1. A - Z of Accident Causes ACTS OR OMISSIONS CONDITIONS PERSONAL FACTORS
INITIAL DESCRIPTION AND COMMUNICATION OF
THE INCIDENT
EVIDENCE GATHERING
IDENTIFICATION OF CRITICAL FACTORS
Raise First Alert
Cover the who / what / when / where / how as known at the time
Communicate to relevant parties
Consider Premises, Plant, Substances, Procedures & People
Collect direct evidence (scene and witnesses)
Collect indirect evidence (written material e.g. work plan)
Organise all evidence
Map evidence
Identify critical factors
Identify all immediate and root causes using the process below
IMMEDIATE CAUSES
ACTS OR OMISSIONS
CONDITIONS
Non application by supervisor
Non application by group
Non application by individual
Other
A-3
A-2
A.1
A-4
A Procedures e.g. PTW, Method Statements, etc
Improper use of equipment
Improper use of tools
Improper storage of tools, equipment or materials
Use of defective tools (aware)
Use of defective equipment (aware)
Other
Maintenance of tools & equipment
B-1
B-2
B-5
B-4
B-3
B-7
B-6
B Use of Tools or Equipment
Personal protective equipment improperly used
Personal protective equipment not used
Personal protective equipment not available Disabled guards, warning systems or safety devices
Removal of guards, warning systems or safety devices
Other
C-1
C-2
C-4
C-3
C-5
C-6
C Use of Protective Methods
Lapse of attention
Mistaken action
Wilfulness
Mistaken priority
Misperception
Other
Acts of violence
D-1
D-2
D-5
D-4
D-3
D-7
D-6
D Human Error
Inadequate personal protective equipment
Defective guards or proactive devices
Inadequate guards or protective devices
Defective warning systems
Inadequate warning systems
Defective personal protective equipment
Defective safety devices
Inadequate safety devices
Inadequate isolation of process or equipment
Other
E-3
E-2
E-1
E-6
E-5
E-4
E-9
E-8
E-7
E-10
E Protective Systems
Improperly prepared equipment
Inadequate equipment
Defective equipment
Improperly prepared tools
Inadequate tools
Defective tools
Improperly prepared vehicle
Inadequate vehicle for the purpose
Defective vehicle
Other
F-3
F-2
F-1
F-6
F-5
F-4
F-9
F-8
F-7
F-10
F Tools, Equipment and Vehicles
G Exposure to:
Slippery floors or walkways
Clutter or Debris
Congestion or restricted motion
Unprotected height
Inadequate ventilation
Inadequate or excessive illumination
Inadequate machinery, equipment or vehicle ergonomics
Inadequate workplace ergonomics
Other
H-3
H-2
H-1
H-6
H-5
H-4
H-8
H-7
H-9
H Workplace Environment / Layout
G-1
G-4
G-3
G-2
G-7
G-6
G-5
G-10
G-9
G-8
G-11
Fire or explosion
Pressurised release
Live electricity
Noise
Hazardous chemicals
Temperature extremes
Radiation
Extreme weather or acts of nature
Asphyxiants
Mechanical hazards
Other
ROOT CAUSES
PERSONAL FACTORS
JOB FACTORS
Capability
I Physical
Condition
J Physical
K Mental State
L Mental Stress
M Behaviour
N Skill Level
Knowledge Transfer
O Competence /Training /
P Safety Leadership
and Engagement
Q Contractor Selection
Commissioning
R Engineering / Design /
S Planning
T Materials
U Work Equipment
V Standards & Processes
W Communication
I-1
Eyesight
Hearing
Other sensory deficiency
Reduced respiratory capacity
Other permanent physical disabilities
Temporary disabilities
Restricted range of movement
Substance sensitivities or allergies
Inadequate size or strength
Diminished capacity due to medication
Other
J-1
Previous injury or illness
Fatigue
due to lack of rest
due to workload
due to sensory overload
due to temperature extremes
Diminished performance
due to oxygen deficiency
due to atmospheric pressure variation
Blood sugar level
Impairment due to drug or alcohol misuse
Impairment due to medication
Other
Mental Illness
Memory failure
Emotional disturbance
Fears or phobias
Impairment due to drug or alcohol misuse
Impairment due to medication
Other
K-1
K-2
K-3
K-4
K-5
K-6
K-7
Preoccupation with problems
Frustration
directions/demands
Confusing
Conflicting directions/demands
Meaningless or degrading activities
Emotional overload
Extreme judgement decisions/demands
Intensive concentration/ perception demands
Extreme boredom
Other
L-1
L-2
L-3
L-4
L-5
L-6
L-7
L-8
L-9
L-10
Unsafe behaviour is being rewarded
Inappropriate peer pressure
Inadequate identification of safe behaviour
Inadequate reinforcement of safe behaviour
Inadequate disciplinary process
Production incentives causing unsafe behaviours
Poor supervisory example
Supervisor imposed time constraints
Employee perceived time constraints
Wilful disregard of controls
Other
M-1
M-2
M-3
M-4
M-5
M-6
M-7
M-8
M-9
M-10
M-11
Inadequate definition of skill requirement
Inadequate practice of skill
Infrequent performance of skill
Other
N-1
N-2
N-3
N-4
Inadequate employee selection
Inadequate employee induction
Inadequate analysis of training needs
Inadequate training programme design
Inadequate training programme delivery
Inadequate training programme review & evaluation
Insufficient training resources
Inadequate training records
Inadequate refresher training
Other
O-1
O-2
O-3
O-4
O-5
O-6
O-7
O-8
O-9
O-10
Inadequate definition of accountability
Inadequate definition of reporting relationships
Inadequate communication of accountability
Inadequate communication of reporting relationships
Poor personal example
Lack of active demonstration of commitment
Standards of performance missing or not enforced
Inadequate promotion of safe working
Inadequate promotion of systems for the identification & elimination of hazards
Other
P-1
P-2
P-3
P-4
P-5
P-6
P-7
P-8
P-9
P-10
Lack of contractor pre-qualifications
Inadequate contractor pre-qualifications
Inappropriate contractor selection
Use of non-approved contractor
Inadequate system for positive engagement of contractors
Inadequate system for the evaluation of contractor performance
Other
Q-1
Q-2
Q-3
Q-4
Q-5
Q-6
Q-7
Inadequate design input (e.g. incorrect standards, specs, and/or design criteria)
Inadequate design output
Inadequate independent design review
Inadequate assessment of design risks
Inadequate assessment of constructability
Inadequate assessment of maintainability
Inadequate O&M manuals
Inadequate assessment of operability
Inadequate communication of
design risks
Inadequate commissioning
Inadequate handover schedule
Inadequate evaluation and/or documentation of change
Other
R-1
S-1
Unrealistic timescale
Insufficient manpower numbers
Inadequate skills identified
Inadequate identification of roles & responsibilities
Inadequate budget
Inadequate material schedule
Inadequate planning documentation(e.g. risk assessment, execution plans, etc)
Other
T-1
Inadequate procurement of materials
Incorrect materials supplied
Inadequate QC processes
Inadequate health and safety data
Inadequate use of health and safety data
Improper identification of hazardous materials
Improper handling of materials
Shelf life exceeded
Improper storage of materials or spare parts
Inadequate material packaging
Improper salvage and/or waste disposal
Other
U-1
Inadequate assessment of needs and risks (e.g. human factors /ergonomics)
Inadequate standards or specifications of work equipment
Incorrect work equipment supplied
Inadequate QC processes
Inadequate information on operation
Inadequate use of information on operation
Inadequate information on maintenance
Inadequate use of information on maintenance
Inadequate removal / replacement of unsuitable items
Other
V-1
Lack of S&P for the task
Inadequate S&P for the task
Inadequate briefing of S&P
Inadequate implementation of S&P
Inadequate monitoring of implementation of S&P
Inadequate understanding of S&P
Inadequate version control
Other
W-1
Inadequate comms in work team
Inadequate communication between work teams
Inadequate comms between supervisor and work team
Inadequate comms between management and supervisor/ work team
Inadequate communication between shifts
Inadequate communication with others
No communication method available
communication method
Inadequate
Inadequate understanding of communication (e.g. language, terminology, etc)
Inadequate framework for two-way communication on safety
Other
I-2
J-2
S-2
T-2
V-2
I-3
W-2
R-2
S-3
T-3
U-2
V-3
I-4
W-3
I-5
J-3
R-3
S-4
T-4
U-3
V-4
R-4
I-6
S-5
T-5
U-4
V-5
W-4
I-7
R-5
S-6
T-6
U-5
V-6
J-4
W-5
I-8
R-6
S-7
J-5
T-7
U-6
V-7
I-9
R-7
W-6
J-6
R-8
S-8
T-8
T-9
U-7
V-8
I-10
J-7
U-8
W-7
I-11
R-9
T-10
W-8
R-10
T-11
U-9
W-9
R-11
T-12
U-10
X Risk Management
X Risk Management (con´t)
Y Learning from Experience
Z Monitor & Review
R-12
W-10
X-1
Inadequate Hazard identification
Inadequate consultation on hazards
Inadequate identification of controls
Inadequate briefing on controls
Inadequate definition of responsibilities for controls
Inadequate implementation of controls
Inadequate monitoring of RA process/controls
Inappropriate use of generic risk assessments
Inadequate management of change
assessment Guide
Inadequate Risk
Inadequate active/reactive review of RA process
Inadequate contingency /ER planning
Other
X-7
Y-1
Failure to communicate previous learning
Failure to act on that information
Failure to monitor that learning has taken place
Other
Z-1
No monitoring & review system
Inadequate monitoring & review system
Failure to identify trends through active monitoring
Failure to communicate the output of monitoring & review
Failure to act on the output of monitoring & review
Failure to monitor close-out of corrective actions
Other
R-13
X-2
X-8
Y-2
Z-2
W-11
X-3
X-9
Y-3
Z-3
X-4
X-10
Y-4
Z-4
X-5
X-11
For each identified critical factor, consider if any of the listed root cause categories apply. If “yes”, circle the specific root cause. If the root cause is not listed then enter under “Other”.
Z-5
X-6
X-12
Z-6
X-13
Z-7
SYSTEM CAUSES
Align with AMEC Performance Standards
Leadership and Commitment
Involvement
Management Systems
Policy, Strategy & Objectives
Risk Management
Legal Compliance
Employee Health
Training & Competence
Emergency Planning
Supply Chain Management
Accidents & Incidents
Environmental Impacts
Measurement & Benchmarking
Auditing
Management Review