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