FISHBONE DIAGRAM
Environment
People
Equipment
No task light/
local illumination
source
Chisel and
hammer not
included in RAMS
Incompetent
supervision (Only
leadman was present)
No duct covering
the cable
Work demand was high,
as civil team should
complete work in 5+
locations in single night
work shift
Organisation
No training on
chipping process
Civil work checkpoint
checklist not available
Improper coordination
between civil and
design team
No defined process
instead of chipping
for clearing the
cable blockage
Chipping process not
included in RAMS
As built drawing didn’t
include the missing of
duct in grouting area
around the cable
Procedures
25mm Low
Voltage cable
damaged during
chipping
process at P37