Inident Investigation Root Cause Analysis

Incident Investigation & Root Cause Analysis
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
H|S|E|Q Trainers, Consultants and Risk Management Advisors
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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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1.5 Incident Reporting and Investigation Process
The following schematic diagram outlines the significant steps of the process and their
usual sequence.
Incident Report
Analysis of
Incident
Incident
Investigation
Investigation
Report
Trend Analysis &

Corrective
Actions
End
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.
2.
Nature of Injury.
Foreign body
Cut
Bruises
Strain & sprain
Fracture
Burns
Amputation
Puncture wound
Hernia
Dermatitis
Abrasions
Others
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.
6.
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
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 dont 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 wasnt 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 didnt 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 closeout 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
Page 21 of 61
Event & Condition Mapping

Human Error Analysis
Change Analysis
The main classes of accident models are (based on Kjelln, 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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DOEs core analytical techniques5
Events and causal factors charting (ECFC)

Events and causal factors charting is a graphical display of the accidents chronology and is
used primarily for compiling and organizing evidence to portray the sequence of the
accidents 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 barriers 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.
Kjelln, 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 barriers 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
accidentfree 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 accidents 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 Rrosbanen just before the
sta-accident. This event tree reveals the lack of reliable safety barriers in order to prevent
train collision at Rrosbanen 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
Kjelln 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 This can be addressed either by reinforcing
the work did not have access to the procedure Stop work when not sure or by making the
and consequently relied on memory to do the procedure available.
work properly.
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

See above.
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.
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.

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

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)
This is a behavioral situation equivalent to a

help understand the factors underlying the
behavior.

investigation.
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.
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.
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.
Page 40 of 61

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

investigation.
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: This is typically an equipment issue and
guards or protective devices needed to protect requires an equipment solution.
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.
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
This is typically an equipment issue and

requires an equipment solution.
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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.

equipment.
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.
This is typically an equipment issue and

requires an equipment solution.
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.)

equipment.

investigation.
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.

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

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.

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

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.

is a vehicle issue, a procedural issue or a
behavioral issue and then verify the
recommendation fits their conclusion.

investigation.
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

See above.
exposed to hazardous chemicals in an amount
or dose capable of causing an adverse health
effect.
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.

investigation.
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
persons 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
Page 44 of 61

address how fall protection will be provided.
8.5 Workplace displays: displays used to
A recommendation addressing the cause
provide information to workers did not give
must cover how the information flow to the
necessary information to the worker.
worker will be improved.
Examples would include labels which were not
readable, warning lights that were burnt out,
mislabeled equip or chemicals, or inaccurate
process info. or alarms.

investigation.
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 persons 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 persons ability to
perform their job. This could include
permanent hearing loss up to deafness.
See above.
9.3 Other sensory deficiency: an existing

See above.
deficiency, in taste, touch or smell, affected on
a persons ability to perform their job.
9.4 Other permanent physical disabilities: all
See above.
other permanent physical disabilities which
affected a persons ability to perform their job.
Examples would include restriction of range of
motion, inability to maintain proper work
posture, lifting restrictions or reduced
Page 45 of 61

respiratory capacity.
9.5 Substance sensitivities or allergies: an
existing sensitivity or allergy affected a
persons 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, couldnt reach, couldnt lift.
See above.

investigation.
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 wasnt 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.

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
persons 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
Page 46 of 61

medications.

investigation.
11. Mental capability

Note: Capabilities refer to a permanent issue with this person.
11.1 Memory failure: the persons 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

persons 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 persons 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 persons 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 persons

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 persons 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 persons 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 persons actions, &
the person does not execute to that
instruction, that is a violation, not a
Page 47 of 61

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

investigation.
12. Mental stress

Note: Capabilities refer to a permanent issue with this person
12.1 Preoccupation with problems: the
persons job performance was affected
because they were preoccupied with problems
and were not fully concentrating on the
activities in progress.
This is a behavioral situation and requires a

12.2 Frustration: the persons job performance

was affected by high levels of frustration,
which led to the person acting inappropriately.
See above.
12.3 Confusing directions/demands: the

persons 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

persons 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 persons

job performance was affected by high stress

Page 48 of 61

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


investigation.
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 persons 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

persons 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
persons 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.
Page 49 of 61

behaviours.

investigation.
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.)

investigation.
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
Page 50 of 61

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.

investigation.
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

underlying the leaders behavior. Proper
recommendation needs to address the
issues which are driving the leaders
personal behavior.
Page 51 of 61
16.2 Participation in safety efforts not effective: See above.

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.
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
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
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 See above.

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.
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.
Page 52 of 61
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

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 PHAs.

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.

investigation.
17. Contractor Selection and Oversight

17.1 No contractor pre-qualification process:
there was no standard contractor prequalification 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 contractors
capabilities.

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 prequalification 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.

recommendation would address the needed
improvements in the pre-qualification
process.
Page 53 of 61
17.5 No job oversight process: no process

was in place to monitor or inspect a contractor
firms 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 recommendation would address the needed
firms work, but deficiencies in methods or
improvements in the job oversight process.
performance were not identified or corrected.
17.7 Other: must define

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.

one was assigned to perform the
assessment) or behavioral (if someone was
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.

one was assigned to monitor the initial
operation) or behavioral (if someone was
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.

investigation.
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

This is likely a behavioral issue and an A-Bpeople performing the work were informed of
C analysis can be used to help understand
the controls necessary to mitigate the hazards why the undesired behavior was present.
present, but did not follow those controls.
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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.
This is likely a behavioral issue and an A-BC analysis can be used to help understand
why the undesired behavior was present.
19.6 Worksite not left safe: work was

completed or interrupted, but one or more
hazards were not completely controlled or
eliminated.
This is likely a behavioral issue and an A-BC analysis can be used to help understand
why the undesired behavior was present.

investigation.
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.

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.

investigation.
21. Tools and plant/equipment

Page 56 of 61
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.
Page 57 of 61

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 coordination 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.
Page 58 of 61

investigation.
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 See above.

effective: individuals in two different work
groups, working on the same task, did not
communicate important information.
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 This is likely a knowledge issue, especially
in the incident was given information, but that if the person did not recognize the
Page 59 of 61

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.

investigation.
Page 60 of 61

An Overview
Page 61 of 61

Inident Investigation Root Cause Analysis

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Inident Investigation Root Cause Analysis

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Incident Investigation & Root Cause Analysis

Incident Investigation An Introduction

1.1 Fundamental Defininitions / Terminology.

1.2 Incident Reporting

Incident Investigation & Root Cause Analysis

1.3 Incident Analysis

1.4 Incident Investigation

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

Incident Investigation & Root Cause Analysis

Trend Analysis &

1.6 The Typical Accident Investigation.

Incident Investigation & Root Cause Analysis

What should be done to avoid recurrence

The objective is to identify the causal factors and recommend

Strain & sprain

Incident Investigation & Root Cause Analysis

Sheet stock / scrap

Conveyors & elevators

Floors & surfaces

High pressure / temperature releases

Incident Investigation & Root Cause Analysis

Control the Scene (Initial Response)

2.1 Initial Response

Take all steps necessary to provide emergency

Take those actions that will prevent or minimize the

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

Incident Investigation & Root Cause Analysis

2.2 Gathering Data

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?

positions of injured workers

equipment being used

materials being used

Incident Investigation & Root Cause Analysis

safety devices in use

position of appropriate guards

position of controls of machinery

Incident Investigation & Root Cause Analysis

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?

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)?