ZOHR HSE General Department

Comprehensive List of Causes (CLC) Parts

A TOOL FOR ROOT CAUSE ANALYSIS

DESCRIPTION OF INCIDENT IMPLEMENTATION & RESEARCH PHASES: ANALYSIS PHASE:

EVIDENCE GATHERING IDENTIFICATION OF CRITICAL FACTORS
• Document the type / severity of event • Gather relevant evidence • Organize all evidence

• Cover the who / what / when / where / how as known • Implementation phase = direct evidence (scene and witnesses) • Map evidence Positions Procedures
at the time • Research phase = indirect evidence (written sources) • Identify critical factors
• Consider People / Parts / Position / Paper • Use CLC to identify all immediate and root causes

POSSIBLE IMMEDIATE CAUSES

ACTIONS CONDITIONS
1. Following Procedures 2. Use of Tools or Equipment 3. Use of Protective Methods 4. Inattention / Lack of Awareness 5. Protective Systems 6. Tools, Equipment & Vehicles 7. Work Exposures to 8. Work Place Environment / Layout
1-1 Violation by individual 2-1 Improper use of equipment 3-1 Lack of knowledge of hazards present 4-1 Improper decision making or lack of judgment 5-1 Inadequate guards or protective devices 6-1 Defective equipment 7-1 Fire or explosion 8-1 Congestion or restricted motion
1-2 Violation by group 2-2 Improper use of tools 3-2 Personal protective equipment not used 4-2 Distracted by other concerns 5-2 Defective guards or protective devices 6-2 Inadequate equipment 7-2 Noise 8-2 Inadequate or excessive illumination
1-3 Violation by supervisor 2-3 Use of defective equipment (aware) 3-3 Improper use of proper personal protective 4-3 Inattention to footing and surroundings 5-3 Inadequate personal protective equipment 6-3 Improperly prepared equipment 7-3 Energized electrical systems 8-3 Inadequate ventilation
1-4 Operation of equipment without authority 2-4 Use of defective tools (aware) equipment 4-4 Horseplay 5-4 Defective personal protective equipment 6-4 Defective tools 7-4 Energized systems, other than electrical 8-4 Unprotected height
1-5 Improper position or posture for the task 2-5 Improper placement of tools, equipment or 3-4 Servicing of energized equipment 4-5 Acts of violence 5-5 Inadequate warning systems 6-5 Inadequate tools 7-5 Radiation 8-5 Inadequate work place layout
1-6 Overexertion of physical capability materials 3-5 Equipment or materials not secured 4-6 Failure to warn 5-6 Defective warning systems 6-6 Improperly prepared tools 7-6 Temperature extremes • controls less than adequate
1-7 Work or motion at improper speed 2-6 Operation of equipment at improper speed 3-6 Disabled guards, warning systems or safety 4-7 Use of drugs or alcohol 5-7 Inadequate isolation of process or equipment 6-7 Defective vehicle 7-7 Hazardous chemicals • displays less than adequate
1-8 Improper lifting 2-7 Servicing of equipment in operation devices 4-8 Routine activity without thought 5-8 Inadequate safety devices 6-8 Inadequate vehicle for the purpose 7-8 Mechanical hazards • labels less than adequate
1-9 Improper loading 2-8 Other 3-7 Removal of guards, warning systems or safety 4-9 Overconfidence 5-9 Defective safety devices 6-9 Improperly prepared vehicle 7-9 Clutter or debris • locations out of reach or sight
1-10 Shortcuts devices 4-10 Other 5-10 Other 6-10 Other 7-10 Storms or acts of nature • conflicting information is presented
1-11 Other 3-8 Personal protective equipment not available 7-11 Slippery floors or walkways 8-6 Other
3-9 Other 7-12 Other

POSSIBLE SYSTEM CAUSES

PERSONAL FACTORS JOB FACTORS
7. Training / Knowledge 9. Contractor Selection
1. Physical Capability 2. Physical 3. Mental State 4. Mental Stress 5. Behavior 6. Skill Level 8. Management / 11. Work Planning 12. Purchasing, Material 13. Tools & Equipment 14. Work Rules / Policies / 15. Communication
Transfer & Oversight 10. Engineering /
1-1 Vision deficiency Condition 3-1 Poor judgment 4-1 Preoccupation with 5-1 Improper performance 6-1 Inadequate Supervision / Employee 11-1 Inadequate work Handling & Material 13-1 Inadequate Standards / Procedures (PSP) 15-1 Inadequate horizontal
9-1 Lack of contractor Design
1-2 Hearing deficiency 2-1 Previous injury or 3-2 Memory failure problems is rewarded assessment of Leadership planning Control assessment of needs 14-1 Lack of PSP for the task communication
7-1 Inadequate knowledge pre-qualifications 10-1 Inadequate technical
1-3 Other sensory illness 3-3 Poor coordination 4-2 Frustration • saves time or effort required skills 8-1 Conflicting roles / 11-2 Inadequate preventive 12-1 Incorrect item and risks •lack of defined responsibility between peers
transfer 9-2 Inadequate design
deficiency 2-2 Fatigue or reaction time 4-3 Confusing • avoids discomfort 6-2 Inadequate responsibilities maintenance received 13-2 Inadequate human for PSP 15-2 Inadequate vertical
• inability to contractor pre- • design input
1-4 Reduced respiratory •due to 3-4 Emotional directions / • gains attention practice of skill • unclear reporting • assessment of •inadequate factors / ergonomics •lack of job safety analysis communication
comprehend qualifications obsolete
capacity workload disturbance demands 5-2 Improper supervisory 6-3 Infrequent relationships needs specifications to considerations •inadequate job safety between supervisor
• inadequate 9-3 Inadequate • design input not
1-5 Other permanent •due to lack of 3-5 Fears or phobias 4-4 Conflicting example performance of • conflicting reporting • lubrication / vendor analysis and person
instructor contractor selection correct
physical disabilities rest 3-6 Low mechanical directions / 5-3 Inadequate skill relationship servicing •inadequate 13-2a Corrosion of Pipes 14-2 Inadequate development of 15-3 Inadequate
qualifications 9-4 Use of non-approved • design input not
1-6 Temporary •due to aptitude demands identification of critical 6-4 Lack of coaching • unclear assignment of • adjustment / specifications on 13-3 Inadequate standards PSP communication
• inadequate training contractor available
disabilities sensory 3-7 Low learning 4-5 Meaningless or safe behaviors on skill responsibility assembly requisition or specifications •inadequate coordination with between different
equipment 9-5 Lack of job oversight • design output
1-7 Inability to sustain overload aptitude degrading activities 5-4 Inadequate 6-5 Insufficient review • conflicting assignment • cleaning / •inadequate control 13-4 Inadequate availability process / equipment design organizations
• misunderstood 9-6 Inadequate oversight inadequate
body positions 2-3 Diminished 3-8 Influenced by 4-6 Emotional overload reinforcement of of instruction to of responsibility resurfacing on changes to 13-5 Inadequate •inadequate employee 15-4 Inadequate
instructions • design input
1-8 Restricted range of performance medication 4-7 Extreme critical safe behaviors establish skill • improper or 9-7 Other 11-3 Inadequate repair orders adjustment / repair / involvement in the communication
7-2 Inadequate recall of infeasible
body movement •due to judgment / decision • proper insufficient delegation  • communication of •unauthorized maintenance development between work groups
3-9 Other 6-6 Other training material Not Applicable • design output
1-9 Substance temperature demands performance is of authority needed repair substitution 13-6 Inadequate salvage •inadequate definition of 15-5 Inadequate
 Not Applicable  Not Applicable • training not unclear
sensitivities or extremes 4-8 Extreme criticized 8-2 Inadequate leadership • scheduling of work •inadequate product and reclamation corrective actions communication
reinforced on the job • design output not
allergies •due to oxygen concentration / • inappropriate peer • standards of • examination of acceptance 13-7 Inadequate removal / •inadequate format for easy between shifts
• inadequate correct
1-10 Inadequate size or deficiency perception pressure performance missing parts requirements replacement of use 15-6 Inadequate
refresher training • design output
strength •due to demands • inadequate or not enforced • parts substitution •no acceptance unsuitable items 14-3 Inadequate implementation of communication
frequency inconsistent
1-11 Diminished capacity atmospheric 4-9 Extreme boredom performance • inadequate 11-4 Excessive wear and verification 13-8 No equipment record PSP, due to deficiencies methods
7-3 Inadequate training • no independent
due to medication pressure feedback accountability tear performed history •contradictory requirements 15-7 No communication
4-10 Other effort design review
variation • inadequate • inadequate or • inadequate 12-2 Inadequate research 13-9 Inadequate equipment •confusing format method available
1-12 Other  • inadequate training 10-2 Inadequate
2-4 Blood sugar Not Applicable disciplinary incorrect performance planning for use on materials / record history •more than one action per 15-8 Incorrect instructions
 Not Applicable program design standards,
insufficiency process feedback • extension of equipment step 15-9 Inadequate
• inadequate training specifications, and /
2-5 Impairment due 5-5 Inappropriate • inadequate work site service life 12-3 Inadequate mode or •no check-off spaces communication due
goals / objectives or design criteria 13-10 Other
to drug or alcohol aggression walk-through • improper loading route of shipment provided to job turnover
• inadequate new 10-3 Inadequate
use 5-6 Improper use of • inadequate safety • use by untrained 12-4 Improper handling of  •inaccurate sequence of 15-10 Inadequate
employee assessment of Not Applicable
production incentives promotion people materials steps communication of
2-6 Other orientation potential failure
5-7 Supervisor implied 8-3 Inadequate correction of • use for wrong 12-5 Improper storage of •confusing instructions safety and health
 Not Applicable • inadequate initial 10-4 Inadequate
haste prior hazard / incident purpose materials or spare •technical error / missing data, regulations or
training ergonomic design
5-8 Employee perceived 8-4 Inadequate identification 11-5 Inadequate reference parts steps guidelines
• inadequate means 10-5 Inadequate
haste of worksite / job hazards materials or 12-6 Inadequate material •excessive references 15-11 Standard terminology
to determine if monitoring of
8-5 Inadequate management publications packaging •potential situations not not used
5-9 Other qualified for job construction
of change system 11-6 Inadequate audit / 12-7 Material shelf life covered 15-12 Verification /
 Not Applicable 7-4 No training provided 10-6 Inadequate
8-6 Inadequate incident inspection / monitoring exceeded 14-4 Inadequate enforcement of PSP repeat back
• need for training not assessment of
For each identified critical factor, identified
reporting / investigation
system
operational
• no documentation
• no correction
12-8 Improper identification
of hazardous
•inadequate monitoring of
work 15-13
techniques not used
Messages too long
• training records readiness
consider if any of the listed root cause incorrect or out of
date
8-7 Inadequate or lack of
safety meetings
10-7 Inadequate
monitoring of initial
responsibility
assigned 12-9
materials
Improper salvage
•inadequate supervisory
knowledge
15-14
15-15
Speech interference
Other
• no accountability and / or waste •inadequate reinforcement
categories apply. If 'yes,' circle the • new work methods
introduced without
8-8 Inadequate performance
measurement &
10-8
operation
Inadequate
for corrective action disposal •non-compliance not  Not Applicable
assessment 11-7 Inadequate job 12-10 Inadequate use of corrected
specific root cause. training
• decision made not 8-9 Other
evaluation and / or
documentation of
placement
• appropriate
safety and health data 14-5 Inadequate communication of
PSP
If none of the root causes in the 7-5 Other
to train  Not Applicable change
10-9 Other
personnel not
identified
12-11

Other
Not Applicable
•incomplete distribution to
work groups
category apply, then check the 'not  Not Applicable  Not Applicable • appropriate
personnel not
•inadequate translation to
appropriate languages

applicable' box at the bottom of the available

• appropriate
•incomplete integration with
training

column. personnel not

provided
•out of date revisions still in
use
14-6 Other
11-8 Other
 Not Applicable  Not Applicable

CORRECTIVE PHASE: PROPOSALS FOR CORRECTIVE ACTION

Leadership, Commitment Training, competency Facilities Design and Operations and Incidents Analysis and Interaction with Employees, Contractors commitment and Information and
Risk Assessment , Management Management of Change Crisis preparedness Auditing, Assurance, Measurement
and Accountability and Behaviours Construction Prevention Stakeholders Regulators & involvement Documentation
and Compliance Maintenance and Improvement
community