Corporate

2 | 310-BZN-01-ISDO Table of Contents • Risk Statement • Identified Causal Factors & Top 10 Primary Causal Factors • Top 5 Immediate Actions Root Cause Analysis workshop results • Fishbone Diagrams • Top 10 Primary Causal Factors and Recommended Controls/Solutions • Workshop Contacts Appendices

• Slide Number 1
• Table of Contents
• RA RCA project overview
• Introduction
• Industry Selection
• A Collective Process
• Introduction (1)
• 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 – 35 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
• Final Workshop Recommendations and Conclusions
• Next steps – Rca workshop
• Next Steps
• Slide Number 27
• Appendix A – Fishbone diagrams
• Primary Causal Factors
• Slide Number 30
• Slide Number 31
• Slide Number 32
• Slide Number 33
• Slide Number 34
• Slide Number 35
• 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)
• 1. Process – Inadequate Training (6)
• 1. Process – Inadequate Training (7)
• 2. Environment – Poor Workstation Design/Layout
• 2. Environment – Poor Workstation Design/Layout (1)
• 2. Environment – Poor Workstation Design/Layout (2)
• 2. Environment – Poor Workstation Design/Layout (3)
• 2. Environment – Poor Workstation Design/Layout (4)
• 3. People – Poor Technique
• 3. People – Poor Technique (1)
• 3. People – Poor Technique (2)
• 3. People – Poor Technique (3)
• 3. Culture – Lack of Effective Supervision
• 3. Culture – Lack of Effective Supervision (1)
• 3. Culture – Lack of Effective Supervision (2)
• 5. Measures – Lack of Evaluation of Effectiveness of Training
• 5. Measures – Lack of Evaluation of Effectiveness of Training (1)
• 5. Measures – Lack of Evaluation of Effectiveness of Training (2)
• 5. Environment – Lack of Storage Capacity
• 5. Environment – Lack of Storage Capacity (1)
• 5. Environment – Lack of Storage Capacity (2)
• 5. Environment – Lack of Storage Capacity (3)
• 7. People – Fatigue
• 7. People – Fatigue (1)
• 7. People – Fatigue (2)
• 7. People – Fatigue (3)
• 8. Process – Inadequate/Lack of Safe Work Practices (SWPs)
• 8. Process – Inadequate/Lack of Safe Work Practices (SWPs) (1)
• 8. Process – Inadequate/Lack of Safe Work Practices (SWPs) (2)
• 8. Process – Inadequate/Lack of Safe Work Practices (SWPs) (3)
• 8. Tools & Machines – Incorrect Use of/Failure to Use Equipment
• 8. Tools & Machines – Incorrect Use of/Failure to Use Equipment (1)
• 8. Tools & Machines – Incorrect Use of/Failure to Use Equipment (2)
• 8. Tools & Machines – Incorrect Use of/Failure to Use Equipment (3)
• 10. Process – Inadequate Staffing
• 10. Process – Inadequate Staffing (1)
• Appendix c – workshop contacts
• Workshop Contacts
• Disclaimer
• Slide Number 81