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9. PhysicalCapabilities

9-1 Visiondeficiency

9-2 Hearingdeficiency

9-3 Othersensorydeficiency

9-4 Otherpermanentphysicaldisabilities

9-5 Substancesensitivitiesorallergies

9-6 Inadequatesize orstrength

9-7 Other

10. PhysicalCondition

10-1 Previousinjuryorillness

10-2 Fatigue

10-3 Diminishedperformance

10-4 Impairmentdueto drug,alcoholor medication

10-5 Other

11. MentalCapability

11-1 Memoryfailure

11-2 Poorco-ordination orreactiontime

11-3 Emotionalstatus

11-4 Fearsor phobias

11-5 Lowmechanicalaptitude

11-6 Lowlearning aptitude

11-7 Poorjudgment

11-8 Other

12. MentalStress

12-1 Preoccupationwithproblems

12-2 Frustration

12-3 Confusingdirections/demands

12-4 Conflictingdirections/demands

12-5 Extremedecisiondemands

12-6 Extremeconcentrationorperception demands

12-7 Otheremotionaloverload

12-8 Other

13. Behaviour

13-1 Antecedentnot present

13-2 Inadequateantecedent

13-3 Inappropriatebehaviourreinforced

13-4 Inappropriatebehaviournotconfronted

13-5 Properbehaviour notrewarded

13-6 Inadequatebehaviouralanalysisprocess

13-7 Other

17. ContractorSelectionandOversight

17-1 Lackofcontractorpre-qualificationprocess

17-2 Inadequatecontractorpre-qualificationprocess

17-3 Useofanon-approvedcontractor

17-4 Inappropriatecontractorselection

17-5 Nojoboversightprocess

17-6 Inadequatejoboversight

17-7 Other

20. Purchasing,MaterialHandling& MaterialControl

20-1 Incorrectitem ordered

20-2 Incorrectitem received

20-3 Inadequatehandlingorshipping

20-4 Improperstorageofmaterials

20-5 Inadequatelabelingo fmaterials

20-6 Other

21. ToolsandEquipment

21-1 Wrongtoolsorequipmentprovided

21-2 Propertoolsorequipmentnot available

21-3 Inadequateinspection

21-4 Inadequateadjustment/repair/maintenance

21-5 Inadequateremovalorreplacemento funsuitableitems

21-6 Nopreventativemaintenanceprogram

21-6 Other

23. Communication

23-1 Inadequatehorizontalcommunicationbetweenpeers

23-2 Inadequateverticalcommunicationbetweensupervisorand person

23-3 Inadequatecommunicationbetweendifferent organisations

23-4 Inadequatecommunicationbetweenwork groups

23-5 Inadequatecommunicationbetweenshifts

23-6 Communicationnot received

23-7 Incorrectinformation

23-8 Informationnot understood

23-9 Other

1. FailuretoFollowExistingProcedures1-1 Violation(byindividual)1-2 Violat ion(bygroup)1-3 Violation(bysupervisor)1-4 Procedurenotavailable1-5 Procedurewasnotunderstood1- 6 O ther

2. UseofToolsorEquipment2-1 Useofequipmentinthewrongway2-2 Useoftoolsinthewrongway2-3 Continueduseofequipmentwithknowndefect2-4 Continueduseoftoolswithaknowndefect2-5 Improperplacementoftools,equipment

ormaterials2-6 Continuedoperationofequipmentat

improperspeed2-7 Other

3. UseofProtectiveEquipmentorMethods3-1 Needforprotectiveequipmentormethodsnot

recognized3-2 PersonalProtectiveEquipmentormethodsnotused3-3 ImproperuseofPersonalProtectiveEquipment

ormethods3-4 PersonalProtectiveEquipmentormethodsnotavailable3-5 Disabledguards,warningsystemsorsafetydevices3-7 Removalofguards,warningsystemsorsafetydevices3- 8 Ot her

4. LackofFocusorInat tent ion4-1 Distractedbyotherconcerns4-2 Inattentiontosurroundings4-3 Inappropriateworkplacebehaviour4-4 Failuretoprovideawarning4-5 Unintentionalhumanerror4-6 Routineactivitywithoutthought4-7 Ot her

5 . P ro tect iveSyst ems5-1 Inadequateguardsorprotectivedevices5-2 Defectiveguardsorprotectivedevices5-3 Inadequatepersonalprotectiveequipment5-4 Defectivepersonalprotectiveequipment5-5 Inadequatewarningsystems5-6 Defectivewarningsystems5-7 Inadequatesafetydevices5-8 Defectivesafetydevices5-9 Other

6. Tools,Equipment&Vehicle6-1 Equipmentmalfunction6-2 Preparationofequipment6-3 Toolmalfunct ion6-4 Preparat ionoftools6-5 Vehiclemalfunction6-6 Preparationofvehicle6-7 Other

7. Unant icipatedExposureto7-1 Fireandexplosion7-2 Noi se7-3 Energisedelectricalsystems7-4 Energisedsourcesotherthanelectrical7-5 Temperatureextremes7-6 Hazardouschemicals7-7 Mechanicalhazards7-8 Stormsoractsofnature7-9 Other

8 . WorkPl aceLayout8 -1 Congest ion8-2 Inadequateorexcessiveillumination8-3 Inadequateventilation8-4 Unprotectedheight8-5 Inadequateworkplacedisplays8- 6 Other

AnAntecedent-Behaviour-ConsequenceAnalysis (ABCAnalysis) isuseful tobetter understandwhy peoplebehaveastheyintendtodo.ThisunderstandingprovidesaqualitycauseanalysisintheCLC. ToperformanABCAnalysis:

Identifythebehaviour(s)inthiscriticalfactorabehaviourisanobservableaction,i.e.whatapersondoesordoesntdoorsay.

Writeastatementofthebehaviour,includingwhoperformedthebehaviour,whattheydidordidnot do,orsay,andwhatwastheoutcomeofthat.

SeeAGuidetoABCAnalysisformoredetail.

Therearetwotoolsforanalysisofbehaviourandwedeterminewhichtooltousebasedonwhetherthebehaviourwasintended.Verifythateachbehaviourwasanintentionalaction.Mostbehavioursareintentional,eveniftheoutcomeof thatbehaviour wasunintentional orundesired.

Ifthebehaviourwasintentional,proceedwiththeABCAnalysis.

Ifthebehaviourwasunintentional,consultwithamasterlevelRootCauseSpecialist,whohasspecificexpertiseinthisarea.

Antecedentsare thethings whichtrigger orpromote aspecific behaviour.Some examplesofcommon antecedentsatworkare:

> Signs > knowledge> war ni ng labels > expec tations of others> t ra in ingprograms > expec ta tionsof yoursuperv isor> policies > tools and equipment> rules > exampleset byothers

Identifytheantecedentspresentinthisinstancepriortothebehaviour.

Rateeachantecedentaspresent&effective,present&noteffectiveornotrelevant.

Usethisunderstandingtoselectappropriatecausesforthecriticalfactorassociatedwiththisbehaviour.

Consequencesarea morepowerful driverfor behaviourthan antecedentsare, butto understandconsequences,wemustconsiderthemfromtheperspectiveofthepersonperformingthatbehaviour.Whatdidthatpersonexpecttogetfromperformingthatway?Remembertwokeypoints1)mostbehaviourisrationaltothepersonperformingitand2)consequencescanbebothpositiveandnegative.Someexamplesofcommonconsequencesatwork:

> savestimeoreffort > get injured> savesmoney > getcaught bysupervisor> get approva l fromasuperv isor > get cor rect edbyaco-worker> gohomeearly > personaldiscomfort> avoidembarrassment

Rateeachconsequenceas1)eitherpositiveornegative,2)certaintooccur,oruncertainand3)immediateor future.

AfteryouhavecompletedtheABCAnalysis,theadditionalinsightsyouhaveintothebehavioursexhibitedbythepeopleinvolvedintheincidentwillassistyouinidentifyingthepropercausesforeachcriticalfactor.

ContinuewiththeCLCprocesstoidentifythecausesofeachcriticalfactor.

Organizeasmallteam,withtheappropriatetrainingandinstruction.

Setatermsofreferenceforthework.

Preservetheevidencepriortostartingtheinvestigation.

SeetheRCAwebsiteformostrecentsupportdocuments https://rca.bpglobal.com.

Visitthesceneoftheincident.

Interviewusingproperinterviewtechniques-funnelingand5WH.

Examinerelevantrecordspaperorelectronic.

Inspecttheequipmentinvolved.

Organizetheevidenceintoatimeline.

Identifyandwritethecriticalfactorsshort,specificandactionorientedisbest.

PerformanABCanalysisasneededtobetterunderstandbehaviourspriortousingtheCLC.

UsetheGlossarywiththeCLCto determinecausesforeachcriticalfactor.

Oncecausesareidentified,youarereadyto writeyourreport withyourrecommendedcorrectiveactions.

Effectivecorrectiveactionsarespecificandtargetedtothecausesthathavebeenidentified.

Eachcauselistedneedstobecoveredoraddressedbya correctiveaction.

Firstconsidertheexistingbarriersin placetoguardagainstthisrisk. Fixor strengthenthesebarriersbeforecreatingnew barriers.

Theremustbe symmetrybetweenthe causeandthecorrectiveaction.Forexample,anengineeringcausemusthaveanengineeringcorrectiveactionand abehaviouralcausemust haveabehaviouralcorrectiveaction.Behaviouralissuesmust considertheorganizationalandculturalissueswhichenablethat behaviour.

1) IDENTIFY BEHAVIOURS

POSSIBLE IMMEDIATE CAUSES

Qualitytip:Goodlocalpreparationallowsfora fasterstart tothe investigation,whichyieldsabetter investigation.

GETTING STARTED

Qualitytip:AsolidRCA investigationis dependentonfactualinformation.Themorefactsyougather,the betteryourinvestigation.

GATHERING EVIDENCE USING THE CLC

Qualitytip: Eachcauseyoulist must1) besupportedbyevidenceand2) answerwhythecriticalfactorexisted.Ifacausedoesnotmeetbothoftheseelements,itshouldnotbeused.

Qualitytip:Themorespecificyou areinidentifyingthe behaviour,themorespecifictheABCwill be.Thiswill giveyoua betterunderstandingof causes.

2) CHOOSE THE RIGHT TOOL

Qualitytip: Todetermineifa behaviourwasintentional,focusonthe action,nottheoutcome.Forexample,Iwas usingamobilephonewhiledriving,becamedistractedandhadan accident.Thebehaviorisusinga mobilephonewhiledrivingandit isintentional.Theoutcomewas Ibecamedistractedandhadan accident.Whilethat isanundesirableoutcome,it doesnotchangethefact thebehaviourwasintentional.

3) CONSIDER ANTECEDENTS

Qualitytip:Anantecedentcanbepresentand stillnotpreventan undesiredbehaviour.Forexample,ifa warningsignsaysdonot usethisequipmentanda personignoresthatandusestheequipment,theantecedentispresentandeffectiveitconveyedtherightinformationtotheperson.If anantecedentisratedasineffective,youwillneedtospecify acorrectiveactionforit.

4) CONSIDER CONSEQUENCES

Qualitytip:Behaviourexperts believethat consequenceswhichare positive, immediate,certainandmeaningfulto theindividualarethemost powerfuldriversofbehaviour.

PERFORM AN ANTECEDENT-BEHAVIOUR-CONSEQUENCE ANALYSIS

ACTIONS CONDITIONS

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS

CORRECTIVE ACTIONS

Qualitytip: Thisconceptofsymmetryshouldbeyourfinalqualitycheckbeforesubmittingyourreport.A lackofsymmetrybetweenthecauseandthe correctiveactionisinherentlyineffective.

PEOPLE

PLANT

PROCESS

ComprehensiveList of CausesA Tool for Root Cause Analysis

Qualitytip:Onceyouhaveidentifiedsystemcauses,recognizeyoumaynotyet beat theroot causelevel.Continuetoaskyourselfand yourinvestigationteamwhy? untilyouare satisfiedyouhaveexhaustedallpossibilities.

14. Skil lLevel / Competency

14-1 Inadequateassessmentofrequiredskillsor competency

14-2 Inadequatepracticeofskill

14-3 Lackofcoachingonskill

14-4 Infrequentperformanceof skill

14-5 Other

15. Training/KnowledgeTransfer

15-1 Notraining provided

15-2 Inadequatetrainingeffort

15-3 Inadequateknowledgetransfer

15-4 Inadequaterecall oftrainingmaterials

15-5 Other

16. Management / Supervision/EmployeeLeadership

16-1 Inadequatereinforcementofbehaviour

16-2 Inadequateparticipationin safetyefforts

16-3 Inadequateconsiderationof safetyinstaffing

16-4 Inadequateresourcingforsafety

16-5 Inadequatesupportofpeople

16-6 Inadequatemonitoring/auditingofsafetyprocess

16-7 Failureto embedlessonslearned

16-8 Other

18. Engineering/Design

18-1 Inadequatetechnicaldesign

18-2 Inadequatedesignstandards,specificationsorcriteria

18-3 Inadequateergonomicdesign

18-4 Inadequatemonitoringofconstruction

18-5 Inadequateassessmentofoperationalreadiness

18-6 Inadequatemonitoringofinitialoperation

18-7 Other

19. ControlofWork(CoW)

19-1 Noworkplanningorriskassessmentperformed

19-2 Inadequateriskassessment

19-3 Requiredpermit notobtained

19-4 Specifiedcontrols notfollowed

19-5 Changeinjobscope

19-6 Worksitenotleftsafe

19-7 Other

22. Standards/Practices/Procedures(SPP )

22-1 LackofSPPforthetask

22-2 InadequatedevelopmentofSP P

22-3 InadequatecommunicationofSPP

22-4 Inadequateimplementationof SPP

22-5 InadequateenforcementofSPP

22-6 Other