Corporate

14 | 330-BUD-01-IMOT Identified Primary Causal Factors Root cause analysis on inadequate control of hazardous energy during routine operations was completed on September 24-25, 2024. 25 primary casual factors were identified.

• Slide Number 1
• Disclaimer
• Table of Contents
• RA RCA project overview
• Introduction
• Industry Selection
• A Collaborative Approach
• Risk Assessment Workshop
• WSPS Communications – Risk Assessment Results
• RCA workshop Results
• Risk Statement
• Participant List: Subject Matter Experts
• RCA Results
• Identified Primary Causal Factors
• Category Breakdown – 25 Primary Causal Factors
• Voting Process – Level of Importance
• Top 10 Primary Causal Factors
• Employer vs. Workshop Results
• Worker vs. Workshop Results
• Employer vs. Worker Results
• Top 10 Comparison
• Recommendations
• Top Workshop Recommendations
• Next steps – Rca workshop
• RCA Infographic
• Next Steps
• Slide Number 27
• Appendix A – Fishbone diagrams
• Primary Causal Factors
• Overall Fishbone
• Slide Number 31
• Slide Number 32
• Slide Number 33
• Slide Number 34
• Slide Number 35
• Slide Number 36
• Appendix B – Controls/Solutions for top primary causal factors
• 1. Process: Inadequate Training
• 1. Process: Inadequate Training (1)
• 1. Process: Inadequate Training (2)
• 1. Process: Inadequate Training (3)
• 1. Process: Inadequate Training (4)
• 1. Process: Inadequate Training (5)
• 2. Process: Lack of Hazard Identification/Risk Assessment
• 2. Process: Lack of Hazard Identification/Risk Assessment (1)
• 2. Process: Lack of Hazard Identification/Risk Assessment (2)
• 2. Process: Lack of Hazard Identification/Risk Assessment (3)
• 3. Process: Lack of/Inadequate Documented Program
• 3. Process: Lack of/Inadequate Documented Program (1)
• 3. Process: Lack of/Inadequate Documented Program (2)
• 4. People: Lack of Worker Competency
• 4. People: Lack of Worker Competency (1)
• 4. People: Lack of Worker Competency (2)
• 4. People: Lack of Worker Competency (3)
• 4. People: Lack of Worker Competency (4)
• 4. People: Lack of Worker Competency (5)
• 4. People: Lack of Worker Competency (6)
• 5. Culture: Accepted Work Norms
• 5. Culture: Accepted Work Norms (1)
• 5. Culture: Accepted Work Norms (2)
• 5. Culture: Accepted Work Norms (3)
• 5. Culture: Accepted Work Norms (4)
• 6. People: Taking Shortcuts
• 6. People: Taking Shortcuts (1)
• 6. People: Taking Shortcuts (2)
• 6. People: Taking Shortcuts (3)
• 7. Tools and Machines: Inadequate Equipment
• 7. Tools and Machines: Inadequate Equipment (1)
• 7. Tools and Machines: Inadequate Equipment (2)
• 7. Tools and Machines: Inadequate Equipment (3)
• 8. Process: Lack of Monitoring
• 8. Process: Lack of Monitoring (1)
• 8. Process: Lack of Monitoring (2)
• 9. Tools and Machines: Inadequate Maintenance
• 9. Tools and Machines: Inadequate Maintenance (1)
• 9. Tools and Machines: Inadequate Maintenance (2)
• 10. Culture: Performance Evaluation
• 10. Culture: Performance Evaluation (1)
• 10. Culture: Performance Evaluation (2)
• Top 5 Immediate Actions (System)
• Appendix c – workshop contacts
• Workshop Contacts
• Slide Number 83