System Cause Analyzed Technique

Accident investigation root analysis cause checklist

Accident type Possible immediate causes

1. Struck against (running or bumping into) 1, 2, 4, 5, 6, 11, 14, 15, 16, 21, 22, 23, 24, 25, 27, 31, 39, 40
2. Struck by (hit by moving object) 1, 2, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23,
24, 25, 27, 31, 39, 40
3. Fall from height 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 21, 22, 23, 27, 33, 36, 40
4. Fall on same level (slip, trip, fall) 4, 9, 11, 13, 14, 15, 16, 17, 19, 23, 26, 27, 31, 33
5. Caught in (pinch and nip points) 5, 6, 11, 15, 16, 17, 19, 21, 22, 23, 34
6. Caught on (snagged, hung) 4, 5, 6, 9, 10, 11, 12, 15, 16, 17, 18, 21, 23, 35
7. Caught between or under (crush, amputation) 2, 3, 5, 6, 8, 9, 11, 12, 15, 16, 17, 18, 19, 20, 21, 24, 25, 34, 36, 38
8. Contact with (electricity, heat, cold, radiation, chemical, 2, 3, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24,
biological, noise) 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 40
9. Abnormal operation 1, 2, 3, 6, 9, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 27, 31, 33,
34, 35, 36, 37, 38
10. Product contamination 1, 2, 3, 5, 6, 9, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 27, 31,
34, 35, 36, 37, 38
11. Overstress, overpressure, overexertion, ergonomic 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17,18, 19, 20, 24, 25, 35, 37, 40
12. Equipment failure 1, 4, 6, 8, 16, 18,23, 25, 30, 32, 33, 34, 35, 37, 38, 40

13. Environmental release 1, 2, 3, 5, 6, 8, 9, 12, 15, 16, 17, 18, 19, 20, 23, 25, 26, 30, 32, 33, 34,
35, 36, 38

Immediate cause Possible basic causes

Unsafe acts
1. Operating equipment without authority 2, 4, 5, 7, 8, 9, 13, 14, 16
2. Failure to warn 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 14, 15, 16
3. Failure to secure 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 14
4. Operating at improper speed 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14
5. Making safety devices inoperative 2, 4, 5, 6, 7, 8, 9, 10
6. Using defective equipment 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
7. Failing to use PPE properly 1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 13, 14, 15, 16
8. Improper loading 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14
9. Improper placement 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14
10. Improper lifting 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14
11. Improper position for task 1, 2, 3, 4, 5, 6, 7, 9, 10, 13, 14, 16
12. Servicing equipment in operation 3, 4, 5, 6, 7, 9, 10, 12, 13, 14, 15, 16
13. Horseplay 2, 3, 4, 5, 7, 8, 9, 14
14. Under influence of alcohol/ drugs 1, 2, 3, 4, 5, 7, 8, 9, 14
15. Using equipment improperly 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16
16. Failure to follow procedure/ instruction 1, 2, 3, 4, 5, 6, 7, 8, 9, 14, 16

17. Failure to identify hazard/ risk 3, 4, 5, 6, 7, 9, 14

18. Failure to check/ monitor 2, 3, 4, 5, 6, 7, 9, 10, 12, 13, 14, 15, 16

19. Failure to react/ correct 1, 2, 3, 4, 5, 6, 7, 9, 13, 14, 16

20. Failure to communicate/ coordinate 3, 4, 5, 7, 9, 10, 16

Unsafe condition s
21. Inadequate guards or barriers 5, 9, 10, 11, 12, 13, 15
22. Inadequate or improper protective equipment 5, 7, 8, 9, 10, 11, 12, 13, 15
23. Defective tools, equipment or materials 8, 9, 10, 11, 12, 13, 15

24. Congestion or restricted action 9, 10, 11, 14

25. Inadequate warning system 8, 9, 10, 11, 12, 13, 15, 16

26. Fire & explosion hazards 5, 6, 7, 8, 9, 10, 11, 12, 13, 15
27. Poor housekeeping/ disorder 7, 8, 9, 10, 12, 14, 16
28. Noise exposure 5, 7, 8, 9, 10, 11, 12, 13, 14, 16
29. Radiation exposure 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
30. Temperature extremes 5, 7, 9, 10, 14
31. Inadequate or excess illumination 5, 7, 9, 10,11, 12, 13, 15
32. Inadequate ventilation 5, 7, 9, 10, 12, 13, 15

33. Presence of harmful materials 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16

34. Inadequate procedures/ instructions 5, 6, 7, 9, 10, 14, 16

35. Inadequate information/ data 5, 6, 9, 10, 11, 12, 16

36. Inadequate preparation/ planning 5, 6, 7, 9, 14, 16
37. Inadequate support/ assistance 7, 9, 11, 12, 16
38. Inadequate communications/hardware/ software/ process 7, 9, 10, 11, 12, 13, 15, 16
39. road conditions 5, 7, 8, 9, 10, 12, 13, 14, 15
40. weather conditions 5, 7, 9, 13, 14, 16
Basic cause Areas for corrective actions(s)
Personal factors
1. Inadequate physical/ physiological capability 4, 6, 11, 12, 13, 15, 18
a. Inappropriate height, weight, size, strength, reach, etc.
b. Restricted range of body movement
c. Limited ability to sustain body positions
d. Substance sensitivities or allergies
e. Sensitivities to sensory extremes (temperature, sound, etc.)
f. Vision deficiency
g. Hearing deficiency
h. Other sensory deficiency (touch, taste, smell, balance)
i. Respiratory incapacity
j. Other temporary/ permanent physical incapability
2. Inadequate mental/ psychological capability 1, 4, 6, 8, 12, 13, 15, 18, 20
a. Fears and phobias
b. Emotional disturbance
c. Mental illness
d. Intelligence level
e. Inability to comprehend
f. Poor coordination
g. Slow reaction time
h. Low mechanical aptitude
i. Low learning aptitude
j. Memory failure
Physical or physiological stress 4, 5, 6, 7, 9, 11, 12, 15, 18, 20, 22
a. Injury or illness
b. Fatigue due to task load or duration
c. Fatigue due to lack of rest
d. Fatigue due to sensory overload
e. Exposure to health hazards
f. Exposure to temperature extremes
g. Oxygen deficiency
h. Atmospheric pressure variation
i. Constrained movement
j. Blood sugar insufficiency
k. Drugs
3. Mental or psychological stress 1, 4, 5, 6, 7, 9, 10, 12, 13, 15, 16, 18, 20, 21, 22
a. Emotional overload
b. Fatigue due to mental task load or speed
c. Extreme judgment/ decision demands
d. Routine, monotony, demand for uneventful vigilance
e. Extreme concentration/ perception demands
f. “Meaningless” or “degrading” activity
g. Confusing directions/ demands
h. Conflicting demands/ directions
i. Preoccupation with problems
j. Mental illness
Lack of knowledge 2, 4, 5, 6, 8, 9, 10, 11, 14, 15, 16, 17, 18, 21, 22
a. Lack of experience
b. Inadequate orientation
c. Inadequate initial/ refresher training
d. Misunderstood directions
e. Lack of situational awareness
4. Lack of skill 2, 4, 6, 7, 9, 10, 13, 15, 16, 18, 21, 22
a. Inadequate initial instruction
b. Inadequate practice
c. Infrequent performance
d. Lack of coaching
e. Inadequate review instruction
5. Improper motivation 1, 2, 4, 5, 6, 8, 10, 11, 13, 15, 16, 17, 20, 21, 22
a. Improper performance is rewarded
b. Proper performance is punished
c. Lack of incentives
d. Excessive frustration
e. Inappropriate aggression
f. Improper attempt to save time or effort
g. Improper attempt to avoid discomfort
h. Improper attempt to gain attention
i. Inadequate discipline
j. Inappropriate peer pressure
k. Improper supervisory example
l. Inadequate performance feed back
m. Inadequate reinforcement of proper behaviour
n. Improper production incentives
6. Abuse or misuse 1, 2, 3, 4, 5, 6, 8, 10, 13, 14, 15, 21, 22
a. Improper conduct that is condoned intentional
b. Improper conduct that is condoned unintentional
c. Proper conduct that is not condoned intentional
d. Proper conduct that is not condoned unintentional
7. Inadequate leadership/ supervision 1, 2, 3, 5, 6, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22
a. Unclear or conflicting reporting lines
b. Unclear or conflicting assignment of responsibilities
c. Improper of insufficient delegation
d. Giving inadequate procedures/ instructions
e. Giving objectives, goals or standards that conflict
f. Inadequate work planning or programming
g. Inadequate instructions, orientation and/ or training
h. Providing inadequate reference documents
i. Inadequate identification and evaluation of hazards/ exposures
j. Lack of supervisory/ management job knowledge
k. Inadequate matching of individual qualifications and job/ task requirements
l. Inadequate performance measurement and evaluation (appraisal)
m. Inadequate or incorrect performance feed back
8. Inadequate engineering 1, 3, 4, 12, 13, 14, 19, 21, 22
a. Inadequate HSE assessment
b. Inadequate human factors/ ergonomics assessment
c. Inadequate standards, specification and/ or design criteria
d. Inadequate monitoring of construction
e. Inadequate assessment of operational readiness
f. Inadequate or improper controls
 g. Inadequate monitoring of initial operation
h. Inadequate evaluation of changes
9. Inadequate purchasing 1, 3, 6, 11, 12, 13, 14, 19, 21, 22
a. Inadequate specification on requisition/ to vendor
b. Inadequate research on materials/ equipment
c. Inadequate mode or route of shipment
d. Inadequate receiving inspection and acceptance
e. Inadequate communication of HSE data
f. Improper handling/ storage of materials
g. Inadequate identification of hazardous materials
h. Improper salvage and/ or waste disposal
i. Inadequate contractor selection
10. Inadequate maintenance 3, 4, 6, 8, 10, 13, 14, 19, 21, 22
a. Inadequate preventive maintenance
b. Inadequate corrective maintenance
11. Inadequate tools and equipment 1, 3, 4, 6, 7, 8, 11, 12, 13, 19, 21, 22
a. Inadequate assessment of needs and risks
b. Inadequate human factors/ ergonomic considerations
c. Inadequate standard or specification
d. Inadequate availability
e. Inadequate repair/ maintenance/ adjustment
f. Inadequate salvage and reclamation
g. Inadequate removal and replacement of unsuitable items
12. Inadequate work standards 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 21, 22
a. Inadequate development of standard
b. Inadequate communication of standard
c. Inadequate maintenance of standard
d. Inadequate monitoring of compliance
13. Excessive wear and tear 3, 4, 6, 9, 11, 12, 13, 14, 19, 21, 22
a. Inadequate planning of use
b. Improper extension of service life
c. Inadequate inspection and/ or monitoring
d. Improper loading or rate of use
e. Inadequate maintenance
f. Use by unqualified person or untrained people
g. Use for wrong purpose
14. Inadequate communications 1, 2, 4, 5, 6 ,7, 9, 10, 12, 14, 15, 17, 19, 21, 22
a. Inadequate horizontal communication between peers
b. Inadequate vertical communication between supervisor and operator
c. Inadequate communication between different organisations/ departments/
shifts
d. Inadequate communication methods
e. Incorrect instructions
f. Inadequate communication due to job turnover
g. Inadequate communication of HSE information
h. Standard terminology not used
i. Verification/ repeat feedback techniques not used
j. Message too long
k. Speech interference
Management system areas for corrective action
Specific check: procedure/ process available, procedure/ process adequate, procedure/ process followed?
1. HSE Leadership and administration a) General policy statement
b) HSE coordinator qualifications
c) Management participation in HSE
d) HSE expectations for all employees
e) HSE manual
f) Annual HSE goals established
g) HSE committees and representatives
h) Policy on all employees responsibility to stop unsafe work
i) Identification of applicable regulation, codes and standards
j) Communication with external parties
2. Leadership training a) Training needs analysis
b) HSE introduction for new leaders/ management
c) Initial and refresher training of leaders/ management
d) Formal training HSE coordinator
3. Planned inspection and maintenance a) Planned general HSE
b) Action tracking and follow-up
c) Critical parts/ equipment/ systems identification
d) Preventive maintenance system
e) Pre-use equipment inspections
f) Reporting system for unsafe equipment/ conditions
g) Regulatory inspections
4. Critical task analysis and procedures a) Task analysis system
b) Critical tasks identified
c) Proper controls defined for identified hazards
d) Controls included in procedures, instructions
e) Action tracking and follow-up
f) Critical tasks procedures updated
5. Incident investigation a) HSE Incident and near miss reporting & investigation system
b) Manufacturing management participation
c) Trend analysis and root cause corrective action
d) Action tracking and follow-up
6. Task observation a) Task – behaviour observation system
b) Observation system for critical/ high risk tasks
c) Action tracking and follow-up
7. Emergency preparedness a) Identification of emergencies
b) Emergency plan – roles responsibilities
c) Off-site emergencies
d) Sources of energy controls
e) Emergency and rescue systems
f) Drills and exercises
g) Action tracking and follow-up
h) Coordination with outside service providers
i) Emergency communications
j) Post event planning
8. Rules and work permits a) General HSE expectations – rules
b) Specific HSE expectations (job description, procedures)
c) Permit to work system
d) Regulatory permits to operate
e) Signage and colour coding
9. Incident analysis See 5.
10. Knowledge and skill training a) Training and needs analysis
b) Instructor qualifications
c) Training systems (completion tracking, records)
d) Training effectiveness evaluation and follow-up
11. Personal protective equipment (PPE) a) Identification of PPE needs
b) PPE availability and choice

c) PPE rule compliance/ enforcement/ inspections

Health and hygiene control a) Identification and evaluation of health hazards (qualitative)
b) Occupational health and industrial hygiene monitoring (quantitative)
c) Health and industrial hygiene controls incorporation in procedures/ instructions
d) Healthcare system and medical examinations
e) Ergonomic program
f) Professional assistance/ consultant support
g) Internal communication
12. System evaluation a) Assessment of HSE requirements (management system and regulation)
b) Employee perception surveys

c) Management system review of performance (audit results, inspection scores, near

miss/ accident trends, corrective action completion etc.)
Management of change a) Hazard identification & risk assessment
b) Project reviews and identification of changes
c) Action tracking
13. Personal communication a) Training in personal communication methods
b) Individual job orientation/ induction
c) Task instruction
d) Planned personal contacts
14. Group communication a) Quantity and quality of group HSE meetings
b) Management involvement in HSE meetings
15. General awareness a) HSE communication (bulletin board, newsletter, posters, etc.)
b) Use of incident trends/ HSE measurements (KPI) information
c) Critical topic awareness
d) Individual/ group rewards and recognition
e) Communication of HSE matters with community
16. Hiring and placement a) Job capability requirements established
b) Medical examination
c) General orientation/ induction
d) Pre-employment/ pre-placement qualification check
17. Materials and services management a) Procurement/ sourcing of goods
b) Contractor selection
c) Clear HSE requirements in specification of goods/ services

d) Management of contractors
18. Off the job safety a) Problem identification and analysis
b) Off-the-job safety education
19. Environmental management -
20. Quality management -