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SYSTEMATIC CAUSE ANALYSIS TECHNIQUE (SCAT ) v8.1

People (Safety/Health) Financial (Fines, Claims, Insurance) Process/Business DESCRIPTION OF EVENT

Asset (Damage) Non-Conformity (Product/Service) Security

Environmental Reputation/Complaint

EVALUATION OF LOSS POTENTIAL IF NOT CONTROLLED

Loss Severity Potential Possibility of Recurrence Frequency of Exposure
Major (A) Serious (B) Minor (C) High (A) Moderate (B) Low (C) Extensive (A) Moderate (B) Low (C)

TYPE OF EVENT
1. Struck Against/Into 7. Contact with Electricity 13. Loss of Primary Containment 19. Failure of Instrumentation/Logic/Loop
(Running/Bumping/Colliding/Grounding/Crashing) (DCs:1,2,3,5,6,7,8,10,12,14,15,16,17,18,19,25,26,27,28, (DCs:1,2,3,5,6,7,8,9,11,12,13,15,16,17,18,19,25,26,27,28, (DCs:1,4,5,6,9,11,12,13,17,25,26,28,29,30,35,
(DCs:1,2,3,4,5,6,7,14,16,17,19,22,23,24,25,26,32,33,34,35,38,41,47) 29,30,32,33,34,35,38,41,46,47) 29,30,31,32,34,35,37,38,42,43,44,47) 37,42,43,46,47)
2. Struck By (Hit By Moving Object) 8. Exposure to Noise 14. Environmental Release (to Air/Water/Soil) 20. Failure of Civil Structure
(DCs:1,2,3,4,5,6,7,8,10,11,12,13,14,15,16,17,18,19,22,23, (DCs:2,3,5,6,7,8,10,12,14,15,16,17,18,19,25,26,27,28,29, (DCs:1,2,3,4,5,6,7,8,9,11,17,18,19,20,21,25,26,27,28, (DCs:1,2,3,4,5,6,7,9,11,12,14,17,18,25,26,28,29,
24,25,26,28,32,33,34,35,41,47) 32,33,34,35,38,39,41,44,46,47) 29,30,31,32,34,35,37,38,43,44,46,47) 30,34,35,38,42,43,44,46,47)
3. Fall from Elevation (Person/Equipment/Material) 9. Exposure to Vibration 15. Fire (Pool Fire/Jet Fire/Flash Fire) 21. Abnormal Operation/Process Disturbance
(DCs:2,3,5,6,7,8,10,11,12,13,14,15,16,17,18,19,24,25, (DCs:1,2,3,5,6,7,8,11,12,14,15,16,17,18,19,25,26,27,28,29, (DCs:1,2,3,4,5,6,7,8,9,11,12,13,14,15,16,17,18,19,22,23,25, (DCs:1,2,3,5,6,7,8,9,11,12,14,16,17,18,19,25,26,27,28,29,
26,32,33,38,41,47) 30,32,34,35,38,41,42,46,47) 26,27,28,29,30,31,32,35,36,37,38,40,43,44,45,46,47) 30,31,35,37,38,40,42,43,44,46)
4. Fall on Same Level (Slip and Fall/Trip Over) 10. Exposure to Ionising Radiation 16. Explosion (Vapour Cloud/Dust/Pressure Burst/BLEVE) 22. Unstable process/reaction
(DCs:4,7,11,12,13,14,15,16,17,18,19, (DCs:1,2,3,5,6,7,8,10,12,14,15,16,17,18,19,25,26,27,28,29, (DCs:1,2,3,4,5,6,7,8,9,11,15,16,17,18,20,21,22,23,25,26, (DCs:1,2,3,5,6,7,8,9,11,12,13,14,16,17,18,19,25,26,27,28,29,
24,25,26,38,41,47) 32,33,34,35,36,37,38,40,41,43,45,46,47) 27,28,29,30,31,32,35,36,37,38,40,43,44,45,46,47) 30,31,34,35,38,40,42,43,44,46)
5. Caught In, On, Between or Under 11. Mechanical Overstress (by Overload/Overpressure) 17. Failure of Mechanical Equipment 23. Customers/Stakeholders Complaints
(DCs:1,2,3,4,5,6,7,8,10,11,12,13,14,15,16,17,18,19,24,25, (DCs:1,2,3,4,5,6,7,8,9,11,12,13,14,17,18,25,26,28,29,31, (DCs:1,4,6,9,11,12,13,17,18,25,26,28,29,30,35,37, (DCs:1,2,5,6,7,8,9,10,11,12,13,15,16,17,19,20,21,25,26,27,28,
26,27,28,29,32,33,34,35,38,41,44,46,47) 34,35,42,43,44,46,47) 42,43,44,46,47) 29,30,31,35,38,39,40,41,42,46,47)
6. Contact with Temperature Extremes (Heat/Cold) 12. Contact with Hazardous Substance/Dose 18. Failure of Electrical System 24. Act of Violence
(DCs:1,2,3,5,6,7,8,9,10,12,14,15,16,17,18,19,25,26,27,28, (Toxic/Corrosive/ Carcinogenic/ Biological/Viral) (DCs:1,4,6,9,11,12,13,17,25,26,28,29,30,35,37, (DCs:15,16,17,18,19,22,23,32,35)
29,30,31,32,33,34,35,38,41,43,44,45,46,47) (DCs:1,2,3,5,6,7,8,9,10,11,12,13,14,15,16,17,18,25,26,27, 42,43,45,46,47)
28,29,30,31,32,33,34,35,37,38,41,44,45,47)

DIRECT CAUSES
S U B S TA N D A R D A C T S S U B S TA N D A R D C O N D I T I O N S
1. Operating Equipment Without Authority 13. Improper Lifting 24. Inadequate Condition of Floor/Surface 36. Presence of Flammable/Explosive Atmosphere
(RCs:2,4,5,6,7,8,9,14,15,16,17) (RCs:1,2,3,4,5,6,8,9,10,11,12,14,15,16) (RCs:10,12,13,14,16,17) (RCs:5,6,7,8,9,10,11,12,13,14,15)
2. Failure to Inform/Warn 14. Improper Position for Task 25. Defective Tool/Equipment 37. Unauthorized Presence of Hazardous Materials
(RCs:1,2,3,4,5,6,7,8,9,11,13,16,17) (RCs:1,2,3,4,5,6,10,14,15,16,17) (RCs:8,9,10,11,12,13,14,15) (RCs:5,6,7,8,9,10,11,12,13,14,15,16,17)
3. Failure to Secure 15. Improper/Inappropriate Behavior 26. Incorrect/Inadequate Tool/Equipment 38. Poor Housekeeping/Order
(RCs:1,2,3,4,5,6,8,9,11,13,16,17) (RCs:2,3,4,5,6,7,8,9,16) (RCs:3,4,5,6,9,10,11,12,13,14,16,17) (RCs:6,7,8,9,10,12,16,17)
4. Operating at Improper Speed 16. Under the Influence of Medicine/Alcohol/Drugs 27. Inadequate Integrity of Equipment 39. Noise Level Over Threshold
(RCs:2,3,4,5,6,8,9,10,14,15,16) (RCs:1,2,3,4,5,6,8,9,16) (RCs:8,10,11,12,13,14,15,16) (RCs:8,9,10,11,12,13,14,15,16,17)
5. Making Critical Safety Devices Inoperative 17. Failure to Follow Procedure/Instruction 28. Failure to Detect/Measure 40. Radiation Hazard Over Threshold
(RCs:2,4,5,6,7,8,9,10,12,17) (RCs:1,2,3,4,5,6,7,8,9,11,16) (RCs:1,2,3,4,5,6,8,9,10,12,13,14,15,16,17) (RCs:8,9,10,11,12,13,14,15,16,17)
6. Using Defective Tool/Equipment/Machinery/Device 18. Failure to Identify Hazard 29. Improper Measurement/Signal Conversion 41. Insufficient/Excessive Illumination
(RCs:2,3,4,5,6,8,9,10,11,12,13,14,15,16,17) (RCs:3,4,5,6,7,8,9,10,12,16) (RCs:1,2,3,4,5,6,8,9,10,12,13,14,15,16,17) (RCs:8,9,10,11,12,13,14,15,16,17)
7. Improper Operation of Tool/Equipment/Machinery/Device 19. Substandard Act by External Party (not under own control) 30. Incorrect Material 42. Vibration Over Threshold
(RCs:1,2,3,4,5,6,7,8,9,10,11,13,14,15,16,17) (RCs:6,7,8,9,10,11,16,17) (RCs:8,9,10,11,12,13,14,15) (RCs:6,8,9,10,11,12,13,14,15,16,17)
8. Inadequate Servicing of Equipment/Machinery in Operation 20. Failure to Identify Customer/Stakeholder Requirements 31. Incorrect Composition of Material/Gas 43. Temperature Outside Limits
(RCs:3,4,5,6,7,8,9,10,12,13,14,15,16,17) (RCs:4,5,6,7,8,9,10,11,12,13,14,15,16,17) (RCs:8,9,10,11,12,13,14,15,16,17) (RCs:6,8,9,10,11,12,13,14,15,16,17)
9. Using Incorrect/Improper Material 21. Failure to Comply with Customers/Stakeholders Requirements 32. Inadequate Guard/Barrier 44. Pressure Outside Limits
(RCs:4,5,6,7,8,9,10,11,12,13,14,15,16,17) (RCs:4,5,6,7,8,9,10,11,12,13,14,15,16,17) (RCs:5,8,9,10,11,12,13,14,15) (RCs:6,8,9,10,11,12,13,14,15,16,17)
10. Failing to Use Personal Protective Equipment Properly 22. Civil Disturbance (Riot, Unrest, Warfare) 33. Inadequate/Improper Personal Protective Equipment 45. Inadequate Ventilation
(RCs:1,2,3,4,5,6,8,9,11,12,13,14,15,16,17) (RCs:3,4,6,8,9,11,16,17) (RCs:5,6,8,9,10,11,12,13,14,15) (RCs:8,9,10,11,12,13,14,15,16,17)
11. Improper Loading 23. Criminal Activities 34. Congestion/Restricted Space for Action 46. Inadequate Information
(RCs:1,2,3,4,5,6,8,9,10,11,12,13,14,15,16) (RCs:5,6,8,11,12,16,17) (RCs:8,9,11,16) (RCs:5,8,9,10,11,12,17)
12. Improper Placement 35. Inadequate Warning System 47. Exposure to Adverse Weather Condition
(RCs:1,2,3,4,5,6,8,9,10,11,12,14,15,16) (RCs:7,8,9,10,11,12,13,14,15,17) (RCs:5,6,8,9,10,12,13,14,15,16,17)
 ROOT CAUSES
P E R S O N A L FA C TO R S 4.2.Fatigue due to mental task load or speed J O B FA C TO R S 10.13.Inadequate monitoring of initial operation 14.5.Inadequate availability of tool / equipment / machinery / device
1. Inadequate Physical/Physiological Capability 4.3.Extreme judgment/decision demands 7. Unclear Organizational Structure 10.14.Inadequate management of change process 14.6.Inadequate inspection/repair/maintenance
(CAs: 1,3,4,5,7,8,9,11,13,14,15) 4.4.Routine/monotony/boredom/overly routine tasks (CAs: 1,2,4,5,6,8,9,11,13,15) 11. Inadequate Supply Chain Management 14.7.Inadequate adjustment/calibration
1.1.Inappropriate height/weight/size/strength/reach, etc. 4.5.Extreme concentration/perception demands 7.1.Unclear/conflicting reporting relationship (CAs: 1,2,3,4,5,6,8,9,10,11,13,14,15) 14.8.Inadequate removal and replacement of unsuitable items
1.2.Restricted range of body movement 4.6.“Meaningless”/“degrading” activities 7.2.Unclear/conflicting assignment of function/role 11.1.Inadequate specification on requisition/purchase order 15. Inadequate Product/Service Design
1.3.Limited ability/inability to sustain body positions 4.7.Confusing directions/demands 7.3.Unclear/conflicting accountability/responsibility/task 11.2.Inadequate research on material / equipment / tool / supply / etc (CAs: 1,2,3,5,6,7,9,10,11,13,14,15)
1.4.Substance sensitivity/allergy 4.8.Conflicting demands/directions 8. Inadequate Leadership 11.3.Inadequate specification to vendor 15.1.Inadequate assessment of needs and risks
1.5.Sensitivities to sensory extreme (temperature/sound/etc.) 4.9.Preoccupation with problems/Distraction by concern (CAs: 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15) 11.4.Inadequate mode/route of shipment 15.2 Inadequate product/service standard/specification/concession system
1.6.Vision deficiency 4.10.Frustration 8.1.Inadequate HSEQ/asset strategy 11.5.Inadequate communication of information about hazards 15.3 Inadequate product/service design/development
1.7.Hearing deficiency 4.11.Mental illness 8.2.Inadequate leadership development 11.6.Inadequate receiving inspection/acceptance 15.4 Inadequate product/service standard
1.8.Other sensory deficiency (touch/taste/smell/balance) 5. Lack of Competence 8.3.Inadequate delegation 11.7.Improper handling of material 15.5 Inadequate product/service design validation
1.9.Respiratory incapacity (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15) 8.4.Inadequate standards 11.8.Improper storage of material 15.6 Inadequate product/service design verification
1.10.Other permanent physical disability 5.1.Inadequate experience 8.5.Inadequate communication/implementation of policy/procedure/practice 11.9.Improper transporting of material 15.7 Inadequate product/service planning
1.11.Temporary disability 5.2.Inadequate orientation/induction 8.6.Conflicting policy/procedure/practice 11.10.Inadequate shelf life/validation for re-use of materials/equipment 15.8 Inadequate product/service quality verification
2. Inadequate Mental/Psychological Capability 5.3.Inadequate initial training 8.7.Inadequate work/process planning/programming 11.11.Inadequate identification of material 16. Inadequate Work/Production Standards
(CAs: 1,2,3,4,5,7,8,9,10,11,13,14,15) 5.4.Inadequate update/refresher training 8.8.Condone deviation from policy/procedure/practice 11.12.Improper salvage/waste disposal (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15)
2.1.Fears and phobias 5.5.Misunderstood instruction/information 8.9.Condone misuse of equipment/tool 11.13.Inadequate selection of contractor/supplier 16.1.Inadequate identification of requirements
2.2.Emotional disturbance 5.6.Lack of situational awareness/risk perception/risk awareness 8.10.Condone improper/inappropriate behavior 12. Inadequate Maintenance/Inspection (regulatory/industry code/permit-to-operate)
2.3.Mental illness 5.7.Inadequate initial instruction/skill training 8.11.Inadequate management information (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15) 16.2.Inadequate risk identification/evaluation in development of standard
2.4.Intelligence level 5.8.Inadequate practice 8.12 Inadequate monitoring/closure of audit actions 12.1.Inadequate assessment of preventive maintenance needs 16.3.Inadequate standard from supplier/contractor
2.5.Inability to comprehend 5.9.Infrequent performance 9. Inadequate Supervision/Coaching 12.2.Inadequate preventive lubrication and servicing 16.4.Inadequate coordination with process design when developing standard
2.6.Poor coordination 5.10.Inadequate coaching (CAs: 1,2,4,5,6,7,8,9,11,13) 12.3.Inadequate adjustment/assembly 16.5.Inadequate employee involvement in developing standard
2.7.Slow reaction time 5.11.Inadequate review instruction 9.1.Inadequate instruction/orientation/training 12.4.Inadequate preventive cleaning/resurfacing 16.6.Conflicting standards/improper prioritization of standards
2.8.Low mechanical aptitude 6. Improper Motivation 9.2.Inadequate information documents in supervision/coaching 12.5.Inadequate communication of corrective maintenance needs 16.7.Inadequate publication of standard
2.9.Low learning aptitude (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15) 9.3.Lack of supervisory/management job knowledge 12.6.Inadequate scheduling of maintenance work 16.8.Inadequate distribution of standard
2.10.Memory failure/lapse 6.1.Improper performance/behavior is tolerated/rewarded 9.4.Inadequate match between qualifications and job/task requirements 12.7.Inadequate assessment of repair needs 16.9.Inadequate translation of appropriate language
3. Physical/Physiological Stress 6.2.Proper performance/behavior is discouraged/punished 9.5.Inadequate performance measurement and evaluation 12.8.Inadequate parts substitution/replacement 16.10.Improper use of language
(CAs: 1,2,3,4,5,6,7,8,9,10,11,12,13,14) 6.3.Lack of incentive 9.6.Inadequate performance feedback 12.9.Inadequate inspection method/interval 16.11.Inadequate training of standard
3.1.Injury or illness 6.4 Improper production incentive 10. Inadequate Management of Change 12.10.Unable to inspect 16.12.Inadequate reinforcing of standard with signs, color codes and job aids
3.2.Fatigue due to task load or duration 6.5 Improper Cost Reduction Incentive (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15) 13. Excessive Wear/Tear 16.13.Inadequate monitoring of standard compliance
3.3.Fatigue due to lack of rest 6.6.Excessive frustration 10.1.Inadequate hazard identification/risk evaluation in design (CAs: 1,2,3,4,5,7,8,9,10,11,13,14,15) 17. Inadequate Communication/Information
3.4.Fatigue due to sensory overload 6.7.Inappropriate aggression 10.2.Inadequate identification of failure mode 13.1.Inadequate planning of use (CAs: 1,2,3,4,5,6,7,8,9,10,11,13,14,15)
3.5.Exposure to health hazard 6.8.Improper attempt to save time/effort 10.3.Inadequate evaluation of customer/stakeholder requirement 13.2.Improper decision on extension of service life 17.1.Inadequate information handling
3.6.Exposure to temperature extreme 6.9.Improper attempt to avoid discomfort 10.4.Inadequate identification of legal requirement 13.3.Inadequate inspection/monitoring 17.2.Unclear information
3.7.Oxygen deficiency 6.10.Improper attempt to gain attention 10.5.Inadequate consideration of human/ergonomic factor in design 13.4.Improper loading/rate of use 17.3.Inadequate transfer of information between processes/organizational units
3.8.Atmospheric pressure variation 6.11.Inadequate discipline 10.6.Inadequate design process / standard / specification / criterion 13.5.Used for wrong purpose/task/activity 17.4.Inadequate transfer of information with client/stakeholder
3.9.Constrained movement 6.12.Inappropriate peer pressure 10.7.Inadequate process control automation 14. Inadequate Tool/Equipment/Machinery/Device 17.5.Inadequate transfer of information with authorities
3.10.Blood sugar insufficiency 6.13.Improper leadership example 10.8.Inadequate (technical) standard/specification or absence thereof (CAs: 1,2,3,4,5,6,8,9,10,11,12,13,14,15) 17.6.Inadequate transfer of information with suppliers/contractors/third parties
3.11.Alcohol/Drugs/Other Self Imposed Stress 6.14.Inadequate performance feedback 10.9.Inadequate review of project risks 14.1.Inadequate assessment of needs and risks 17.7.Inadequate communication structure
4. Mental/Psychological Stress 6.15.Inadequate reinforcement of proper behavior 10.10.Inadequate monitoring of construction / fabrication / assembly 14.2.Inadequate consideration of human factors/ergonomics 17.8.Inadequate databases/information system
(CAs: 1,2,4,6,7,8,9,10,11,12,13,14,15) 6.16.Abuse (intentionally) 10.11.Inadequate assessment of operational readiness 14.3.Inadequate (supplier) standard/specification 17.9.Inadequate communication method/technique used
4.1.Emotional overload 6.17.Misuse (unintentionally) 10.12.Inadequate commissioning/handover process 14.4 Incorrect measurement/detection/(process) control

CONTROL AREAS FOR IMPROVEMENT ACTIONS

S PS C S PS C S PS C S PS C S PS C

1 - LEADERSHIP 4.5. Leaving the Organization 8.3. Management Meetings 10.10. Inspection, Measuring and Test Equipment 13.5. Complaints Management
1.1. Purpose and Values 4.6. Management of Organizational Change 8.4. Group Meetings 10.11. Acquisition and Sale 13.6. Event Announcements
1.2. Goals 4.7. Process Safety Human Resources 8.5. Joint Committee/Council 10.12. Asset Integrity Program 13.7. Away-from-Work Accidents
1.3. Policy 5 - COMPLIANCE ASSURANCE 8.6. Coaching 10.13. Process Safety Inspections 13.8. Action Follow-Up
1.4. Strategy 5.1. Regulations 8.7. Recognition 11 - CONTRACTOR MANAGEMENT / PURCHASING 13.9. LFE Reporting Verification
1.5. Stakeholder Engagement 5.2. External Authorizations to Operate 8.8. Promotion Campaigns 11.1. Contractor/Supplier Selection 13.10. Event Analysis
1.6. Business Processes 5.3. Industry Codes and Standards 8.9. Away from Work Safety Information 11.2. Contractor Operations 13.11. Improvement Teams
1.7. Business Risks 5.4. Reporting to Authorities 8.10. Process Safety Awareness 11.3. Contractor/Supplier Assurance 14 - RISK MONITORING
1.8. Accountabilities 5.5. Information Security 9 - RISK CONTROL 11.4. Supply Chain and Purchasing 14.1. Health Hazard Monitoring
1.9. Management Commitment 5.6. Product Stewardship 9.1. Health Hazards Controls 11.5. Logistics 14.2. Safety Hazard Monitoring
1.10. Process Safety Leadership 5.7. Compliance Assessment 9.2. Safety Hazards Controls 11.6. Managing Contractors in Process Areas 14.3. Security Hazard Monitoring
2 - PLANNING AND ADMINISTRATION 5.8. Process Safety Regulations 9.3. Security Controls 12 - EMERGENCY PREPAREDNESS 14.4. Environmental Hazard Monitoring
2.1. Business Planning 5.9. Security of Process Information 9.4. Environmental Hazard Controls 12.1. Emergency Needs Assessment 14.5. Customer Satisfaction
2.2. Work Planning and Control 6 - PROJECT MANAGEMENT 9.5. Quality Control of Materials and Products 12.2. Site Emergency Plan 14.6. Effectiveness of Monitoring
2.3. Action Tracking 6.1. Project Co-ordination 9.6. Process Control and Operating Procedures 12.3. Off-Site Emergency Plan 14.7. Perception Surveys
2.4. Management System Documentation 6.2. Project Planning 9.7. Rules 12.4. Crisis Plan 14.8. Behavioral Observation
2.5. Records 6.3. Project Execution 9.8. Work Permits 12.5. Business Continuity Plan 14.9. Task Observations
2.6. Process Safety Planning 6.4. Project Control 9.9. Warning Signs and Notices 12.6. Emergency Plan Review 14.10. Audits
3 - RISK EVALUATION 6.5. Project Close Out 9.10. Personal Protective Equipment 12.7. Emergency Communications 14.11. Process Hazard Monitoring
3.1. Health Hazard Identification and Evaluation 6.6. Process Safety Project Reviews 9.11. Process Hazard Controls 12.8. Emergency Protection Systems 15 - RESULTS AND REVIEW
3.2. Safety Hazard Identification and Evaluation 7 - TRAINING AND COMPETENCE 9.12. Operating Procedures for Controlling Process Risks 12.9. Energy Controls 15.1. Business Results
3.3. Security Hazard Identification and Evaluation 7.1. Training System 9.13. Major Hazard Reports 12.10. Emergency Teams 15.2. Management Review
3.4. Environmental Hazards Identification and Evaluation 7.2. Training Needs Analysis 10 - ASSET MANAGEMENT 12.11. Drills and Exercises 15.3. Reporting to Stakeholders
3.5. Customer Expectations Identification and Evaluation 7.3. Instructor Competence 10.1. Maintenance Program 12.12. First Aid 15.4. Residual Risk Management
3.6. Task Risk Evaluation 7.4. Delivery of Training 10.2. Maintenance Planning and Scheduling 12.13. Medical Support
LEGEND
3.7. Process Safety Information 7.5. Leadership Orientation/Induction 10.3. Execution of Maintenance 12.14. Organized Outside Help and Mutual Aid S - System Inadequate. Action required to fill the gap in our management
3.8. Process Hazard Analysis 7.6. General Orientation/Induction 10.4. Maintenance Review 12.15. Preparedness for Major Accidents system e.g., improvement team to develop a new system, process or procedure.
4 - HUMAN RESOURCES 7.7. Job Orientation/Induction 10.5. General Conditions Inspections 13 - LEARNING FROM EVENTS PS - Performance Standard Inadequate. Action required to define better WHO
4.1. Human Resources System 7.8. Training Systems Evaluation 10.6. Physical Conditions Tour 13.1. Learning from Events System does WHAT and WHEN e.g., change the procedure, instruction or rule.
4.2. Recruitment 8 - COMMUNICATIONS AND PROMOTION 10.7. Special Equipment Inspections 13.2. Learning from Success C - Compliance with Performance Standard Inadequate. Action required to
4.3. Managing Individual Performance 8.1. Communication System 10.8. Pre-Use Equipment Inspections 13.3. Participation in Investigations improve compliance e.g., implement a program of training, coaching or
promotion.
4.4. Recognition and Discipline 8.2. Meeting Co-ordination 10.9. Engineering Change Management 13.4. Near-Miss and Substandard Conditions

The DNV GL Systematic Cause Analysis Technique is designed to improve the quality and effectiveness of incident investigations and the resulting improvement actions. The suggested links between Type of Event, Direct Causes, Root Causes and Control Areas for Improvement Actions are for guidance only based on the causation of typical events and may not be comprehensive for all events. For information on related products and services see www.dnvgl.com/isrs.
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