Comprehensive List of Causes DEFENSE

A TOOL FOR ROOT CAUSE ANALYSIS IMMEDIATE CAUSE

ROOT CAUSE
DESCRIPTION OF INCIDENT IMPLEMENTATION & RESEARCH PHASES: EVIDENCE GATHERING ANALYSIS PHASE: IDENTIFICATION OF CRITICAL FACTORS
GOLDEN RULE
Gather relevant evidence Organize all evidence
Document the type / severity of event
Implementation phase = direct evidence (scene and witnesses) Map evidence E P HOUSE RULE
Cover the who / what / when / where Identify critical factors
Research phase = indirect evidence (written sources)
/ how as known at the time
Consider People / Parts / Position / Paper Use CLC to identify all immediate and root causes HSSE MS ELEMENT

POSSIBLE IMMEDIATE CAUSES

UNSAFE ACTS UNSAFE 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 E Violation by individual 2-1 D 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 D Defective equipment 7-1 Fire or explosion 8-1 G Congestion or restricted motion
1-2 Violation by group 2-2 D Improper use of tools 3-2 I Personal protective equipment not used 4-2 Improper decision making of unnecessary confined space entry 5-2 Defective guards or protective devices 6-2 D Defective oxygen/gas detector equipment 7-2 Noise 8-2 Inadequate or excessive illumination
1-3 Violation by supervisor 2-3 D Use of defective equipment (aware) 3-3 F Lack of use of seat belt 4-3 Improper decision making of unnecessary work at heights 5-3 Inadequate personal protective equipment 6-3 D Inadequate equipment for work at heights 7-3 Energized electrical systems 8-3 Inadequate ventilation
1-4 Operation of equipment without authority 2-4 D Use of defective tools (aware) 3-4 I Improper breathing apparatus/wind socks for a H 2S 4-4 Distracted by other concerns 5-4 Defective personal protective equipment 6-4 D Inadequate equipment 7-4 Energized systems, other than electrical 8-4 Inadequate constant atmospheric test for confined space entry
1-5 Improper position or posture for the task 2-5 G Improper placement of tools, equipment or exposed work environment 4-5 Inattention to footing and surroundings 5-5 Inadequate warning systems 6-5 D Improperly prepared equipment 7-5 Radiation 8-5 Inadequate atmospheric test for the H2S exposed space
1-6 Overexertion of physical capability materials 3-5 I Improper use of proper personal protective equipment 4-6 F Distracted by use of mobile phone while driving 5-6 Defective warning systems 6-6 D Defective tools 7-6 Temperature extremes 8-6 Unprotected height
1-7 Work or motion at improper speed 2-6 D Operation of equipment at improper speed 3-6 I Improper use of fall arrestor equipment 4-7 Horseplay 5-7 Inadequate isolation of process or equipment 6-7 D Inadequate tools 7-7 Hazardous chemicals 8-7 Inadequate work place layout
1-8 Improper lifting 2-7 D Disrespect to the speed limit 3-7 Servicing of energized equipment 4-8 Acts of violence 5-8 Inadequate isolation of lifting area 6-8 D Improperly prepared tools 7-8 Mechanical hazards controls less than adequate
1-9 Improper loading 2-8 D Servicing of equipment in operation 3-8 Equipment or materials not secured 4-9 Failure to warn 5-9 Inadequate safety devices 6-9 D Defective vehicle 7-9 Clutter or debris displays less than adequate
1-10 Shortcuts 2-9 Other 3-9 Disabled guards, warning systems or safety devices 4-10 Use of drugs or alcohol 5-10 Defective safety devices 6-10 D Inadequate vehicle for the purpose 7-10 Storms or acts of nature labels less than adequate
1-11 Improper load vehicle capacity 3-10 Removal of guards, warning systems or safety devices 4-11 Routine activity without thought 5-11 Other 6-11 D Improperly prepared vehicle 7-11 Slippery floors or walkways locations out of reach or sight
1-12 Improper use of handrail 3-11 I Personal protective equipment not available 4-12 Inattention to housekeeping 6-12 Other 7-12 Other conflicting information is presented
1-13 Other 3-12 Other 4-13 Other 8-8 Other

POSSIBLE SYSTEM CAUSES (ROOT CAUSES)

PERSONAL FACTORS JOB FACTORS
1. Physical Capability 2. Physical Condition 3.Mental State 4.Mental Stress 5.Behavior 6.Skill Level 7.Training / Knowledge Transfer 8.Management / Supervision / 9.Contractor Selection & 10.Engineering / 11.Work Planning 12.Purchasing, Material Handling & 13.Tools & Equipment 14.Work Rules / Policies / 15.Communication
Employee Leadership Oversight Design Material Control Standards / Procedures (PSP)

1-1 A Vision deficiency 2-1 C Previous injury 3-1 Poor judgment (3.3) 4-1 Preoccupation with 5-1 Improper performance is 6-1 Inadequate 7-1 Inadequate knowledge 8-1 Conflicting roles / 9-1 A Lack of contractor 10-1 Inadequate technical 11-1 A Inadequate work planning (5.3) 12-1 Incorrect item received (5.3) 13-1 B Inadequate 14-1 Lack of PSP for the task (5.3) 15-1 B Inadequate horizontal
(3.3) or illness (3.3) 3-2 Memory failure (3.3) problems (3.3) rewarded (1.1) assessment of transfer (3.4) responsibilities (3.1) pre-qualifications design (5.2) 11-2 A Inadequate journey risk assessment inadequate assessment of needs lack of defined responsibility for PSP communication between
1-2 B Hearing 2-2 Fatigue (3.3) 3-3 Poor coordination 4-2 Frustration (3.3) saves time or required skills inability to unclear reporting (3.5) design input (4.2) specifications to vendor and risks (4.2) lack of job safety analysis peers (3.6)
deficiency(3.3) due to or reaction time 4-3 Confusing effort (3.4) comprehend relationships 9-2 A Inadequate obsolete 11-3 A Inadequate use of the buddy inadequate 13-2 Inadequate human inadequate job safety analysis 15-2 C Inadequate vertical
1-3 C Other sensory workload (3.4) directions / avoids discomfort 6-2 Inadequate inadequate conflicting reporting contractor design input not system for a confined space entry (5.3) specifications on factors / ergonomics 14-2 Lack of Permit to work system ( 5.3) communication between
deficiency (3.3) due to lack 3-4 A Emotional demands (3.1) gains attention practice instructor relationship pre-qualifications correct 11-4 Lack of awareness regarding wind (4.2) requisition considerations (4.2) 14-3 Inadequate development of PSP (5.3) supervisor and person (3.6)
1-4 C Reduced of rest disturbance ( 3.3) 4-4 Conflicting 5-2 Improper supervisory of skill (3.4) qualifications unclear assignment of
(3.5)
design input not direction and appropriate escapes inadequate control on 13-3 Inadequate standards inadequate coordination with 15-3 A Inadequate
respiratory capacity 3-5 C Fears or phobias 6-3 Infrequent (3.4) 9-3 A Inadequate
C due to directions / example (1.1) inadequate training responsibility available routes changes to orders or specifications (5.3) process / equipment design communication between
(3.3) (3.3) performance of contractor selection
sensory demands (3.1) 5-3 Inadequate identification equipment conflicting assignment (7.3) design output 11-5 Inadequate lifting plan unauthorized 13-4 Inadequate availability inadequate employee involvement in different organizations (3.6)
1-5 C Other permanent 3-6 B Low mechanical skill
overload 4-5 Meaningless or of critical safe behaviors misunderstood of responsibility 9-4 A Use of non- inadequate in place (5.3) substitution (5.3) the development 15-4 B Inadequate
physical disabilities aptitude (3.4) (1.1) 6-4 Lack of coaching
(3.3) 2-3 B Diminished degrading instructions improper or insufficient approved contractor design input 11-6 A Inadequate preventive maintenance inadequate product 13-5 A Inadequate inadequate definition of corrective communication between
performance (3.3) 3-7 Low learning activities(3.3) 5-4 Inadequate on skill (3.4) 7-2 Inadequate recall of delegation of authority (7.3) infeasible (5.2) acceptance adjustment / repair / actions work groups (3.6)
1-6 C Temporary
due to aptitude (3.4) 4-6 B Emotional reinforcement 6-5 Insufficient training material (3.4) 8-2 Inadequate leadership (1.1) 9-5 A Lack of job design output assessment of needs requirements maintenance (5.3) inadequate format for easy use 15-5 Inadequate
disabilities (3.3)
temperature 3-8 Influenced by overload (3.3) of critical safe behaviors review training not standards of oversight (7.3) unclear lubrication / servicing no acceptance 13-6 B Inadequate salvage 14-4 Inadequate implementation of PSP, due to communication between
1-7 C Inability to (1.1)
extremes medication (3.3) 4-7 Extreme judgment of instruction to reinforced on the job performance missing or 9-6 A Inadequate design output not adjustment / assembly verification performed and reclamation (5.3) deficiencies (5.3) shifts (3.6)
sustain body proper
due to 3-9 Other / decision demands establish skill inadequate not enforced oversight (7.3) correct cleaning / resurfacing 12-2 Inadequate research on 13-7 B Inadequate removal / contradictory requirements 15-6 Inadequate
positions (3.3) performance is (3.4)
oxygen Not Applicable (3.3) refresher training inadequate 9-7 Other design output 11-7 A Inadequate repair (5.2) materials/equipment (3.4) replacement of confusing format communication methods
1-8 C Restricted range criticized 6-6 Other
deficiency 4-8 Extreme frequency accountability Not Applicable inconsistent communication of needed repair 12-3 A Inadequate mode or route unsuitable items (5.3) more than one action per step (3.6)
of body movement inappropriate Not Applicable
(3.3) due to concentration / 7-3 Inadequate training for inadequate or incorrect no independent scheduling of work of shipment (3.4) 13-8 No equipment record no check-off spaces provided 15-7 B Inadequate lines of
perception peer pressure examination of parts communication while in a
1-9 Substance atmospheric working on a H2S performance feedback design review 12-4 A Improper handling of history (4.3) inaccurate sequence of steps
demands (3.3) inadequate parts substitution confined space (3.6)
sensitivities pressure designated area (3.4) inadequate work site 10-2 Inadequate standards, materials (3.4) 13-9 A Inadequate confusing instructions
4-9 Extreme boredom performance 11-8 B Excessive wear and tear (5.2) 15-8 No communication
or allergies (3.3) variation 7-4 Inadequate training effort walk-through specifications, and / or 12-5 A Improper storage of equipment record technical error / missing steps
(3.3) feedback inadequate planning for use method available ( 3.6)
1-10 C Inadequate size 2-4 C Blood sugar (3.4) inadequate safety design criteria (5.2) materials or spare parts (5.3) history (4.3) excessive references
4-10 Other inadequate extension of service life 15-9 Incorrect instructions (5.3)
or strength (3.3) insufficiency (3.3) inadequate training promotion 10-3 A Inadequate 12-6 A Inadequate material 13-10 Other potential situations not covered
Not Applicable disciplinary improper loading 15-10 Inadequate
1-11 Diminished 2-5 A Impairment due program design 8-3 A Inadequate risk assessment assessment of potential packaging (4.1) Not Applicable 14-5 Inadequate enforcement of PSP (3.6)
process use by untrained people communication due to job
capacity due to to drug or alcohol inadequate training regarding: (4.2) failure (4.2) 12-7 B Material shelf life inadequate monitoring of work
5-5 C Inappropriate use for wrong purpose turnover (3.4)
medication (3.3) use (2.1) goals / objectives Confined space entry 10-4 Inadequate ergonomic exceeded (4.1) inadequate supervisory knowledge
aggression (3.3) 11-9 Inadequate reference materials or 15-11 Inadequate
1-12 Other 2-6 Other inadequate new H2S design (4.1) 12-8 B Improper identification of inadequate reinforcement
5-6 Improper use of publications (5.3) communication of safety
Not Applicable Not Applicable employee orientation Dropped Object 10-5 Inadequate design of hazardous materials (4.1) non-compliance not corrected
production incentives 11-10 A Inadequate and health data,
(1.2)
inadequate initial Excavation excavation ( 4.1) 12-9 H Improper salvage 14-6 Inadequate communication of PSP (3.6)
training Work at Heights 10-6 Inadequate monitoring of audit/inspection/monitoring (5.2) and / or waste disposal (4.5) incomplete distribution to work regulations or guidelines
5-7 B Supervisor implied (3.4)
inadequate means 8-4 B Inadequate correction of construction (7.1) no documentation 12-10 A Inadequate use of safety groups
haste (1.2) 15-12 Standard terminology
to determine if prior hazard / incident (4.5) 10-7 A Inadequate no correction responsibility and health data (4.3) inadequate translation to appropriate
5-8 B Employee perceived not used (5.3)
qualified for job 8-5 B Inadequate identification of assessment of assigned 12-11 Other languages
haste (3.3) 15-13 Verification/repeat back
7-5 No training provided (3.4) worksite / job hazards (4.1) operational readiness no accountability for corrective Not Applicable incomplete integration with training
5-9 Inadequate techniques not used (3.6)
need for training 8-6 B Inadequate monitoring of (5.4) action out of date revisions still in use
housekepping behaviour 15-14 Messages too long ( 3.6)
not identified weather conditions (4.4) 10-8 Inadequate monitoring of 11-11 A Inadequate inspection of lifting 14-7 Inadequate accountability for the Permit to
5-10 Other 15-15 Speech interference (3.6)
training records 8-7 Inadequate management of initial operation (6.1) equipment and safety devices (5.2) Work system (5.3)
Not Applicable 15-16 Other
incorrect or out of change system (5.4) 10-9 Inadequate evaluation 11-12 A Inadequate Emergency Plan in place 14-8 Other
and / or documentation (5.5) Not Applicable\
date 8-8 A Inadequate incident Not Applicable
of change (5.4) 11-13 A Inadequate job placement (3.3)
For each identified critical factor, consider if any of the listed root cause new work methods reporting / investigation
10-10 Other appropriate personnel not
categories apply. If 'yes,' circle the specific root cause. introduced without system (6.4)
Not Applicable identified
If none of the root causes in the category apply, then check the 'not training 8-9 Inadequate or lack of safety
appropriate personnel not
applicable' box at the bottom of the column. decision made not meetings (3.6) OBS.: The HSE MS sub-element is identified in brackets next to each root cause.
available
to train 8-10 Inadequate performance
appropriate personnel not e.g.: Root Cause 15-3, Inadequate communication between different organizations
7-6 Other measurement & assessment
(6.1)
provided
Not Applicable HSE MS Sub-element (3.6) - Communication
8-11 Other 11-14 Other
Not Applicable Not Applicable

GOLDEN RULES EP HOUSE RULES

Developed by SBEP HSSE Team

Comply with the law, standards Intervene in unsafe and non- I use the right Tools for the I am Aware of and understand I Naturally hold the handrail I Do use a seatbelt and do not I keep my work Area clean, I Dress with the correct Personal
A and procedures B compliant situations C Respect our neighbours B I Stop any job that feels unsafe D job and use them correctly A the rules for a job or I find out E when using the stairs F use a cell phone whilst Driving G tidy and free of obstruction H I Reduce sources of waste I Protective Equipment (PPE) for the task

HEALTH, SAFETY, SECURITY AND ENVIRONMENT MANAGEMENT SYSTEM

1. LEADERSHIP AND COMMITMENT 2. POLICY AND STRATEGIC OBJECTIVES 3. ORGANISATION, RESPONSIBILITIES, RESOURCES, STANDARDS AND DOCUMENTS 4. HAZARD AND EFFECTS MANAGEMENT
1.2 Proactive in 1.3 Informed 2.1 Content 2.2 Dissemination 2.3 Strategic 3.1 Roles & Responsibilities 3.2 HSE Advisors & 3.3 Resources 3.4 Competence 3.5 Contractors 3.6 Communication 3.7 Documentation & Control 3.8 Documentation & Control 4.1 Identification of 4.3 Recording of
1.1 Visibility 4.2 Assessment
target setting involvement Objectives Management Representatives BG 14 POINTS HSE MS HSE Cases Hazards & Effects Hazards & Effects

4. HAZARD AND EFFECTS MANAGEMENT (cont.) 5. PLANNING AND PROCEDURES 6. IMPLEMENTATION AND MONITORING 7. AUDIT 8. MANAGEMENT REVIEW
4.4 Performance Criteria for 4.5 Risk Reduction Measures 4.6 Risk Reduction Measures 5.3 Procedures & Work 5.4 Management of 5.5 Contingency & 6.1 Performance 6.3 Non Compliance & 6.4 Incident Reporting & 7.2 Auditor 7.3 Contractor
Monitoring Controls Controls & Ownership Recovery 5.1 HSE Plan 5.2 Asset Integrity
Instructions Change Emergency Planning
6.2 Records
Corrective Action Follow Up
7.1 Audit Plan
Competency Audits
8.1 Review
Monitoring