GasLog LNG Services Ltd.
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Comprehensive List of Causes CLC
i. Failure to follow rules and
regulations
ii. Failure to use personal
protective equipment
properly
iii. Operating equipment or
machinery without authority
Physical incapacity
Hearing deficiency
Inappropriate height, weight, size, strength, reach etc.
Limited ability to sustain body positions
Other permanent physical disabilities
Others sensory deficiency (tooth, taste, smell, balance)
Respiratory Incapacity
Restricted range of body movement
Sensitivities to sensory extremes (temperature, sound etc)
Substance sensitivities or allergies
Temporary disabilities
Vision deficiency
Mental/psychological incapacity
Emotional disturbance
Fears & phobias
Inability to comprehend
Intelligence level
Low hearing aptitude
Low mechanical aptitude
Memory failure
Mental illness
Poor co-ordination
Poor judgment
Slow reaction time
Physical stress
Physical Stress
Atmospheric pressure variations
Blood sugar insufficiency
Constrained movement
Drugs
Exposure to health hazards
Exposure to temperature extremes
Fatigue due to Circadian rhythm disturbance
Fatigue due to lack of rest
Fatigue due to sensory overload
Fatigue due to task load or duration
Rev.
Effective Date: 01.Nov.2012
PRIOR STARTING COLLECTION OF EVIDENCE
INCIDENT/ Selection of Investigation Team: People taking part in the Position : take photos ,make sketches of the position of all participants from all angle
investigation team should be involved in the incident and have the
Parts : Evidence on the scene (equipment, tools, materials)
appropriate qualifications
ACCIDENT Secure evidence : Team should preserve the evidence prior starting People : Conduct Interviews no more than 24 hrs after the incident
the investigations Paper: Relevant documentation (permits, certificates, training records etc.)
IMMEDIATE CAUSES
UNSAFE ACTS UNSAFE CONDITIONS
iv. Incorrect use of equipment or viii. Failure to warn xiv. Under influence of i. Inadequate guards or v. Inadequate warning system xi. Fire and explosion hazards xvii. Bunkers and/or lub
machinery ix. Failure to secure alcohol and/or other barriers vi. Adverse weather conditions xii. Noise or temperature oils
v. Using defective equipment or x. Making safety devices drugs ii. Inadequate or defective vii. Adverse sea conditions xviii. Port and berthing
xiii. Radiation exposure
facilities
machinery inoperable xv. Sabotage, willful damage personal protective viii. Poor housekeeping xiv. Inadequate ventilation xix. Cargo
vi. Failure to follow xi. Improper position for task xvi. Suicide/Homicide equipment ix. Congestion or restricted action xv. Environmental conditions xx. Other substandard
repair/maintenance xii. Improper lifting, handling or xvii. Other substandard acts iii. Defective equipment, x. Inadequate or excessive xvi. Outdated charts, publications or conditions
instructions storage xviii. Failure to focus on the machinery or tools illumination xxi. Condition of Fire /
other documentations
vii. Incorrect navigation of ship conducted task iv. Hull and structural Emergency equipment
xiii. Inappropriate behavior
handling xix. Inappropriate pace
conditions
ROOT CAUSES
PERSONAL FACTORS JOB FACTORS
ROOT CAUSE ANALYSIS
Injury or illness Inadequate leadership or/and supervision Inadequate research on materials / equipment Inadequate implementation of work
Oxygen deficiency Inadequate specification on requisitions standards/procedures
Consideration of HSSE in staffing not effective
Inadequate specifications to vendors Inadequate maintenance of standards
Mental or psychological stress Giving inadequate policy, procedure, practices or
guidelines Inadequate maintenance o Monitoring use of standards/procedures/rules
Conflict demands o Updating
Giving objectives, goals or standards that conflict Inadequate preventative
Confusing directions Inadequate management of change controls in place
Improper or insufficient delegation o Adjustment / assembly
Emotional overload
Inadequate Hazard and/or Risk Assessment o Assessment of needs Excessive wear and tear
Extreme concentration/ perception demands
Inadequate matching of individual qualifications and o Cleaning or resurfacing Improper extension of service life
Fatigue due to mental task load or speed
job/task requirements o Lubrication and servicing Improper loading or rate of use
Frustration
Inadequate or incorrect performance feedback Inadequate repetitive Inadequate inspection and/or monitoring
Meaningless or disregarding activities
Inadequate performance measurement and evaluation o Communication of needs Inadequate maintenance
Mental illness
Inadequate reinforcement of correct behaviors o Examination of units Inadequate planning of use
Preoccupation with problems
Routine, monotony, demand of uneventful
Lack of supervisory/management job knowledge o Part substitution Use by unqualified or untrained people
vigilance
Monitoring/Auditing of HSSE not effective o Scheduling of work Abuse or misuse
Support of people not effective Inadequate Tools and Equipment Controlled by supervision
Lack of knowledge/ skill / competence Unclear or conflict assignment of responsibilities
Inadequate adjustment / repair / maintenance o Intentional
Inadequate Competence Assessment Unclear or conflict reporting relationships
Inadequate assessment of needs and risks o Unintentional
Inadequate induction training
Inadequate engineering Inadequate availability No condoned by supervision
Inadequate initial task specific training
Inadequate orientation
Inadequate assessment of operational readiness Inadequate human factors / ergonomics considerations Contractor selection and oversight
Inadequate consideration of human factors/ergonomics Inadequate inspections of the tool, equipment or vehicle Contractor oversight not effective
Inadequate update training
Inadequate evaluation of changes before use Contractor Pre-qualification process not effective
Infrequent performance / Practices
Inadequate hazard and risk assessment Inadequate removal and replacement of unsuitable item No contractor oversight process
Lack of Coaching / Toolbox talks
Inadequate monitoring of construction Inadequate salvage and reclamation No contractor pre-qualification
Lack of experience
Inadequate monitoring of initial operation Inadequate standards and specifications Use of non-approved contractor
Misunderstood directions
Inadequate standards, specification and /or design criteria Inadequate work standards Inadequate Training / Knowledge Transfer
Improper Behavior / motivation
Improper attempt to avoid discomfort
Incorrect technical design Inadequate communications of standards/ procedures Competency not assessed
Inadequate Purchasing o Distribution Inadequate instructions, orientation and /or training
Improper attempt to gain attention
Improper handling of materials o Publication Lessons Learnt not applied
Improper attempt to save time or effort
Improper salvage and/or waste disposal o Reinforcing with signs, color codes and job aids Training not effective
Improper performance rewarding
Improper storage of materials o Translation to appropriate languages
Improper production intensives
Improper transporting of material Inadequate development of standards / procedures
Improper supervisory example
Inadequate communication of safety and health data o Coordination with process design
Inadequate intervention for incorrect behavior
Inadequate identification of hazardous items o Employee involvement
Inadequate reinforcement of correct behavior
Inadequate mode or route of shipment o Inconsistent standards/procedures/rules
Inappropriate aggression
Inadequate receiving inspection and acceptance o Inventory and evaluation of exposures and needs
Inappropriate peer pressure
Lack of incentives
CORRECTIVE & PREVENTIVE ACTIONS