clc glossary english

8/10/2019 CLC Glossary English

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GlossaryNotes: This Glossary is provided to the user of BP Amocos Comprehensive List of Causes chart, as a guide to

further define and eplain the various causes! "ince the causes selected can and #ill $e used for trendanalysis, accuracy in selecting the appropriate cause is important! %sers are encouraged to use this glossaryto ensure proper understanding of each cause category!

&n each category, '(ther) is listed as the last option, in case none of the a$ove causes fit the circumstances!*hile appropriate in some cases, the use of '(ther) should $e minimised, as it adds little value in trendanalysis!

POSSIBLE IMMEDIATE CAUSES

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

Actions

There are four major categories of actions, with an additional level of detail under each of the major categories.

1. Following Proce!res

1-1 "iolation #$y ini%i!al&' one individual fully aware that he was taing a ris !ut stilldecided to do the jo! that way.

1-" "iolation #$y gro!(&' #eo#le fully aware that they were taing a ris !ut still decided to dothe jo! that way, e.g., solving a #ro!lem nowing that they have to infringe on the rules.

1-$ "iolation #$y s!(er%isor&'a su#ervisor or other management #erson fully aware that he wastaing a ris !ut still decided to do the jo! that way.

1-% O(eration o) e*!i(+ent wit,o!t a!t,ority' the #erson involved o#erated equi#ment forwhich he was not authorised to do so, either !ecause he did not have wor #ermit or, for the

#erson woring in his own de#artment, he was told !y his su#ervisor he was not allowed towor on it. This also a##lies in situations where o#erating the equi#ment is not in the #erson&sjo! descri#tion and, therefore, understood that he is not authorised to o#erate the equi#ment,e.g., o#erating a forlift without training or o#erating #rocess equi#ment that is not included inthe worer&s jo! function.

1-' I+(ro(er (osition or (ost!re )or tas-' the #erson did not follow the human inetic#ractices. The #erson was woring on an unsafe, unsta!le or non-standard wor floor or was#lacing !ody #arts in unsafe #ositions.

1-( O%ereertion o) (,ysical ca(a$ility' did more than a #erson is #hysically a!le to do, e.g.,carrying too much weight, etc.

1-) /or- or +otion at i+(ro(er s(ee' the #erson involved was not woring at the #ro#ers#eed, not taing time to do things safely, e.g., driving too fast, running or adding chemicals toofast or too slow, etc.

1-* I+(ro(er li)ting' material !eing lifted, either !y human or mechanical means, was liftedcontrary to #ro#er #ractices or was over the ca#acity of the #erson or the lifting equi#ment.

1-+ I+(ro(er loaing' the equi#ment was im#ro#erly loaded, e.g., a vehicle or centrifuge loadedto one side or overloaded or wrong #roduct in wrong cycle.

1-1 S,ortc!ts' the #erson involved in the wor too a shortcut instead of #erforming the wor inaccord with the #rocedure.

1-11 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

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0. Use o) Tools or E*!i(+ent

"-1 I+(ro(er !se o) e*!i(+ent' equi#ment was used for activities for which it was not designed

or equi#ment was misused, e.g., o#erating equi#ment !eyond the ma/imum recommendedtem#erature.

"-" I+(ro(er !se o) tools' tools were used for activities for which they were not designed or

tools were misused, e.g., #ossi!ly wrong tool for jo!, using e/cessive force on a tool, etc."-$ Use o) e)ecti%e e*!i(+ent #aware&'nowing that the equi#ment was defective and still

going on with the wor, e.g., running a forlift with leaing hydraulics."-% Use o) e)ecti%e tools #aware&' nowing that the tools were defective and still using them.

"-' I+(ro(er (lace+ent o) tools e*!i(+ent or +aterials' material or equi#ment #laced in#otentially ha0ardous #osition.

"-( O(eration o) e*!i(+ent at i+(ro(er s(ee' an o#erating limit was e/ceeded - the s#eed ofa grinding wheel, the assem!ly line was s#eeded u#, o#erating through#ut was sur#assed, etc.

"-) Ser%icing o) e*!i(+ent in o(eration'an attem#t was made to service equi#ment withoutturning it off - trying to clear a jammed machine, rodding out a #lugged line, etc.

"-* Ot,er' if none of the a!ove categories a##ly, this category can !e used.

$. Use o) Protecti%e Met,os

$-1 Lac- o) -nowlege o) ,a2ars (resent' nowing that the situation was not normal, the

#erson involved in the incident was not warned a!out the ha0ards.$-" Personal Protecti%e E*!i(+ent not !se' equi#ment #rescri!ed in the #rocedures was not

used.$-$ I+(ro(er !se o) Personal Protecti%e E*!i(+ent' the required ersonal rotective

2qui#ment was used, !ut it was not used in the #ro#er way, e.g., non-fitting gas mas or wrong

si0e of safety glasses or incorrect ty#e of res#irator, not maintaining or ins#ecting theequi#ment correctly.

$-% Ser%icing o) energise e*!i(+ent' the equi#ment was not electrically or mechanicallysafeguarded according to locout, red tag or line and equi#ment o#ening #rocedures.

$-' E*!i(+ent or +aterials not sec!re' equi#ment, materials or #erson was not securedagainst movement or falling, e.g., ladder not secured, load not rigged #ro#erly, no toe !oards on

scaffolding, etc.$-( Disa$le g!ars warning syste+s or sa)ety e%ices' the #ro#er guards, warning systems or

other safety devices were in #lace, !ut were disa!led or overridden to allow the wor to

#roceed without these #rotections.$-) 3e+o%al o) g!ars warning syste+s or sa)ety e%ices' the #ro#er guards, warning systems

or other safety devices had !een removed at the some #rior time, and not reinstalled orreactivated.

$-* Personal Protection E*!i(+ent not a%aila$le' the necessary #ersonal #rotective equi#ment

was not availa!le at the jo! site.$-+ Ot,er' if none of the a!ove categories a##ly, this category can !e used.

%. Inattention4Lac- o) Awareness

%-1 I+(ro(er ecision +a-ing or lac- o) 5!ge+ent' the situation was wrongly judged and thewrong decision was made.

%-" Distracte $y ot,er concerns' the #erson involved was distracted and not attentive to thewor in #rogress3 therefore, the #erson was not aware or aware too late that something had

gone wrong.%-$ Inattention )or )ooting an s!rro!nings' the #erson was just waling around and did not

notice the o!stacle or the surface conditions of the ground.%-% 6orse(lay' #erson4s5 involved in the event were engaged in ina##ro#riate activities, including

#ractical joes or clowning around.

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%-' Acts o) %iolence' any ty#e of #hysical or mental confrontations that can cause !odily injury or

mental anguish.%-( Fail!re to warn' an individual had nowledge of a dangerous condition or activity, !ut did not

warn current or future #ersons of the e/#osure, e.g., not tagging a defective tool.

%-) Use o) r!gs or alco,ol' #erson4s5 involved in the event were determined to !e under theinfluence of drugs or alcohol.

%-* 3o!tine acti%ity wit,o!t t,o!g,t' the #erson involved was #erforming a routine activity,such as waling, sitting down, ste##ing, etc., without conscious thought, and was e/#osed to a

ha0ard as a result.%-+ Ot,er' if none of the a!ove categories a##ly, this category can !e used.

Conitions

There are four major categories of conditions, with an additional level of detail under each of the majorcategories.

'. Protecti%e Syste+s

'-1 Inae*!ate g!ars or (rotecti%e e%ices' adequate guards and #rotective devices that were

needed to #rotect the worer were not #resent.'-" De)ecti%e g!ars or (rotecti%e e%ices' guards and #rotective devices were installed !ut

failed at the time of the incident.

'-$ Inae*!ate Personal Protecti%e E*!i(+ent' the ersonal rotective 2qui#ment used wasnot adequate for the situation at the time of the incident or the wrong ty#e of ersonalrotective 2qui#ment was s#ecified.

'-% De)ecti%e Personal Protecti%e E*!i(+ent' the ersonal rotective 2qui#ment wassufficient, !ut the ersonal rotective 2qui#ment used was defective at the time of the incident.

'-' Inae*!ate warning syste+s' adequate warning systems were #resent !ut failed to #rovidenotice at the time of the incident.

'-( De)ecti%e warning syste+s' adequate warning systems were #resent !ut failed at the time ofthe incident.

'-) Inae*!ate isolation o) (rocess or e*!i(+ent' the equi#ment was not #ro#erly isolated and

the #eo#le involved were e/#osed to chemicals, hot surfaces, electricity, etc.'-* Inae*!ate sa)ety e%ices' safety devices such as #ressure relief valves or tur!ine overs#eed

tri#s were #resent, !ut did not act quicly enough to #revent the accident.'-+ De)ecti%e sa)ety e%ices' safety devices such as #ressure relief valves or tur!ine overs#eed

tri#s failed to activate.'-1 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

(. Tools E*!i(+ent 7 "e,icle

(-1 De)ecti%e e*!i(+ent' the right equi#ment was selected !ut the equi#ment involved wasdefective.

(-" Inae*!ate e*!i(+ent' the necessary equi#ment needed to do the jo! was in some way

inadequate or not su##lied.(-$ I+(ro(erly (re(are e*!i(+ent' the equi#ment was not #re#ared adequately #rior to the

jo! or maintenance wor, e.g., a vessel not thoroughly cleaned of #rocess chemicals #rior toentry.

(-% De)ecti%e tools' the right ind of tool was selected !ut the tool involved was defective.(-' Inae*!ate tools' the tools were not adequate for this #ur#ose, or the #ro#er tools were not

su##lied.(-( I+(ro(erly (re(are tools' the tools were not #re#ared #ro#erly !efore the jo!, e.g., not

re#aired #ro#erly or not cleaned of contaminants.(-) De)ecti%e %e,icle' the right ty#e of vehicle was !eing used, !ut the vehicle was defective.

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(-* Inae*!ate %e,icle )or t,e (!r(ose' the necessary ty#e of vehicle to #erform the function

was not availa!le, e.g., forlift !eing used as a crane.(-+ I+(ro(erly (re(are %e,icle' the right vehicle was !eing used, !ut the vehicle had not !een

#ro#erly re#aired or serviced for use.

(-1 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

). /or- E(os!re to

)-1 Fire an e(losion' the incident was caused !y a fire andor e/#losion.)-" 8oise' the incident was caused !y a short term e/#osure to e/tremely high noise levels or !y

continuous overe/#osure to noise, e.g., shoc effect, #rocess equi#ment, high noise-#roducing

tools.)-$ Energise electrical syste+s' incident caused !y system not fully de-energised.

)-% Energise syste+s ot,er t,an electrical'incident was caused !y a system not fully isolatedfrom gravitational, #neumatic, hydraulic or chemical energy sources.

)-' 3aiation' the incident was caused !y dangerous radiation, e.g., /-ray, high frequencyradiation, laser, etc.

)-( Te+(erat!re etre+es' the incident was caused !y an e/#osure to e/treme high or low

tem#eratures.

)-) 6a2aro!s c,e+icals' the incident was caused !y e/tremely ha0ardous chemicals used in the#rocess, e.g., reactive, to/ic or ecologically dangerous chemicals.

)-* Mec,anical ,a2ars' incident caused !y shar# edges, moving equi#ment, etc.

)-+ Cl!tter or e$ris' houseee#ing was inadequate or wor location was not clean and orderly.)-1 Stor+s or acts o) nat!re' the incident was a direct or indirect result of a storm, tornado,

hurricane, hail storm, etc.

)-11 Sli((ery )loors or wal-ways' the incident was caused !y a sli##ery waling or woringsurface.

)-1" Ot,er' if none of the a!ove categories a##ly, this category can !e used.

*. /or- Place 6a2ars

*-1 Congestion or restricte +otion' layout of the wor#lace was #oor and not enough

clearances were availa!le or accessi!ility to equi#ment or tools was #oor.*-" Inae*!ate or ecessi%e ill!+ination' the wor#lace was #oorly illuminated or the visi!ility

was #oor.*-$ Inae*!ate %entilation' #oor ventilation, e.g., the tem#erature could rise too high,

concentrations of chemicals could rise or o/ygen levels could decrease, etc.*-% Un(rotecte ,eig,t' a contri!uting factor was wor at an un#rotected height, e.g., scaffold

!uilding, in towers, or on roofs, etc.

*-' Inae*!ate wor- (lace layo!t' the controls, la!els or dis#lays used to monitor the wor werenot adequate, e.g., the controls were out of normal reach, la!els or dis#lays were out of sight.

Can also include misinformation - such as misla!elled equi#ment or chemicals.*-( Ot,er' if none of the a!ove categories a##ly, this category can !e used.

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POSSIBLE S9STEM CAUSES

6ystem causes are covered in the final two quandrants entitled: ersonal 7actors and 8o! 7actors.

Personal Factors.

There are si/ categories of #ersonal factors, with an additional level of detail under each of the major categories.

1. P,ysical Ca(a$ilities

1-1 "ision e)iciency' the incident ha##ened !ecause the #erson involved had a vision deficiency,

e.g., could not see over long distance, could not see alarms on the #anel, etc.1-" 6earing e)iciency' the incident ha##ened !ecause the #erson involved had a hearing

deficiency, e.g., could not hear the alarm.1-$ Ot,er sensory e)iciency' a deficiency, lie reduced feel or smell, contri!uted to the incident.

1-% 3e!ce res(iratory ca(acity' asthma, silicosis, as!estosis, and other related diseasescontri!uted to the incident or seriousness of the incident.

1-' Ot,er (er+anent (,ysical isa$ilities' all other #hysical disa!ilities not mentioned a!ove,

e.g., wea !ac, anles, etc.

1-( Te+(orary isa$ilities' disa!ilities which are tem#orary lie !roen !ones, muscle #ain,migraine headache, etc.

1-) Ina$ility to s!stain $oy (ositions' the incident ha##ened !ecause the #erson involved did

not have the ca#a!ility to sustain the required !ody #osition for a longer time.1-* 3estricte range o) $oy +o%e+ent' a #hysical condition restricted the #erson&s movement

and wasn&t #lanned for in the jo! activity, e.g., a tem#orary or #ermanent #hysical disa!ility,

wearing of ersonal rotective 2qui#ment, unusual weight, unusual heights, etc.1-+ S!$stance sensiti%ities or allergies' the #erson involved in the incident was medically #roven

to !e allergic or sensitive to the su!stances involved.1-1 Inae*!ate si2e or strengt,' the #erson assigned to the wor did not have the si0e or strength

to com#lete the tas safely, e.g., couldn&t reach, couldn&t lift.1-11 Di+inis,e ca(acity !e to +eication' the side effects of medication limited the #erson&s

#hysical ca#a!ility.

1-1" Ot,er' if none of the a!ove categories a##ly, this category can !e used.

". P,ysical Conitions

"-1 Pre%io!s in5!ry or illness' the incident ha##ened !ecause the #erson involved was ill 4feveror any other ind of illness5 or had an e/isting injury !efore the incident ha##ened.

"-" Fatig!e' the #erson involved in the incident was fatigued due to worload or to lac of rest,

e.g., too long woring hours without time to rela/, woring more than * hours #er shift,woring dou!le shifts over a long #eriod of time, or woring for a too long #eriod 4e.g., no days

off over a #eriod of more than seven days5."-$ Di+inis,e (er)or+ance' the surroundings or conditions have lead to less than ordinary

#erformance, e.g., tem#erature e/tremes, lac of o/ygen due to high elevations, atmos#heric

#ressure changes, such as encountered during diving wor."-% Bloo s!gar e)iciency' at the time of the incident, the #erson involved had a too low !lood

sugar. This should !e medically esta!lished."-' I+(air+ent !e to r!g or alco,ol !se' at the time of the incident, the #erson involved was

under the influence of alcohol or drugs."-( Ot,er' if none of the a!ove categories a##ly, this category can !e used.

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$. Mental State

$-1 Poor 5!ge+ent' although the #erson involved was well trained at the time of the incident, the#erson did not choose an a##ro#riate course of action.

$-" Me+ory )ail!re' although the #erson involved was well trained at the time of the incident, the#erson could not remem!er how to act or react.

$-$ Poor coorination or reaction ti+e' although the #erson involved new e/actly whichactions to tae, the #erson was not ca#a!le of coordinating all the required actions or thereaction time was too long.

$-% E+otional ist!r$ance' the incident ha##ened !ecause the #erson involved was emotionallydistur!ed.

$-' Fears or (,o$ias' the incident ha##ened !ecause the #erson involved had a fear or #ho!ia,e.g., someone who is afraid of woring on heights, clim!ing ladders or claustro#ho!ia, etc.

$-( Low +ec,anical a(tit!e' the #erson was confused on what actions to tae !ecause they didnot understand !asic elements of how mechanical things wor.

$-) Low learning a(tit!e' the #erson involved had !een well trained, !ut was confused due tolimited learning ca#a!ility.

$-* In)l!ence $y +eication' the #erson&s mental state was diminished due to side effects ofmedication 4e.g., drowsy, light-headed5

$-+ Ot,er' if none of the a!ove categories a##ly, this category can !e used.

%. Mental Stress

%-1 Preocc!(ation wit, (ro$le+s' the #erson involved in the incident was #reoccu#ied with#ro!lems and was not fully concentrated on the activities in #rogress, e.g., #ro!lems at wor orat home.

%-" Fr!stration' the incident ha##ened !ecause the #erson involved was frustrated, e.g., no#romotion, never received a #ositive reward from his su#ervisor, doing his very !est and seeingno results, etc.

%-$ Con)!sing irections4e+ans' the #erson involved in the incident felt the wor was notwell-defined with #ro#er direction or demands. Can !e the result of too many #eo#le givingorders.

%-% Con)licting irections4e+ans' conflicting directions or demands led to an incident, e.g., arush jo! !ut still having to follow all the time-consuming safety #rocedures.

%-' :Meaningless; or :egraing; acti%ities' the #erson involved in the incident felt the worthe #erson was doing was meaningless, e.g., cleaning u# and the ne/t day it is filthy again,degrading or too much e/#erience or education for this low classified jo!.

%-( E+otional o%erloa' the #erson was under high stress from either wor or #ersonal issuesthat affects their emotional state.

%-) Etre+e 5!ge+ent4ecision e+ans' the wor !eing done required judgement anddecision maing that created stress, e.g., time sensitive decisions, high staes in the outcome,incom#lete information in which to !ase the decision.

%-* Etre+e concentration or (erce(tion e+ans' the wor environment contri!uted to theincident, as the wor required great concentration, e.g., a #erson is so a!sor!ed in what theyare doing, they fail to recognise a ha0ard.

%-+ Etre+e $oreo+' the #erson is adversely affected !y monotonous or re#etitive wor.

%-1 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

'. Be,a%io!r

'-1 I+(ro(er (er)or+ance is reware' although the su#ervisor new that the #erson was notfollowing the safety #rocedures, guidelines or 86As, the #erson was rewarded !ecause the jo!was com#leted quicly. The worer may also have felt rewarded !y #erforming im#ro#erly,e.g., if !y taing shortcuts, an un#leasant jo! is finished quicer.

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'-" I+(ro(er s!(er%isory ea+(le' su#ervisors not giving the #ro#er e/am#le to the #eo#leworing in their organisations.

'-$ Inae*!ate ienti)ication o) critical sa)e $e,a%io!rs' in the organisation, it was not wellidentified which safe !ehaviours were critical to #reventing incidents.

'-% Inae*!ate rein)orce+ent o) critical $e,a%io!rs' a su#ervisor seeing someone notfollowing the safety #rocedures and guidelines and not correcting immediately is an e/am#le of

inadequate reinforcement of #ro#er !ehaviour. 6imilarly, su#ervisors must note whenem#loyees are #erforming correctly to adequately reinforce the #ro#er #erformance. eer#ressure can also #lay a role, if #ro#er #erformance is criticised.

'-' Ina((ro(riate aggression' either the #eo#le were aggressive or actions were done anddecisions were taen in an aggressive way without really having an overview of theconsequences.

'-( I+(ro(er !se o) (ro!ction incenti%es' the use of incentives for #roduction or timelinesshave created an incentive to ignore safety requirements.

'-) S!(er%isor i+(lie ,aste' the incident was caused !y the su#ervisor&s im#lication that s#eedin com#leting the wor was more im#ortant than safety considerations.

'-* E+(loyee i+(lie ,aste' the incident was caused !y the em#loyee&s assum#tion that s#eed incom#leting the wor was more im#ortant than safety considerations.

'-+ Ot,er' if none of the a!ove categories a##ly, this category can !e used.

(. S-ill Le%el

(-1 Inae*!ate assess+ent o) re*!ire s-ills' the #erson involved !elieved they had the #ro#ersills to #erform the wor, !ut in fact, laced required sills.

(-" Inae*!ate (ractice o) s-ill' the #erson involved was theoretically e/#erienced !ut laced#ractice in #erforming the tas.

(-$ In)re*!ent (er)or+ance o) s-ill' the #erson was trained in the jo! !ut the activity involvedin the incident was done on a very low frequency or the #erson involved rarely #erformed theactivity.

(-% Lac- o) coac,ing on s-ill' the incident ha##ened !ecause the #erson involved did not havethe coaching of a su#ervisor or e/#erienced co-worer.

(-' Ins!))icient re%iew o) instr!ction to esta$lis, s-ill' the #erson involved had training, !ut

was not given the o##ortunity to #ractice or #erform the tas as #art of training to firmlyesta!lish the sill.(-( Ot,er' if none of the a!ove categories a##ly, this category can !e used.


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)-$ Inae*!ate training e))ort' some training was conducted, !ut it failed to accom#lish thenecessary nowledge transfer. otential causes include inadequate training #rogram design,#oorly develo#ed training o!jectives, inadequate orientation #rograms, inadequate initialraining efforts or #oor means to determine if students have indeed mastered the material!eing taught.

)-% 8o training (ro%ie' there was no effort made to train the #articular #erson in this su!ject.

easons for this can include a failure to identify training was necessary, reliance on out of dateor inaccurate training records, a change in wor methods or a conscious decision to foregotraining.

)-' Ot,er' if none of the a!ove categories a##ly, this category can !e used.

*. Manage+ent4S!(er%ision4E+(loyee Leaers,i(

*-1 Con)licting roles4res(onsi$ilities' who was to !e res#onsi!le for what was not clear and welldefined. This could include unclear re#orting relationshi#s, unclear assignments ofres#onsi!ilities, im#ro#er delegation or conflicting situations where more than one #artya##ears to !e res#onsi!le for the same issue.

*-" Inae*!ate leaers,i(' the #erson assigned with the res#onsi!ility for as#ects of safety hadnot carried out their res#onsi!ility to the degree necessary for safe wor. This could include,

la/ standards of #erformance !eing tolerated, inadequate accounta!ility for safety #erformance,little #erformance feed!ac, inadequate nowledge of conditions at the wor site or inadequatesafety #romotion.

*-$ Inae*!ate correction o) wor-site45o$ ,a2ars' a ha0ard or incident had #reviouslyoccurred to draw attention to a deficiency, !ut there was an inadequate effort to correct thatdeficiency.

*-% Inae*!ate ienti)ication o) wor-site45o$ ,a2ars' the incident was caused !y the failure to#erform or #ro#erly res#ond to a loss e/#osure study, such as a 9A; review or 8o! 6afetyAnalysis.

*-' Inae*!ate +anage+ent o) c,ange syste+' the incident ha##ened !ecause a system or#rocedure did not e/ist or was incom#lete to ensure that changes which affect the #rocess areadequately assessed, documented and communicated.

*-( Inae*!ate incient re(orting4in%estigation syste+' the incident re#orting and

investigation #rocedures and guidelines were not followed for incidents that ha##ened in thede#artment. Therefore, the learning e/#eriences and recommendations that could have#revented similar incidents were not discovered or lac of tracing system to ensure follow-u#was done or not communicating the results of the investigations.

*-) Inae*!ate or lac- o) sa)ety +eetings' safety meetings were not held or did not transferessential nowledge a!out safety issues related to the incident.

*-* Inae*!ate (er)or+ance +eas!re+ent an assess+ent' the means to measure and tracsafety #erformance were inadequate, leaving the organisation unsure of what needed to !edone.

*-+ Ot,er' if none of the a!ove categories a##ly, this category can !e used.

+. Contractor Selection an O%ersig,t

+-1 Lac- o) contractor (re>*!ali)ication' a contractor firm was hired to #erform wor withoutsuccessfully com#leting a #re-qualification review.+-" Inae*!ate contractor (re>*!ali)ications' a #re-qualification review was conducted, !ut it

failed to identify deficiencies in the contractor&s ca#a!ilities.+-$ Inae*!ate contractor selection' the selection of a contractor was made without all relevant

data, or without #ro#er consideration of safety ca#a!ilities.+-% Use o) a non>a((ro%e contractor' a contractor firm who did not meet #re-qualification

criteria was hired to #erform wor.+-' Lac- o) 5o$ o%ersig,t' a contractor firm&s wor was not ins#ected or audited to identify

deficiencies in outcomes or methods.

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+-( Inae*!ate o%ersig,t' a contractor firm&s wor was ins#ected or audited, !ut deficiencies#resent were not identified.

+-) Ot,er' if none of the a!ove categories a##ly, this category can !e used.

1. Engineering4Design

1-1 Inae*!ate tec,nical esign' the incident was caused !y a #oor technical design, weamaterials of construction, valves in the wrong s#ot, lines in walways, etc. The reasons forinadequate technical design can !e faulty in#ut into the design #rocess 4!ad information5 orfaulty design out#ut 4a !ad design5.

1-" Inae*!ate stanars s(eci)ications an4or esign criteria' although the design criteriaand s#ecifications had !een followed, the s#ecifications and criteria were not adequate and hadto !e ada#ted.

1-$ Inae*!ate assess+ent o) (otential )ail!re' the incident was caused !y the fact that the#otential failure was not adequately assessed in the initial design stage.

1-% Inae*!ate ergono+ic esign' the incident was caused !y a #oor ergonomic design, meaningthat there was not an o#timal tuning !etween the equi#ment and human woring with theequi#ment.

1-' Inae*!ate +onitoring o) constr!ction' although all design s#ecifications and criteria had!een followed, ins#ections during the construction were not done adequately.1-( Inae*!ate assess+ent o) o(erational reainess' the incident ha##ened !ecause either the

#rocedure for handover from construction to #roduction was not followed, software changeswere not fully tested or o#erating manuals and training were not com#leted.

1-) Inae*!ate +onitoring o) initial o(eration' the incident ha##ened !ecause there was notenough monitoring and analyses of the initial o#eration information.

1-* Inae*!ate e%al!ation an4or oc!+entation o) c,ange' the incident ha##ened !ecauseunevaluated changes were made and an unsafe situation was introduced.


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1". P!rc,asing Material 6anling 7 Material Control

1"-1 Incorrect ite+ recei%e' the correct item was ordered, !ut an incorrect item was received.easons for this can include incorrect s#ecifications to vendors, inaccurate information on therequisition, inadequate control on who can modify orders, an unauthorised su!stitution !y thevendor, inadequate #roduct acce#tance #rocedures or a failure to verify recei#t of #ro#er goods.

1"-" Inae*!ate researc, on +aterials4e*!i(+ent' the lac of nowledge led to the wrong item!eing ordered.1"-$ Inae*!ate +oe or ro!te o) s,i((ing' the ha0ard was created during shi#ment of the item -

either !y lost custody or #roduct degradation.1"-% I+(ro(er ,anling o) +aterials' the ha0ard was created due to im#ro#er handling of the

material.1"-' I+(ro(er storage o) +aterials or s(are (arts' the ha0ard was created as the item degraded

while in storage.1"-( Inae*!ate +aterial (ac-aging' the ha0ard was created when the item was damaged due to

im#ro#er #acaging.1"-) Material s,el) li)e eceee' the ha0ard was created when outdated materials were used.1"-* I+(ro(er ienti)ication o) ,a2aro!s +aterials' the materials were not #ro#erly identified,

and a##ro#riate handling #rocedures were not used.

1"-+ I+(ro(er sal%age or waste is(osal' the ha0ard was created when an item was im#ro#erlyde-commissioned and dis#osed.1"-1 Inae*!ate !se o) ,ealt, an sa)ety ata' the ha0ard was created when relevant health and

safety information was not e/changed or used.1"-11 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

1$. Tools an E*!i(+ent

1$-1 Inae*!ate assess+ent o) nees an ris-s' the wrong tools and equi#ment were #rovided, asa result of the faulty assessment of what was needed to #ro#erly #erform the wor.

1$-" Inae*!ate ,!+an )actors4ergono+ics consierations' the tools and equi#ment #rovideddid not reflect the needs of the #erson #erforming the wor.

1$-$ Inae*!ate stanars or s(eci)ications' im#ro#er tools andor equi#ment was #rovided, as a

result of inadequate standards or s#ecifications covering what should have !een #rovided.1$-% Inae*!ate a%aila$ility' the needed tools or equi#ment were not availa!le at the jo! site.1$-' Inae*!ate a5!st+ent4re(air4+aintenance' the #ro#er tools and equi#ment were

availa!le, !ut were not in good re#air when used.1$-( Inae*!ate sal%age an recla+ation' tools and equi#ment that were removed from service

for overhaul were not #ro#erly re#aired or destroyed, creating a ha0ard.1$-) Inae*!ate re+o%al or re(lace+ent o) !ns!ita$le ite+s' items that were no longer

servicea!le remained on the equi#ment.1$-* 8o e*!i(+ent recor ,istory' a ha0ard was created as a result of a failure to maintain

#ro#er records on the equi#ment.1$-+ Inae*!ate e*!i(+ent recor ,istory' records were maintained, !ut failed to #ro#erly

identify a ha0ard.1$-1 Ot,er' if none of the a!ove categories a##ly, this category can !e used.

1%. /or- 3!les4Policies4Stanars4Proce!res #PSP&

1%-1 Lac- o) PSP )or t,e tas-' there were no written 6 covering the wor !eing #erformed atthe time of the incident. This could !e the result of a failure to assign res#onsi!ility for thedevelo#ment of 6, or the failure to com#lete an adequate jo! safety analysis for the tas.

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1%-" Inae*!ate e%elo(+ent o) PSP' there were some 6 in #lace, !ut the 6 that weredevelo#ed did not fully meet the needs of the wor. This could !e the result of inadequate co-ordination with design efforts, having unnowledgea!le #eo#le develo#ing the 6, notidentifying the #ro#er ste#s to tae in #ro!lem situations or a #oor format that made the 6difficult to use.

1%-$ Inae*!ate i+(le+entation o) PSP !e to e)iciencies' there were 6 in #lace, !ut the

im#lementation of the 6 were not com#lete due to deficiencies in these documents. Thiscould include such things as contradictory requirements, confusing formats, inaccuratesequence of ste#s, technical errors, incom#lete instructions, etc.

1%-% Inae*!ate en)orce+ent o) PSP' well crafted 6 were in #lace, !ut their use was not#ro#erly enforced, for reasons such as inadequate monitoring of the wor !eing done,inadequate su#ervisory nowledge of what was to !e done or inadequate reinforcement withla!els or signs.

1%-' Inae*!ate co++!nication o) PSP' there was an a##ro#riate 6 in #lace, !ut it had not!een #ro#erly communicated. This could !e the result of incom#lete distri!ution, languagedifficulties, incom#lete integration with training efforts or out of date 6 still in use.

1%-( Ot,er' if none of the a!ove categories a##ly, this category can !e used.

1'. Co++!nication

1'-1 Inae*!ate ,ori2ontal co++!nication $etween (eers' incident ha##ened !ecause therewas no communication or no adequate communication !etween #eers and colleagues.

1'-" Inae*!ate %ertical co++!nication $etween s!(er%isor an (erson' incident ha##ened!ecause there was no communication or no adequate communication !etween su#ervision andworers, to# !ottom and !ottom u# in the same organisation.

1'-$ Inae*!ate co++!nication $etween i))erent organisations' organisations other than theirown were not #ro#erly informed.

1'-% Inae*!ate co++!nication $etween wor- gro!(s' the incident occurred !ecause two ormore individuals or grou#s were woring on the same tas, !ut did not #ro#erly communicate.

1'-' Inae*!ate co++!nication $etween s,i)ts' the incident occurred due to #oor shift handover#rocedures, e.g., worers not e/#ected to write a detailed account of #ro!lems in a log.

1'-( Inae*!ate co++!nication +et,os' the normal means of communicating information were

not adequate - #hone lines !usy, static on radios, writing was illegi!le, etc.1'-) 8o co++!nication +et,o a%aila$le' the #ro#er tools 4tele#hone, com#uter, mail, #agingsystem for emergencies, ta#es and recorder, slides and #rojector !oards5 were not availa!le.

1'-* Incorrect instr!ctions' the #erson involved was given instructions3 !ut the instructions werenot understood as meant, and they were unclear or incom#lete.

1'-+ Inae*!ate co++!nication !e to 5o$ t!rno%er' the #erson starting a tas was not aroundto finish it, and those assigned to com#lete the wor did not have the necessary information.

1'-1 Inae*!ate co++!nication o) sa)ety an ,ealt, ata reg!lations or g!ielines'the safetyand health data and new regulations were not discussed with the #eo#le #erforming the wor.

1'-11 Stanar ter+inology not !se' incident ha##ened !ecause either terminologies weredifferent de#artments or there was confusion, e.g., different #ieces of equi#ment have the samenum!ers. 6tandard codes and #ractices were not followed, e.g., colour coding for lines,electrical, etc.

1'-1" "eri)ication4re(eat $ac- tec,ni*!es not !se' a ver!al message was misunderstood andwent unidentified !ecause there was no verificationre#eat !ac of the message !y the reci#ient.1'-1$ Messages too long' confusion arose due to the length of the message.1'-1% S(eec, inter)erence' a ver!al message was not #ro#erly transmitted due to !acground noise,

static or other distractions.1'-1' Ot,er' if none of the a!ove categories a##ly, this category can !e used.

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