occurring. Root cause analysis is a systematic process that uses the facts and results from the core analytic techniques to determine the most important reasons for the accident. While the core analytic techniques should provide answers to questions regarding what, when, where, who, and how, root cause analysis should resolve the question why. Root cause analysis requires a certain amount of judgment.

A rather exhaustive list of causal factors must be developed prior to the application of root cause analysis to ensure that final root causes are accurate and comprehensive.

Fault tree analysis

Fault tree analysis is a method for determining the causes of an accident (or top event). The fault tree is a graphic model that displays the various combinations of normal events, equipment failures, human errors, and environmental factors that can result in an accident. An example of a fault tree is shown in the Figure below.

A fault tree analysis may be qualitative, quantitative, or both. Possible results from the analysis may be a listing of the possible combinations of environmental factors, human errors, normal events and component failures that may result in a critical event in the system and the probability that the critical event will occur during a specified time interval.

The strengths of the fault tree, as a qualitative tool is its ability to break down an accident into root causes.



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The undesired event appears as the top event. This event is linked to the basic failure events by logic gats and event statements. A gate symbol can have one or more inputs, but only one output. A summary of common fault tree symbols is given in the Figure below.

Event tree analysis

An event tree is used to analyse event sequences following after an initiating event. The event sequence is influenced by either success or failure of numerous barriers or safety functions/ systems. The event sequence leads to a set of possible consequences. The consequences may be considered as acceptable or unacceptable. The event sequence is illustrated graphically where each safety system is modelled for two states, operation and failure.

The following Figure illustrates an event tree of the situation on Rørosbanen just before the Åsta-accident. This event tree reveals the lack of reliable safety barriers in order to prevent train collision at Rørosbanen at that time.

An event tree analysis is primarily a proactive risk analysis method used to identify possible event sequences. The event tree may be used to identify and illustrate event sequences and also to obtain a qualitative and quantitative representation and assessment. In an accident investigation we may illustrate the accident path as one of the possible event sequences. This is illustrated with the thick line in the Figure below.



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MORT

MORT provides a systematic method (analytic tree) for planning, organizing, and conducting a comprehensive accident investigation. Through MORT analysis, investigators identify deficiencies in specific control factors and in management system factors. These factors are evaluated and analyzed to identify the causal factors of the accident.

Basically, MORT is a graphical checklist which contains generic questions that investigators attempt to answer using available factual data. This enables investigators to focus on potential key causal factors. The upper levels of the MORT diagram are shown in the Figure.

MORT requires extensive training to effectively perform an in-depth analysis of complex accidents involving multiple systems. The first step of the process is to select the MORT chart for the safety program area of interest. The investigators work their way down through the tree, level by level. Events should be coded in a specific color relative to the significance of the accident. An event that is deficient or Less Than Adequate (LTA) in MORT terminology is marked red. The symbol is circled if suspect or coded in red if confirmed. An event that is satisfactory is marked green in the same manner. Unknowns are marked in blue, being circled initially and colored if sufficient data do not become available, and an assumption must be made to continue or conclude the analysis.

When the appropriate segments of the tree have been completed, the path of cause and effect (from lack of management control, to basic causes, contributory causes, and root causes) can easily be traced back through the tree. The tree highlights quite clearly where controls and corrective actions are needed and can be effective in preventing recurrence of the accident.

PET (Project Evaluation Tree) and SMORT (Safety Management and Organisations Review Technique) are both methods based on MORT but simplified and easier to use. PET and SMORT will not be described further. PET is described by DOE (1999) and SMORT by Kjellén et al (1987).



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Systematic Cause Analysis Technique (SCAT)

The International Loss Control Institute (ILCI) developed SCAT for the support of occupational incident investigation. The ILCI Loss Causation Model is the framework for the SCAT system (see Figure below).

The result of an accident is loss, e.g. harm to people, properties, products or the environment. The incident (the contact between the source of energy and the “victim”) is the event that precedes the loss.

The immediate causes of an accident are the circumstances that immediately precede the contact. They usually can be seen or sensed. Frequently they are called unsafe acts or unsafe conditions, but in the ILCI-model the terms substandard acts (or practices) and

substandard conditions are used. Substandard acts and conditions are listed in the Figure

below.



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Basic causes are the diseases or real causes behind the symptoms, the reasons why the substandard acts and conditions occurred. Basic causes help explain why people perform substandard practices and why substandard conditions exists. An overview of personal and job factors are given in the following Figure.

There are three reasons for lack of control: 1. Inadequate program 2. Inadequate program standards and 3. Inadequate compliance with standards The following Figure shows the elements that should be in place in a safety program. The elements are based on research and experience from successful safety programs in different companies.



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The Systematic Cause Analysis Technique is a tool to aid an investigation and evaluation of incidents through the application of a SCAT chart. The chart acts as a checklist or reference to ensure that an investigation has looked at all facets of an incident. There are five blocks on a SCAT chart. Each block corresponds to a block of the loss causation model. Hence, the first block contains space to write a description of the incident. The second block lists the most common categories of contact that could have led to the incident under investigation. The third block lists the most common immediate causes, while the fourth block lists common basic causes. Finally, the bottom block lists activities generally accepted as important for a successful loss control program. The technique is easy to apply and is supported by a training manual.

STEP (Sequential timed events plotting)

The STEP-method was developed by Hendrick and Benner (1987). They propose a systematic process for accident investigation based on multi-linear events sequences and a process view of the accident phenomena.

STEP builds on four concepts:

1. Neither the accident nor its investigation is a single linear chain or sequence of events. Rather, several activities take place atthe same time.

2. The event Building Block format for data is used to develop the accident description in a worksheet. A building block describes one event, i.e. one actor performing one action.

3. Events flow logically during a process. Arrows in the STEP worksheet illustrate the flow.

4. Both productive and accident processes are similar and can be understood using similar investigation procedures. They both involve actors and actions, and both are capable of being repeated once they are understood.

With the process concept, a specific accident begins with the action that started the transformation from the described process to an accident process, and ends with the last connected harmful event of that accident process.

The STEP-worksheet provides a systematic way to organise the building blocks into a comprehensive, multi-linear description of the accident process. The STEP-worksheet is simply a matrix, with rows and columns. There is one row in the worksheet for each actor. The columns are labeled differently, with marks or numbers along a time line across the top of the worksheet. The time scale does not need to be drawn on a linear scale, the main point of the time line is to keep events in order, i.e., how they relate to each other in terms of time.

An event is one actor performing one action. An actor is a person or an item that directly influences the flow or events constituting the accident process. Actors can be involved in two types of changes, adaptive changes or initiating changes. They can either change reactively to sustain dynamic balance or they can introduce changes to which other actors must adapt. An action is something done by the actor. It may be physical and observable, or it may be mental if the actor is a person. An action is something that the actor does and must be stated in the active voice.

The STEP worksheet provides a systematic way to organise the building blocks (or events) into a comprehensive, multi-linear description of the accident process. Figure 23 shows an example on a STEP-diagram of an accident where a stone block falls off a truck and hits a car.



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The above STEP-diagram also shows the use of arrows to link tested relationships among events in the accident chain. An arrow convention is used to show precede/follow and logical relations between two or more events. When an earlier action is necessary for a latter to occur, an arrow should be drawn from the preceding event to the resultant event. The thought process for identifying the links between events is related to the change of state concepts underlying STEP methods. For each event in the worksheet, the investigator asks, “Are the preceding actions sufficient to initiate this actions (or event) or were other actions necessary?” Try to visualize the actors and actions in a “mental movie” in order to develop the links.

MTO-analysis

The basis for the MTO-analysis is that human, organizational, and technical factors should be focused equally in an accident investigation. The MTO-analysis is based on three methods:

1. Structured analysis by use of an event- and cause-diagram.

2. Change analysis by describing how events have deviated from earlier events or common practice.

3. Barrier analysis by identifying technological and administrative barriers in which have failed or are missing.

The first step in an MTO-analysis is to develop the event sequence longitudinally and illustrate the event sequence in a block diagram. Identify possible technical and human causes of each event and draw these vertically to each event in the diagram.

Further, analyze which technical, human or organizational barriers that have failed or was missing during the accident progress.

Assess which deviations or changes in which differ the accident progress from the normal situation. These changes are also illustrated in the diagram.

The basic questions in the analysis are:



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• What may have prevented the continuation of the accident sequence?

• What may the organization have done in the past in order to prevent the accident?

The last important step in the MTO-analysis is to identify and present recommendations. The recommendations should be as realistic and specific as possible, and might be technical, human or organizational.

A checklist for identification of failure causes is also part of the MTO-methodology. The checklist contains the following factors:

1. Organization

2. Work organization

3. Work practice

4. Management of work

5. Change procedures

6. Ergonomic / deficiencies in the technology

7. Communication

8. Instructions/procedures

9. Education/competence

10. Work environment

For each of these failure causes, there is a detailed checklist for basic or fundamental causes. Examples on basic causes for the failure cause work practice are:

• Deviation from work instruction

• Poor preparation or planning

• Lack of self inspection

• Use of wrong equipment

• Wrong use of equipment

TRIPOD

The idea behind TRIPOD is that organisational failures are the main factors in accident causation. These factors are more “latent” and, when contributing to an accident, are always followed by a number of technical and human errors. The following diagram shows the logic.



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Substandard acts and situations do not just occur. They are generated by mechanisms acting in organizations, regardless whether there has been an accident or not. Often these mechanisms result from decisions taken at high level in the organization. These underlying mechanisms are called Basic Risk Factors (BSFs). These BSFs may generate various psychological precursors in which may lead to substandard acts and situations. Examples on psychological precursors of slips, lapses and violations are time pressure, being poorly motivated or depressed. According to this model, eliminating the latent failures categorized in BRFs or reducing their impact will prevent psychological precursors, substandard acts and the operational disturbances. Furthermore, this will result in prevention of accidents.

The identified BRFs cover human, organizational and technical problems. The different Basic Risk Factors are defined in the Table below. Ten of these BRFs leading to the “operational disturbance” (the “preventive” BRFs), and one BRF is aimed at controlling the consequences once the operational disturbance has occurred (the “mitigation” BRF). There are five generic prevention BRFs (6 – 10 in the Table) and five specific BRFs (1 – 5 in the Table). The specific BRFs relate to latent failures that are specific for the operations to be investigated (e.g. the requirements for Tools and Equipment are quite different in a oil drilling environment compared to an intensive care ward in a hospital).

These 11 BRFs have been identified as a result of brainstorming, a study of audit reports, accident scenarios, a theoretical study, and a study on offshore platforms. The division is definitive and has shown to be valid for all industrial applications.



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CLC Glossary Guidance

This Glossary is provided to the user of Comprehensive List of Causes (CLC) chart, as a guide to further define and explain the various causes. Since the causes selected will be used for trend analysis, accuracy in selecting the appropriate cause is important. Users are expected to use this Glossary to ensure proper understanding of each cause category.

In each category, “Other” is listed as the last option, in case none of the above causes fit the circumstances. While appropriate in some cases, the use of “Other” should be minimized, as it adds little value in trend analysis. In all cases – if you use the „other‟ cause, you must explain what that cause is.

Users are reminded that any cause selected must meet two conditions. First, it must be supported by the facts of the case. Additionally, a selected cause must help explain why the Critical Factor under consideration existed at the time of the incident.

One of the key issues for a quality investigation is ensuring each selected cause is addressed through an appropriate recommendation to avoid similar events in the future. There must be symmetry between the cause selected and the type of recommendation. Guidance is provided in the right hand column of this Glossary to help the investigator to achieve this symmetry.

Glossary

Possible immediate causes

Immediate causes are covered in the first two sections entitled: Actions and Conditions.

Actions

There are four major categories of actions, with an additional level of detail under each of the major categories. In actions we are focused on people and their behavior.

1. Did not follow existing procedures

1.1 Violation (by individual): One individual intentionally chose to violate an established safety practice.

An investigation team should only select this cause when there is a clear safety practice or rule in place & that practice or rule is known by the person involved. Violations are behaviors, and require a behavioral recommendation. An additional A-B-C analysis can be useful.

1.2 Violation (by group): more than one individual was involved in the decision to intentionally violate an established safety practice.

See above. Additionally, if a procedure has been routinely violated by many, this is an indication of an organizational or cultural issue, which can be further explored in Columns 16, 17 and 22.

1.3 Violation (by supervisor): a supervisor or other management person either personally violated an established safety practice or directed people under their supervision to do so.

See above.



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1.4 Procedure not available: the person doing the work did not have access to the procedure and consequently relied on memory to do the work properly.

This can be addressed either by reinforcing „Stop work when not sure‟ or by making the procedure available.

1.5 Procedure was not understood: the person relying on the procedure could not comprehend the procedure, due to language, technical capability or complexity.

This is a training issue, which can be addressed either by additional training or assignment of different personnel. The quality / content of the procedure is covered in column 22 – Standards/ Practices/Procedures.

1.6 Other: must define. The use of „other‟ without comment or explanation has no value to your investigation. See above.

2. Use of tools, plant/equipment or vehicle

2.1 Plant/Equipment or vehicle used in the wrong way: equipment or vehicle was used for activities for which it was not designed or the equipment or vehicle was misused, for example, using a forklift to lift a pallet for use as a work platform, or using a handrail as a ladder.

To make a good recommendation, investigation needs to determine if this action was intentional or due to lack of knowledge. If intentional, this is a behavioral issue which requires a behavioral recommendation. An A-B-C analysis can help understand why the person acted this way. If lack of knowledge, then a training solution is appropriate.

2.2 Tools used in the wrong way: tools were used for activities for which they were not designed or tools were misused, for example, using a wrench as a hammer, or a screwdriver as a pry bar.

See above.

2.3 Use of plant/equip or vehicle with known defect: the person using the equip had identified it as being defective, yet continued to use that equip, for example, using a vehicle with inoperative lights or a ladder with a broken rung. (Hidden or unidentified defects are covered in Column 6 – Tools, Plant/Equip & Vehicles.)

Since the defect was identified, this is a behavioral issue, and requires a behavioral recommendation. An A-B-C analysis can be helpful in identifying factors which caused the person to act this way.

2.4 Use of tools with a known defect: the person using the tool had identified it as being defective, yet continued to use that tool, for example, using a grinder without a guard, or a extension cord with frayed wires. (Hidden or unidentified defects are covered in Column 6.)

See above.



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2.5 Incorrect placement of tools, equip or materials: the tools, material or equip in use were placed in a position creating a hazard, eg., tools placed overhead fell & struck the person or a truck was parked on a slope & rolled down.

The investigation needs to determine if this was intentional, due to lack of knowledge or due to poor risk awareness. Depending on that conclusion, the recommendation can be behavioral, training or procedural.

2.6 Operation of plant/equip or vehicle at improper speed: once a known operating limit was exceeded, the person did not take the appropriate actions to correct the situation. (Note – this can apply to any process plant operating limitation – temperature, flow, pressure etc.)

This cause is used when there was an intent or effort to correct the situation. This is typically a training issue and requires a training solution. If there is no effort to correct the situation, then the behavior is intentional and violation of procedure is a better cause to select.

2.7 Other: must define. The use of „other‟ without comment or explanation has no value to your investigation.

3. Use of protective equipment or methods

3.1 Need for protective equip or methods not recognized: the person performing the work did not recognize the situation required protective equipment or methods.

This is training deficiency, in either risk assessment or hazard awareness and a training recommendation is appropriate.

3.2 PPE or methods not used: the equip or methods necessary in this situation were not used by the person doing the work.

A behavioral situation equivalent to a violation. An A-B-C analysis can be used to help understand factors underlying the behavior.

3.3 Incorrect use of PPE or methods: the required PPE or methods were used, but not in a correct way to afford the needed protection. Examples could be an incorrect respirator or an incomplete lockout/tagout.

This is likely a training issue and additional training on selection, use and limitations would be appropriate.

3.4 PPE or methods not available: the need for PPE or methods was recognized, but the equipment was either not available or was impossible to employ, yet the work continued. Examples would include no respirators in stock, or no place to install a lock for lockout.

This is a combination of procedural and behavioral issues, but is best addressed via procedural changes to ensure the equipment or methods are present and usable.

3.5 Disabled guards, warning systems or safety devices: the correct guards, warning systems or other safety devices were in place, but were disabled or overridden to allow the work to proceed without these protections.

This is a behavioral situation equivalent to a violation. An A-B-C analysis can be used to help understand the factors underlying the behavior.



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This includes de-activation or bypassing of interlocks or safety instrumented systems.

3.6 Removal of guards, warning systems or safety devices: the correct guards, warning systems or other safety devices had been removed at some prior time, & not reinstalled or reactivated. (Equip that was never installed or was defective is covered in Column 5 – Protective Systems)



4. Lack of focus or inattention

4.1 Distracted by other concerns: the person involved was distracted & not attentive to the work in progress, & the person was not aware or became aware too late that something had gone wrong. This would include failure to control visitors, inadequate alarm management or personal issues.

This is a behavioral issue, but there is evidence of a work setting which did not allow the person to concentrate on their work. This can be addressed by eliminating the distraction or training the person to minimize the distraction before proceeding.

4.2 Inattention to surroundings: the person was not alert to their surroundings & just tripped or ran into something that was clearly visible & obvious.

A behavioral situation & requires a behavioral solution. An A-B-C analysis can be used to help understand the factors underlying the behavior.

4.3 Inappropriate workplace behaviour: the person(s) involved were engaged in inappropriate activities, such as practical jokes, clowning around or acts of violence.


4.4 No warning provided: a person had awareness of a dangerous condition or activity, but did not warn current or future persons of the exposure, for example, did not tag a defective tool, did not install a safety barrier around a spill or disabled alarms or interlocks.

If there is a clear expectation that a person should have done something to warn others, this is a behavioral issue. If there is not a clear expectation, this can be addressed through training or procedures.

4.5 Unintentional human error: this cause is the opposite of violations, which are intentional acts. Unintended human error can consist of perception errors, memory errors, decision errors or action errors. (If this cause is selected, further inquiry & investigation are required to determine the error type & reasons why the

This is a special situation where the behavior itself was unintentional, and not just the outcome of that behavior. This situation requires special analysis – you should contact a Master Level Root Cause Specialist.



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error was made.)

4.6 Routine activity without thought: the person involved was performing a routine activity, such as walking, sitting down, stepping, etc., without conscious thought, & was exposed to a hazard as a result.

This is a behavioral situation and requires a behavioral solution. An A-B-C analysis can be used to help understand the factors underlying the behavior.


Conditions

There are four major categories of conditions, with an additional level of detail under each of the major categories. In conditions, we are focused on the physical working space and the equipment.

5. Protective systems

5.1 Guards or protective devices not effective: guards or protective devices needed to protect the worker were present & working, but did not prevent the incident. For example, a highway guardrail failed to stop a vehicle or a machinery guard did not restrain flying pieces.

This is typically an equipment issue and requires an equipment solution.

5.2 Defective guards or protective devices: guards or protective devices needed to protect the worker were present, but failed when they were needed. For example, a handrail collapsed when a person fell against it.

This is either an equipment or maintenance issue and the recommendation must address the suitability or reliability of the equipment.

5.3 Incorrect PPE: the PPE used was not correct for the situation at the time of the incident or the wrong type of PPE was specified. For example, a dust respirator was provided when an organic vapour respirator was needed, or a cloth glove was provided when an impervious material glove was needed.

This cause should be limited to situations where the wrong PPE was supplied. If the person involved was knowledgeable and well trained, yet opted for the wrong PPE, that is a behavioral issue – an action – not a condition.

5.4 Defective PPE: the PPE was correctly specified, but the specific piece of PPE was defective at the time of the incident. For example, the seam of a glove opened & allowed material to contact the hand.

This cause is either addressed as a quality control issue or through a procedural change for user inspections.

5.5 Warning systems not effective: a warning system was present and working but failed to provide sufficient notice at the time of the




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incident. For example, an evacuation alarm which could not be heard in all locations.

5.6 Defective warning systems: a warning system was present but failed at the time of the incident. For example, a tank high level alarm failed to activate.


5.7 Safety devices were not effective: safety devices such as pressure relief valves or turbine overspeed trips were present and working, but did not act quickly enough to prevent the accident.


5.8 Defective safety devices: safety devices such as pressure relief valves or turbine over speed trips failed to activate when needed. This would also include interlocks or safety instrumented systems which failed to operate. (Note: safety devices which are intentionally disabled or over-ridden are covered in Column 1 – Did Not Follow Existing Procedures.)



6. Tools, plant/equipment and vehicles

6.1 Plant/equip malfunction: the right equip was selected & used, but the specific piece of equip involved did not operate properly. For example, a drawer of a file cabinet being opened came all the way out and fell.

This cause is limited to equip malfunctions which are invisible or hidden to the user. Defects which are known to the user are best found in Column 2; defects which should be identified in a pre-use check are in Column 22.

6.2 Preparation of plant/equip: the equip was not prepared correctly prior to the job or maint. work, for example, a vessel was not thoroughly cleaned of process chemicals prior to entry.

The investigation needs to determine if this is an equipment issue, a procedural issue or a behavioral issue and then verify the recommendation fits their conclusion.

6.3 Tool malfunction: the right kind of tool was selected and used, but the tool involved did not operate properly. For example, an electric tool had a short that shocked the user.

This cause is limited to tool malfunctions which are invisible or hidden to the user. Defects which are known to the user are best found in Column 2; defects which should be identified in a pre-use check are in Column 22.



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6.4 Preparation of tools: the tools were not prepared correctly before the job, for example, an air monitoring instrument was not calibrated prior to use.

The investigation needs to determine if this is a tool and equipment issue, a procedural issue or a behavioral issue and then verify the recommendation fits their conclusion.

6.5 Vehicle malfunction: the right type of vehicle was selected & used, but the vehicle did not operate correctly. For example, the load indicator on a crane did not properly measure the weight being lifted.

This cause is limited to vehicle malfunctions which are invisible or hidden to the user. Defects which are known to the user are best found in Column 2; defects which should be identified in a pre-use check are in Column 22.

6.6 Preparation of vehicle: the right vehicle was being used, but the vehicle had not been correctly repaired or serviced for use. For example, a vehicle suffered a blow out of a tire because the tire was not set correctly on the rim.

The investigation needs to determine if this is a vehicle issue, a procedural issue or a behavioral issue and then verify the recommendation fits their conclusion.


7. Unanticipated exposure to...

7.1 Fire and explosion: the person was involved in the immediate aftermath of a fire and/or explosion.

This column is limited to unanticipated exposures. If the hazard was anticipated, or if procedures exist to control the hazard, better causes are found in Columns 19 or 22. If the hazard was unanticipated, recommendations need to address either the underlying cause of the event or the lack of risk assessment.

7.2 Noise: the person was exposed to a short term episode of unusually high noise levels, such as a blast or depressurization event.

See above.

7.3 Energized electrical systems: the person was exposed to electrical energy in a system that was believed to have been isolated.

See above.

7.4 Energized sources other than electrical: the person was exposed to sources of energy other than electrical, such as gravitational, pneumatic, hydraulic, chemical energy or radiation sources.

See above.



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7.5 Temperature extremes: the person was exposed to unusually high or low ambient temperatures, or by touching an object or surface that was unusually hot or cold.

See above.

7.6 Hazardous chemicals: the person was exposed to hazardous chemicals in an amount or dose capable of causing an adverse health effect.

See above.

7.7 Mechanical hazards: the person was exposed to sharp edges, moving equip or falling materials.

See above.

7.8 Storms or acts of nature: the person was exposed to the immediate effects of a storm, tornado, hurricane, ice storm, or other acts of nature.

See above.


8. Workplace layout

8.1 Congestion: the layout of the workplace did not provide enough clearance from hazards, accessibility to equipment or tools was obstructed, or persons working could not achieve a correct posture.

This is an issue with plant design and a recommendation addressing this cause must modify the layout or allow work to be done in a different location.

8.2 Illumination: the workplace illumination was so low or so bright, that it impacted a person‟s ability to see.

This is an issue with design and a recommendation addressing this cause must modify the lighting system or provide shielding if too bright.

8.3 Ventilation: there was insufficient air movement, which led to increasing temperature or concentrations of chemicals or a decrease in oxygen levels.

This is an issue with either the design of the workplace or the way a particular job is being done, and a recommendation must address how the ventilation will be improved.

8.4 Unprotected height: work was being done in a location where tie-off to a fall arrest system was not possible and other means of protection, such as guardrails or nets were not present.

This issue is limited to situations where fall protection is not present. Where fall protection is available & not used, see: Column 1 – Did Not Follow Existing Procedures; or Column 13 – Behaviors. If this cause is used, a recommendation must



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address how fall protection will be provided.

8.5 Workplace displays: displays used to provide information to workers did not give necessary information to the worker. Examples would include labels which were not readable, warning lights that were burnt out, mislabeled equip or chemicals, or inaccurate process info. or alarms.

A recommendation addressing the cause must cover how the information flow to the worker will be improved.


Possible system causes

System causes are covered in the final two sections entitled: Personal Factors and Job Factors. Personal Factors are internal to the individual. Job Factors relate to the organizational issues where the work is being done.

Personal factors

There are six categories of personal factors, with an additional level of detail under each of the major categories.

9. Physical capabilities

Note: Capabilities refer to a permanent issue with this person.

9.1 Vision deficiency: an existing vision deficiency affected the person‟s ability to perform their job. This could include colour blindness or an uncorrected vision problem such as cataracts.

As this cause represents a permanent condition, the recommendation for this cause must address either a permanent job re-design or a strategy to move the person to another job which can accommodate their limitation.

9.2 Hearing deficiency: an existing hearing deficiency affected the person‟s ability to perform their job. This could include permanent hearing loss up to deafness.

See above.

9.3 Other sensory deficiency: an existing deficiency, in taste, touch or smell, affected on a person‟s ability to perform their job.

See above.

9.4 Other permanent physical disabilities: all other permanent physical disabilities which affected a person‟s ability to perform their job. Examples would include restriction of range of motion, inability to maintain proper work posture, lifting restrictions or reduced

See above.



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respiratory capacity.

9.5 Substance sensitivities or allergies: an existing sensitivity or allergy affected a person‟s ability to do their job. This could include allergies to bee stings or someone diagnosed with multiple chemical sensitivity.

See above.

9.6 Size or strength limitations: the person assigned to the work did not have the size or strength to complete the task safely, for example, couldn‟t reach, couldn‟t lift.

See above.


10. Physical condition

10.1 Previous injury or illness: the person assigned to the work had a previous injury or illness that affected their ability to perform their job. This previous injury or illness can be either work related or not work related and the injury or illness may or may not have been reported to us.

If the previous injury or illness was known to us, then this is a procedural issue & the recommendation must address why the person was still assigned to that work. If the injury or illness was not reported, that is a behavioral issue & the recommendation must address why it wasn‟t reported.

10.2 Fatigue: the person involved in the incident was fatigued due to high workload or to lack of rest. This cause can include work schedules of extended hours on a given day, numerous overtime shifts in a row, or numerous days of work without a day off. Fatigue may also be present with normal work hours and a failure to rest adequately while off duty.

The investigation needs to determine if this is a procedural issue, a training issue or a behavioral issue and then verify the recommendation fits the conclusion.

10.3 Diminished performance: the surroundings or work site conditions led to less than normal performance. This can be due to temperature or humidity extremes, lack of oxygen due to high elevations, or atmospheric pressure changes, such as encountered during diving work.

The presence of such factors should be identified and controlled through a risk assessment. If the risk assessment did not identify or effectively control these hazards, then the recommendation must address how this will be better managed.

10.4 Impairment due to drug, alcohol or medication: at the time of the incident, the person‟s performance was affected by drugs, alcohol or medications.

This is usually a behavioral issue and the recommendation must address that. This can also be a training issue if the person is unaware of the side effects of certain



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medications.


11. Mental capability

Note: Capabilities refer to a permanent issue with this person.

11.1 Memory failure: the person‟s job performance was affected by their inability to remember or recall information necessary to complete the work.

Use of this cause should be limited to work that is expected to be done from memory, & not for situations where the work should be done with written procedures or checklists. The cause also assumes the person was adequately trained.

11.2 Poor co-ordination or reaction time: the person‟s job performance was affected by their inability to co-ordinate all the required actions or their reaction time was too long.

This cause will usually require some job redesign. In some situations, it may be possible to address this cause with training to build this capability.

11.3 Emotional status: the person‟s job performance was impacted by their emotional status. This can include post traumatic stress situations or flashbacks.

The use of this cause requires medical evidence. This cause is usually addressed with job placement. There may be limited training opportunities to build better coping skills.

11.4 Fears or phobias: the person‟s job performance was affected by an existing fear or phobia, for example, someone who is afraid of working at heights, or climbing ladders or who is claustrophobic.

If the fear or phobia was known, this is a procedural issue as to why the person was assigned such work. If the fear or phobia was not known, then it is a behavioral issue.

11.5 Low mechanical aptitude: the person‟s job performance was affected because they did not understand basic elements of how mechanical things work.

This is a training issue and the recommendation must address how this aptitude will be improved.

11.6 Low learning aptitude: the person‟s job performance was affected because they did not comprehend standard training materials which have been verified as adequate.

This is a training issue and the recommendation must address how additional or enhanced training will be provided. (Poor learning due to language issues are in columns 15 or 23.)

11.7 Incorrect judgment: a person‟s job performance was affected by their inability to make an appropriate judgment when confronted by an ambiguous situation.

This cause is only appropriate when judgment is required. When an instruction is present which dictates a person‟s actions, & the person does not execute to that instruction, that is a violation, not a



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judgment. The recommendation for this cause is difficult – teaching better judgment is not easy.


12. Mental stress

Note: Capabilities refer to a permanent issue with this person

12.1 Preoccupation with problems: the person‟s job performance was affected because they were preoccupied with problems and were not fully concentrating on the activities in progress.


12.2 Frustration: the person‟s job performance was affected by high levels of frustration, which led to the person acting inappropriately.

See above.

12.3 Confusing directions/demands: the person‟s job performance was affected by inconsistent directions, instructions or demands. Examples would include procedures that do not match the existing equipment, a lack of priority to assigned work or too many people giving instructions.

This cause is usually an issue of procedures and a proper recommendation will address how the procedures and/or instructions will be modified to eliminate confusion.

12.4 Conflicting directions/demands: the person‟s job performance was affected because two or more directions, instructions or demands were in conflict, making compliance impossible.

This cause is usually an issue of procedures and a proper recommendation will address how the procedures and/or instructions will be modified to eliminate the conflict.

12.5 Extreme decision demands: the work being done required decision making under high stress, leading to an incorrect decision. Examples would include time sensitive decisions, incomplete information on which to base the decision, or dangerous situations.

This cause is best addressed by a recommendation that clarifies the inputs into the decision or reduces the stress around the decision process. Sophisticated training involving simulations can also be used.

12.6 Unusual concentration or perception demands: the work being done required great concentration, & the person lost situational awareness.

This cause is best addressed by moving such work into a hazard free area or by providing a spotter or watcher.

12.7 Other emotional overload: the person‟s job performance was affected by high stress

This is a behavioral situation and requires a behavioral solution. An A-B-C analysis can



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levels from either work or personal issues, leading to inappropriate actions.

be used to help understand the factors underlying the behavior.


13. Behaviour

Note: Investigators need to understand the behavior of those involved.

This is best done by performing a structured A-B-C Analysis.

13.1 Antecedent not present: antecedents are the things present before a person behaves in some way. Examples include signage, training, procedures and the expectations of others.

This cause is appropriate if the A-B-C analysis indicates a needed antecedent was not present prior to the behavior. Proper recommendation will specify what antecedent is missing and how it will be created in the work environment.

13.2 Antecedent not effective: a needed antecedent to the behaviour was present but did not trigger the proper behaviour.

A proper recommendation will specify what antecedent was inadequate & what needs to be done to strengthen that antecedent so it will trigger the proper behavior.

13.3 Incorrect behaviour reinforced: the person performing a specific behaviour received a positive consequence for doing so. A positive consequence can be saving time or effort, approval of co-workers or avoiding discomfort.

This cause is appropriate when the A-B-C analysis indicates this consequence was an important factor in the person‟s actions. A proper recommendation will address how this consequence can be minimized and/or how other more powerful consequences for the proper behavior can be implemented.

13.4 Incorrect behaviour not confronted: a person‟s inappropriate behaviour was not confronted or challenged by supervisors or peers, and therefore there was no negative consequence to that behaviour.

This cause is appropriate when there were opportunities to intervene, but people did not do so. A proper recommendation will address how future interventions will be more strongly encouraged.

13.5 Proper behaviour not rewarded: a person performing a proper behaviour did not receive any positive consequence for doing so, thereby reducing the motivation to continue to perform proper behaviours.

This cause is appropriate when an A-B-C analysis indicated the lack of positive consequence was an important factor in the person‟s actions. A proper recommendation will address how positive consequences will be made more frequently.

13.6 Behavioral analysis process not effective: there was no systematic use of A-B-C analysis to understand behaviours or to create better antecedents and consequences to influence

This cause is appropriate only if there is no effort in place. A proper recommendation would address the need to understand and utilize behavioral tools to improve safety.



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behaviours.


14. Skill level/competency

Note: Skill is the ability to execute a task a person has been trained to do.

Competency is the overall ability and capacity to perform.

14.1 Assessment of required skills or competency not effective: the person assigned to do the work had the skills and competency believed necessary to do so, but in fact, the job required a person with a higher set of skills and competency.

This cause represents a procedural issue, with the quality of the job assessment. A proper recommendation will address improving the assessment of required skills and competency.

14.2 Practice of skill not effective: the person was properly trained, but did not use the skills enough to ever firmly establish the skill.

This is a training and certification issue, and a proper recommendation will address how the verification of skill can be improved.

14.3 No coaching on skill: the person was properly trained, but did not have access to an experienced person who could monitor and coach their proper performance of that skill.

This is a training and certification issue, and a proper recommendation will address how additional support will be made available to assure skills are properly developed.

14.4 Infrequent performance of skill: the person was properly trained and verified to have the appropriate skill level initially, but the skill was not used frequently enough to maintain the skill.

This is a procedural issue. A proper recommendation will address the procedures necessary to allow adequate practice & periodically assess skill level. (a recommendation to retrain will not be effective – it is practice that is needed.)


Job factors

There are nine categories of job factors, with an additional level of detail.

15. Training/knowledge transfer

Note: Training is used to increase knowledge on a specific issue.

15.1 No training provided: the person was not trained in a specific subject. Examples can include not identifying necessary training, reliance on out of date or inaccurate training records, a change in work methods or a

This cause is usually a procedural issue, although a conscious decision to forego training is a behavioral issue. Proper recommendation will address a better means to determine if training is required



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decision to forego training. and/or better records on which to base such a decision.

15.2 Training effort not effective: some training was conducted, but it did not accomplish the necessary knowledge transfer, due to such factors as training program design, poorly developed training objectives, inadequate orientation programs, inadequate initial training efforts or poor means to determine if students have indeed mastered the material being taught.

This is a training issue & should identify the specific shortcoming. A proper recommendation must address how the training program in question will be improved before it is offered to additional people.

15.3 Knowledge transfer not effective: a well developed training effort was in place, but did not transfer the necessary knowledge, due to such factors as the inability of students to comprehend (material beyond their level, language difficulties), inadequate instructor qualifications, inadequate training equipment (lack of props or means to illustrate the topic) or misunderstood directions on the part of the students.

This is a training issue and should identify the specific shortcoming. A proper recommendation must address how the training program in question will be enhanced or how the prerequisites for the class will be modified before it is offered to additional people.

15.4 Training materials not recalled: a well developed training effort was successful in transferring the necessary knowledge, but students did not recall the material when needed. This could be the result of training not being reinforced on the job, or an inadequate retraining frequency.

This is a procedural issue and a proper recommendation will address how additional reinforcements or reminders will be provided or how the retraining frequency will be adjusted.


16. Management/supervision/employee leadership

Note: Can apply to all levels of management / supervision. Peer or co-worker issues should be addressed in Column 13.

16.1 Behaviors not reinforced: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role in understanding the safety behaviours of others and responding to both positive and inappropriate behaviour.

This is a behavioral situation & requires a behavioral solution. An A-B-C analysis can be used to help understand the factors underlying the leaders‟ behavior. Proper recommendation needs to address the issues which are driving the leaders‟ personal behavior.



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16.2 Participation in safety efforts not effective: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role in visibly participating & leading safety activities. Would also include not fostering widespread workforce involvement in safety efforts.

See above.

16.3 Consideration of safety in staffing not effective: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role considering safety behaviours & performance when making decisions to recruit, select, develop, reward & advance people & when selecting & influencing contractors & partners.

See above.

16.4 Resourcing for safety not effective: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role in providing adequate financial & human resources to deliver safety performance.

See above.

16.5 Support of people not effective: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role in seeking out & supporting those individuals who identify & speak out about safety issues & concerns, or those people affected by an incident.

See above.

16.6 Monitoring/auditing of safety process not effective: the leaders in an area did not demonstrate appropriate personal behaviours with respect to their role in monitoring or auditing the effectiveness of the safety management system using rigorous processes and metrics.

See above.

16.7 Lessons learned not embedded: previous investigations had identified a lesson to be learned, but that learning was not effectively embedded with the workforce.

This cause could be the result of a number of different issues and the investigation would need to explore the reasons why the lessons were not embedded.



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16.8 Leadership or accountability: the leaders in an area did not set the right direction or tone for safety or allowed roles and responsibilities for safety activities to be unclear or undefined.

This is a behavioral situation & requires a behavioral solution. An A-B-C analysis can be used to help understand the factors underlying the leaders‟ behavior. Proper recommendation needs to address the issues which are driving the leaders‟ personal behavior.

16.9 Employee involvement not effective: the leaders in an area did not obtain sufficient employee involvement to foster safety awareness. This can include failing to involve appropriate staff in reviewing procedures or failing to involve operators in PHA‟s.


16.10 Risk analysis or tolerance not effective: the leaders in an area did not fully understand the level of risk present or had a tolerance for an unacceptable level of risk.

This can be either a training or a behavioral issue. If the risk is not understood, training would be an appropriate recommendation. If risk acceptance is the issue, an A-B-C analysis might be helpful.


17. Contractor Selection and Oversight

17.1 No contractor pre-qualification process: there was no standard contractor pre-qualification process to assess the capability of a contractor company prior to hiring that firm.

This is a procedural issue, and a proper recommendation would address the need to enhance the local safety management system to include such a process.

17.2 Contractor pre-qualification process not effective: a pre-qualification process was in place and utilized, but it did not identify relevant deficiencies in the contractor‟s capabilities.

This is a procedural issue and a proper recommendation would address the needed improvements in the pre-qualification process.

17.3 Use of a non-approved contractor: a contractor firm who did not meet pre-qualification requirements or criteria was hired to perform work.

This cause could be the result of a number of different issues & the investigation would need to explore the reasoning behind this decision.

17.4 Contractor selection not effective: the selection of a contractor was made without all relevant data, or without proper consideration of safety capabilities of the contractor for this work.

This is a procedural issue and a proper recommendation would address the needed improvements in the pre-qualification process.



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17.5 No job oversight process: no process was in place to monitor or inspect a contractor firm‟s work to identify deficiencies in methods or performance.

This is a procedural issue, and a proper recommendation would address the need to enhance the local safety management system to include such a process.

17.6 Job oversight not effective: a process was in place to monitor or inspect a contractor firm‟s work, but deficiencies in methods or performance were not identified or corrected.

This is a procedural issue and a proper recommendation would address the needed improvements in the job oversight process.

17.7 Other: must define The use of „other‟ without comment or explanation has no value to your investigation.

18. Engineering/design

Note: This category refers to the design of our facilities.

18.1 Technical design not correct: the design of the facilities involved in the incident was not suitable for the intended use. (Note this does not cover misuse or facilities which have deteriorated.) Examples would include inappropriate metallurgy for the intended service or incorrect support for the intended load. This would also include designs which were not risk assessed, where management of change was not followed, or where inherently safer design issues were not considered.

This cause is not typically a root cause and the investigator will need to determine how this occurred. For example, this could be a training/skills issue with the designer, or a calculation error not discovered in the review process.

18.2 Design standards, specifications or criteria not correct: the information available to the designer was not suitable for use. Examples would include information that was wrong, incomplete or not understandable.

This cause is not typically a root cause & the investigator will need to determine how this occurred. For example, the issue might be why the information provider did not understand what was needed, or the issue might be why the designer did not recognize the deficiency.

18.3 Incorrect ergonomic or human factor design: the facilities where the event occurred were not designed in an ergonomically correct way. Examples would include work areas located too high or low or valves out of normal reach, or poor allocation of function between persons & systems.

A proper recommendation will be specific in what piece of equipment is not proper and what should be done to address the issue.

18.4 Monitoring of construction not effective: design specifications & criteria were proper, but the facility was not constructed in accordance with the design.

This cause can be either procedural (if no one was assigned to monitor the construction) or behavioral (if someone was assigned but did not do so.)



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18.5 Assessment of operational readiness not effective: the procedure for handover from construction to operation did not exist, was not correct or was not followed. Examples would include operational readiness or pre-startup reviews.

This cause can be either procedural (if no one was assigned to perform the assessment) or behavioral (if someone was assigned but did not do so.)

18.6 Monitoring of initial operation not effective: the procedure to monitor the initial start-up of equipment to assure proper functioning did not exist, was not correct or was not followed.

This cause can be either procedural (if no one was assigned to monitor the initial operation) or behavioral (if someone was assigned but did not do so.)

18.7 Technical analysis for risk not effective: the design of a plant or equipment was not properly risk assessed, or the design did not take into account and mitigate a high risk level. This would include a failure to perform appropriate PHSER, HAZOP or LOPA analysis.

This cause can be either a procedural issue or a violation, depending on the expectations in place.


19. Control of Work (CoW)

19.1 No work planning or risk assessment performed: the work being done was not planned or was not risk assessed prior to starting that work.

Assuming this requirement is in place, the failure to perform planning or a risk assessment is a behavioral issue. An A-B-C analysis can help determine why this undesired behavior exists.

19.2 Risk assessment not effective: the work being done was risk assessed, but that risk assessment did not identify all the hazards present, or the controls specified did not protect the people doing the work.

This is likely a training issue, if the person doing the risk assessment did not have appropriate knowledge to complete an acceptable assessment. A proper recommendation will address this training deficiency.

19.3 Required permit not obtained: the type of work being performed required a written permit, but a permit was not obtained.

Investigation will need to determine if this was due to lack of procedures, lack of knowledge or a failure to follow CoW instructions.

19.4 Specified controls not followed: the people performing the work were informed of the controls necessary to mitigate the hazards present, but did not follow those controls.

This is likely a behavioral issue and an A-B-C analysis can be used to help understand why the undesired behavior was present.



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19.5 Change in job scope: as the work progressed, there was a change in job scope beyond what was risk assessed & authorized, but the work was not stopped until a risk assessment could be redone.


19.6 Worksite not left safe: work was completed or interrupted, but one or more hazards were not completely controlled or eliminated.



20. Purchasing, material handling and material control

20.1 Incorrect item ordered: the incorrect item was unintentionally ordered. Reasons for this can include incorrect specifications to vendors, inaccurate information on the requisition, or inadequate control on who can modify orders.

This can be either procedural or behavioral. Investigation must understand what led to the incorrect order. If procedural, the recommendation should address how the procedure will be modified. If behavioral, then an A-B-C analysis may be helpful.

20.2 Incorrect item received: the correct item was ordered, but an incorrect item received. Reasons can include unauthorized substitution by vendor, inadequate product acceptance procedures or a failure to verify receipt of proper goods.

This cause can be either procedural (if no one was assigned to verify proper receipt) or behavioral (if someone was assigned but did not do so).

20.3 Handling or shipping not effective: the materials were damaged in the handling or shipping.

This cause can be either procedural or behavioral. Investigation must understand what led to incorrect handling or shipping. If procedural, the recommendation should address how the procedure will be modified. If behavioral, then an A-B-C analysis may be helpful.

20.5 Labeling of materials not effective: the materials were not labeled or identified correctly, allowing a wrong selection or not providing relevant health & safety information.

This cause is usually procedural, & the recommendation must address how improved labeling will be done.


21. Tools and plant/equipment



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21.1 Wrong tools or plant/equipment provided: the tools and equipment provided were thought to be right, but proved to be the wrong tools or equipment, because the risk associated with their use was incorrectly assessed.

Incorrect risk assessment is either a training or behavioral issue & investigation will determine which it is. If training, a recommendation should address the additional training. If behavioral, an A-B-C analysis should help.

21.2 Correct tools or plant/equipment not available: the needed tools or equipment were not available at the job site, either because they were never supplied, or were inaccessible.

Procedural issue. A proper recommendation will address how the proper gear will be provided in the future. If people knowingly used the wrong tools or equipment, see Column 2.

21.3 No inspection: the tools and equipment were not inspected prior to use, and a defect was not identified before use.

If a procedure is in place & the people have adequate training & skill, the failure to inspect is a behavioral issue. If an inspection was done & the defect was not detected, this may be training issue.

21.4 Incorrect adjustment/repair/ maintenance: the proper tools and equipment were available, but had not been correctly maintained or repaired when last serviced.

Either a training or behavioral issue, depending whether the person performing the service knew what was required to service the tools or equip. Proper recommendation will address either the training deficiency or the undesired behaviour.

21.5 Removal or replacement of unsuitable items not effective: items that were no longer serviceable remained in use.

Either a training or behavioral issue, depending whether the person could recognize that the tool or equipment was no longer serviceable. A proper recommendation will address either the training deficiency or the undesired behaviour.

21.6 No preventative maintenance program: the tools or equipment involved in the incident were not covered by a preventative maintenance program, and became unserviceable.

This is a procedural issue & a proper recommendation will address the need to establish a routine maintenance plan for this tool or equipment.

21.7 Testing of plant, tools or equip not performed Tools/equip were not properly tested or evaluated for fitness for use. This can include failure to inspect plant equip for mechanical integrity or evaluate the electrical integrity of a power tool.

This can be a procedural issue or a violation depending on whether the proper expectations were in place.

21.8 Other: must define. The use of „other‟ without comment or



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explanation has no value to your investigation.

22. Standards/Practices/Procedures (SPP)

Note: SPP covers any written document which instructs people what the expectations are in performing work. These can be very general, like a Golden Rule, or very specific, like a start up procedure for a unique process.

22.1 Lack of SPP for the task: there were no written SPP covering the work being performed at the time of the incident, due to such factors as the failure to assign responsibility for the development of SPP, or the failure to recognize the need for standard instructions for this task.

If the need was not recognized, this is an issue with risk assessment & additional training may be necessary. If the need was identified, then the failure to develop SPP is a behavioral issue. An A-B-C analysis might be helpful. A proper recommendation will address these issues.

22.2 Development of SPP not effective: there were some SPP in place, but the SPP that were developed did not fully meet needs of the work, due to such factors as inadequate co-ordination with design efforts, having unknowledgeable people developing the SPP, not identifying the proper steps to take in problem situations or a poor format that made SPP difficult to use.

At the surface, this is a procedural issue and a recommendation needs to address what needs to be done to improve the SPP. A deeper issue is why the procedure was not right, which may be a training or behavioral issue. Your investigation will need to determine why and then address it with a proper recommendation.

22.3 Communication of SPP not effective: there was an appropriate SPP in place, but it had not been properly communicated, due to such factors as incomplete distribution, language difficulties, incomplete integration with training efforts or out of date SPP still in use.

This is a procedural issue and your investigation will need to determine what is needed to make the communication sufficiently effective, accurate and reliable.

22.4 Implementation of SPP not effective: there were SPP in place, but the implementations of the SPP were not complete, due to such factors as contradictory requirements, confusing formats, inaccurate sequence of steps, technical errors, incomplete instructions, etc.

At the surface, this is a procedural issue & a recommendation needs to address what needs to be done to improve the SPP. A deeper issue is why the procedure was not fully implemented, which may be a training or behavioral issue. Your investigation will need to determine why & then address it with a proper recommendation.

22.5 Enforcement of SPP not effective: well crafted SPP were in place, but their use was not properly enforced to the extent necessary, due to such factors as inadequate monitoring of the work being done, or inadequate supervisory knowledge of what was to be done.

A behavioral issue, both for the employees using the SPP and the supervisors responsible for the work. An A-B-C analysis might be helpful in understanding the undesired behavior.



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23. Communication

Note: Can be written or verbal.

23.1 Horizontal communication between peers not effective: the people involved in the incident did not communicate important information between peers and colleagues.

This is a behavioral issue & you will need to understand why the information was not communicated. An A-B-C analysis might be helpful. The recommendation will need to address how this behavior will be encouraged in the future.

23.2 Vertical communication between supervisor and person not effective: the person & supervisor involved in the incident did not communicate important information. This missing communication can be in either direction.

See above.

23.3 Communication between different organizations not effective: individuals in two different organizations did not communicate important information. For example: operations & maintenance, supplier & purchaser, host employer & contractor, or engineers & operators.

See above.

23.4 Communication between work groups not effective: individuals in two different work groups, working on the same task, did not communicate important information.

See above.

23.5 Communication between shifts not effective: the people involved in making the handover from one shift to the next did not fully communicate all necessary information about current work activities.

See above.

23.6 Communication not received: the individuals involved in the incident attempted to communicate, but the information did not reach the intended person. Examples could include a note that got lost, an email that was misdirected or a phone message not retrieved.

This is likely a procedural issue and your investigation will need to determine why the communication was not received. A proper recommendation will address how communications will be made more reliable.

23.7 Incorrect information: the person involved in the incident was given information, but that

This is likely a knowledge issue, especially if the person did not recognize the



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information proved to be incorrect. information was incorrect. Your investigation will need to determine why the incorrect information was communicated & a proper recommendation will address training needs.

23.8 Information not understood: the people involved in the incident did communicate with one another, but the information conveyed was not understood.

The investigation will need to determine why the information was not understood. A proper recommendation will address how the communication will be improved – for example – verification techniques, simpler language, written versus verbal.




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An Overview

Hazop (incident investigation & root cause analysis )

Business

incident analysis

miss incident

incident reporting statutory

incident investigations

typical accident investigation

magnitude incidents

aid injury

type of incidents