Root Cause Factors

Basic Risk Factors Root Cause Type
Hardware Bad condition (circumstances)
Hardware Bad condition (wear/corrosion)
Hardware Not suitable for purpose
Hardware Procurement and stock management
Hardware Insufficiently delivered
Hardware Unavailable due to theft
Design No standardisation
Design Not ergonomic
Design No indication of condition
Design Badly accessible
Design Illogic lay-out
Design Practical use unknown to designer
Maintenance Management Insufficient supervision on maintenance
Maintenance Management No feedback of condition
Maintenance Management No specialised maintenance staff
Maintenance Management No relevant documentation
Maintenance Management Insufficient planning of maintenance
Procedures Author insufficiently knowledgeable
Procedures Lack of feedback on usability
Procedures Rules difficult to find
Procedures Need insufficiently inventorised
Procedures “Political” reason
Procedures Important rules missing
Procedures Area of scope unclear
Procedures Design of rules unstructured
Error Enforcing Conditions Human physical constraints
Error Enforcing Conditions External influences
Error Enforcing Conditions Socially determined circumstances
Error Enforcing Conditions Personality circumstamces
Error Enforcing Conditions Abuse or addiction
Housekeeping Insufficient means
Housekeeping Lack of management commitment
Housekeeping Wrong image to management
Housekeeping No field visits by management
Housekeeping Difficult due to environmental circumstamces
Housekeeping Unclear responsibility
Housekeeping Bad planning of housekeeping
Incompatible Goals Progress of production
Incompatible Goals Financial constraints
Incompatible Goals Discrepancy between social and individual factors
Incompatible Goals Time pressure
Incompatible Goals Discrepancy between formal and informal practices
Incompatible Goals Discrepancy between short and long term goals
Incompatible Goals Indisticinctness with management
Communication Language problems
Communication Inadequate structure of communication
Communication Erroneously transferred messages
Communication Low ratio of signal versus rustle
Communication Incorrect or ambiguous information
Communication Inconsistently provided information
Communication Loss of information
Communication Overflow of information
Communication Physically or mentally inaccessible
Organisation Badly defined departments
Organisation Unclear delegation of responsibilities
Organisation Discrepancy between policy and execution
Organisation Bad planning or co-ordination
Organisation Much bureaucracy / low flexibility
Organisation Corrupted management of business
Organisation Frequent reorganisations
Organisation Safety a goal instead a medium
Organisation Curing instead of reforming
Organisation No or unclear tasks, authorities and responsibilities
Training Insufficient management commitment
Training Inadequate management training
Training Education inconsistent with requirements
Training Human resource selection inadequate
Training No structured training plan
Training No assessment of training
Training Training not provided or ineffective
Training Discrepancy between training requirements and rules
Training Varying quality requirements
Training Not tuned to targetted population
Training No test of acquaintance and skill
Training Targeted population not identified
Defences Insufficiently ready for emergencies
Defences Inadequate personal protective equipment
Defences Unsuitable detection systems
Defences No emergency procedures or instructions
Defences Insufficient trained on emergency procedures
Defences Detection difficult to recognise
Defences Insufficient awareness of risks
Defences Incapable to restrict consequence
Defences Irreversible situation