Root causes of incidents

Poor judgement.

Memory failure.

Poor coordination or reaction time.

Emotional disturbance.

Fears or phobias.

Low mechanical aptitude.

Low learning aptitude.

Influenced by medication.

Other.

Preoccupation with problems.

Frustration.

Confusing directions / demands.

Conflicting directions / demands.

Meaningless or degrading activities.

Emotional overload.

Extreme judgement / decision demands.

Extreme concentration / perception demands.

Extreme boredom.

Other.

Improper performance is rewarded:

• Saves time or effort.
• Avoids discomfort.
• Gains attention.

Improper supervisory example.

Inadequate identification of critical safe behaviours.

Inadequate reinforcement of critical safe behaviours:

• Proper performance is criticised.
• Inappropriate peer pressure.
• Inadequate performance feedback.
• Inadequate disciplinary process.

Inappropriate aggression.

Improper use of production incentives.

Supervisor implied haste.

Employee perceived haste.

Habit / personal performance.

Vandalism.

Other.

Inadequate assessment of required skills.

Inadequate practice of skill.

Infrequent performance of skill.

Lack of coaching on skill.

Insufficient review of instruction to establish skill.

Other.

Inadequate knowledge transfer:

• Inability to comprehend.
• Inadequate instructor qualifications.
• Inadequate training equipment.
• Misunderstood instructions.

Inadequate recall of training material:

• Training not reinforced on the job.
• Inadequate refresher training frequency.

Inadequate training effort:

• Inadequate training program design.
• Inadequate training goals / objectives.
• Inadequate new employee orientation.
• Inadequate initial training.
• Inadequate means to determine if qualified for job.

No training provided:

• Need for training not identified.
• Training records incorrect or out of date.
• New work methods introduced without training.
• Decision made not to train.

Other.

Conflicting roles / responsibilities:

• Unclear reporting relationships.
• Conflicting reporting relationship.
• Unclear assignment of responsibility.
• Conflicting assignment of responsibility.
• Improper or insufficient delegation of authority.

Inadequate leadership:

• Standards of performance missing or not enforced.
• Inadequate accountability.
• Inadequate or incorrect performance feedback.
• Inadequate work site walk-through.
• Inadequate safety promotion.

Inadequate correction of prior hazard / incident.

Inadequate identification of worksite / job hazards.

Inadequate management of change system.

Inadequate incident reporting / investigation system.

Inadequate or lack of safety meetings.

Inadequate performance measurement and assessment.

Other.

Lack of contractor pre-qualifications.

Inadequate contractor pre-qualifications.

Inadequate contractor selection.

Use of non-approved contractor.

Lack of job oversight.

Inadequate oversight.

Other.

Inadequate technical design:

• Design input obsolete.
• Design input not correct.
• Design input not available.
• Design output inadequate.
• Design input infeasible.
• Design output unclear.
• Design output not correct.
• Design output inconsistent.

No independent design review.

Inadequate standards, specifications and/or design criteria.

Inadequate assessment of potential failure.

Inadequate ergonomic design.

Inadequate monitoring of construction.

Inadequate assessment of operational readiness.

Inadequate monitoring of initial operation.

Inadequate evaluation and/or documentation of change.

Other.

Inadequate work planning.

Inadequate preventive maintenance:

• Assessment of needs.
• Lubrication / servicing.
• Adjustment / assembly.
• Cleaning / resurfacing.

Inadequate repair:

• Communication of needed repair.
• Scheduling of work.
• Examination of parts.
• Parts substitution.

Excessive wear and tear:

• Inadequate planning for use.
• Extension of service life.
• Improper loading.
• Use by untrained people.
• Use for wrong purpose.

Inadequate reference materials of publications.

Inadequate audit / inspection / monitoring:

• No documentation.
• No correction responsibility assigned.
• No accountability for corrective action.

Inadequate job placement:

• Appropriate personnel not identified.
• Appropriate personnel not available.
• Appropriate personnel not provided.

Other.

Incorrect item received:

• Inadequate specifications to vendor.
• Inadequate specifications on requisition.
• Inadequate control on changes to orders.
• Unauthorised substitution.
• Inadequate product acceptance requirements.
• No acceptance verification performed.

Inadequate research on materials / equipment.

Inadequate mode or route of shipment.

Improper handling of materials.

Improper storage of materials or spare parts.

Inadequate material packaging.

Material shelf life exceeded.

Improper identification of hazardous materials.

Improper salvage and/or waste disposal.

Inadequate use of safety and health data.

Other.

Inadequate assessment of needs and risks.

Inadequate human factors / ergonomics considerations.

Inadequate standards or specifications.

Inadequate availability.

Inadequate adjustment / repair / maintenance.

Inadequate salvage and reclamation.

Inadequate removal / replacement of unsuitable items.

No equipment record history.

Inadequate equipment record history.

Other.

Lack of PSP for the task:

• Lack of defined responsibility for PSP.
• Lack of task/job safety analysis.
• Inadequate critical task/job safety analysis.

Inadequate development of PSP:

• Inadequate coordination with process / equipment design.
• Inadequate employee involvement in the development.
• Inadequate definition of corrective actions.
• Inadequate format for easy use.

Inadequate implementation of PSP, due to deficiencies:

• Contradictory requirements.
• Confusing format.
• More than one action per step.
• No check-off spaces provided.
• Inaccurate sequence of steps.
• Confusing instructions.
• Technical error / missing steps.
• Excessive references.
• Potential situations not covered.

Inadequate enforcement of PSP:

• Inadequate monitoring of work.
• Inadequate supervisory knowledge.
• Inadequate reinforcement.
• Non-compliance not corrected.

Inadequate communication of PSP:

• Incomplete distribution to work groups.
• Inadequate translation to appropriate languages.
• Incomplete integration with training.
• Out of date revisions still in use.

Inadequate task observation of PSP.

Other.

Inadequate horizontal communication between peers.

Inadequate vertical communication between supervisor and person.

Inadequate communication between different organisations.

Inadequate communication between work groups.

Inadequate communication between shifts.

Inadequate communication methods.

No communication method available.

Incorrect instruction.

Inadequate communication due to job turnover.

Inadequate communication of safety and health data, regulations or guidelines.

Standard terminology not used.

Verification / repeat back techniques not used.

Messages too long.

Speech interference.

Cultural/ethnic communication barriers.

Other.