Corporate

7 | 330-BUD-01-IMOT A Collaborative Approach Workshop process is open, transparent, and collaborative Ensures that different perspectives or viewpoints are heard Each response received is respected and not freely edited Final workshop results are reviewed/validated by industry participants only Finding acceptable solutions that all members can support: Only industry participants vote, not regulator/HSAs Process is NOT about consensus, although the results demonstrate a significant degree of convergence

• 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