Systematic Cause Analysis Technique

HSE PROCEDURE INCIDENT INVISTIGATION PROCEDURE

Page Doc. No No. Rev

1 of 4 NUS-HSE-IIP/02 02

Date

26/ 07/2016

SystematicCause AnalysisTechnique AnalysisTechnique

SystematicCause AnalysisTechnique

LOSSCateg!y!PtentialLssCateg!y LOSSCateg!y!PtentialLss Categ!y Health

 

Sa"et

En#i!nment En

$ualit y N on on pr pr od od uc uc titi ve ve Ti Ti me me

UseHSESCATfor HEALTH-SAFETY-ENV!"N#ENT HEALTH-SAFETY-ENV!"N#ENT C$useAn$l%sis

"ther

C li en en t Schlumberger  & '$rt !eput$tion Fine('en$lties 'rocess !evenue

INCIDENT!PtentialInci%ent INCIDENT!Ptential Inci%ent T oo oo ls ls ( E *u *u ip ip me me nt nt ( ' ro ro du du ct ct ( F $i $i lu lu re re (# (# $l $l fu fu nc nc titi on on +F +F $i $i l, o o nh nh ol ol e. e.

C he he m ic $ ls ( F lu lu id id s ( S lu lu rr rr % n ot ot pe pe rf rf or or mo mo r p l$ l$ c ed $s $s pe pe r d es es ig ig n/ n/

" ffff d ep ep th th or or i mp mp ro ro pe pe r s p$ p$ ce ce ou ou t

Tools( E*uipment( 'roduct( F$ilure(#$lfunction+F$ilonsurf$ce. lonsurf$ce.

Not meetinge0pect$tion+1ellproduction2 Client2 "thers.3 Tools( E*uipment( 'roduct not $t f$ult/

U np np l$ nn nn ed ed (U (U nd nd es es irir ed ed en en er er g% g% r el el e$ e$ se se

! eg eg ul ul $t $t or or %( %( Co Co nt nt r$ r$ ct ct ( L ic en en se se vi vi ol ol $t $t io io n

,$t$( nform$tion*u$lit%( ntegrit%deliver% f$ilure

Un$ble tore$c hdesireddepth

Loss of ell c ontrol

Loc $t $tionlogistics( 'rocurement( Customs incident

L $t e( e( No ( S ub st st $n $n d$ rd rd de li ve r% r% o f' ro du du ct ct ( Se rv ic e( e( , $t $t $

L os os t(t(, ro rop pe pe di nh nh ol ole +T +T oo oo l2 E *u ip me me nt nt2 " th the rs rs .

 nv oi oi ce ce f$ f$ il ur e

4l ob ob$ l og ogi st st ic s( s( ' ro ro cu cur em em en t(t( Cu st st om oms in ci ci de den t

F$iltodel l todeliver i ver +Custo +Customer mer(( Suppli Supplierinte e rinterde rdepen penden denc%. c%.

Stuc5 Stuc5 inhole inhole+To +Tool2 ol2 C$ble2 C$ble2 'ipe2" 'ipe2"the thers. rs.

I&&EDIATECAUSE I&&EDIATECAUSE

Su'stan%a!%Cn%itins Su'stan%a!% Cn%itins

Su'stan%a!%Acts Su'stan%a!% Acts Using un$uthori6ed e*uipment "per$ting E*uipment ithout $uthorit%

 

"per$ting $t improper speed

n$de*u$te4u$rds or 7$rriers n$de*u$te1$rningS%stem n$de*u$teor mproper e*uipment

"per$tee*uipment outof specific$tion

n$de*u$te&rdp$rt% +non-SL7m$n$ged. e*uipment

8noingl% using defective e*uipment

 

n$de*u$tedocumentedinstructions

Using e*uipment improperl%

n$de*u$te nform$tion(,$t$

#$5ing s$fet% devices inoper$tive

n$de*u$te 9ob(1or5prep$r$tion('l$nning

mproper :obpl$nning

n$de*u$te support( Assist$nce

mproper Lo$ding( Lifting( H$ndling('l$cement( 'osition for t$s5

n$de*u$te communic$tion infr$structure( 'rocess

mproper chemic$lmi0ing(7lending

,efectiveTools2 E*uipment2 #$teri$lsorSoft$re

mproper e*uipment( 'roduct selection( 9obdesign mproper(n$de*u$tem$inten$nce

n$ppropri$teor5sitecondition+Noise2!$di$tion2 n$ppropri$teor5sitecondition+Noise2! $di$tion2 #ud2 Sno2Ventil$tion2 llumin$tion2 H$rmfulm$teri$l2"thers.  

Fire;E0plosionH$6$rd

mproper beh$vior(Fooling$ro beh$vior(Fooling$round und

'oor House5eeping(,isorder 

mproperm$5e-up( Assembl%

Congestionor !estricted Action

mproper Filing( Archiving(!ecord 5eeping

E0tern$l conditions+Se$21e$ther2!o$det conditions+Se$21e$ther2!o$detc/. c/.

mproper stor$ge

,onhole conditions+Temper$ture2' conditions+Temper$ture2'ressure. ressure.

F$ilingtouse''Eproperl%

,onhole conditions+"bstruction2 !estriction2,ebris.

F$ilure to$rn(ntervene

,onhole conditions+S$nd2 Sc$le.

F$ilure tosecure( 'rotect

,onhole conditions+!eservoir2 Flor$te.

F$ilure tofollodocumentedinstructions

,onhole conditions+Chemistr%2 Corrosion.

F$ilure toidentif% H$6$rd(!is5

,onhole conditions+"thers.

F$ilure tochec5(#onitor("bserve F$ilure to!e$ct(Correct F$ilure tocommunic$te(Coordin$t tocommunic$te(Coordin$te e Under influenceof$lcohol $ndor"ther drugs

# ed ed i$ i$ e0 e0 po po su su re re

SystematicCause AnalysisTechnique

ROOTCAUSES Pe!snal(act!s Ina%equate

n$ppropri$te height2 eight2 si6e2 strength2 re$ch2 etc

Physical*Physilgi   calCa+a'ility

Ina%equate&ental * Psychlgical Ca+a'ility

!estrictedr$nge ofbod%movement Limited$bilit%tosust$inbod%positions

)'(act!s Ina%equate Lea%e!shi+ an%*!  Su+e!#isin

Uncle$ror conflictingreportingrel$tionships

4ivingob:ectives2go$ls2orst$nd$rdsth$tconflict

!ep$ir*u$lit%

Visiondeficienc%

n$de*u$teor5(:obpl$nningorprogr$mming

Testing

He$ringdeficienc%

n$de*u$teTe$m7uilding

'$rtsubstitution

n$de*u$teLongTerm'l$nning

!espir$tor%inc$p$cit%

n$de*u$teinstructions2orient$tion2$nd(or tr$ining

Lubric$tion$ndservicing

"therperm$nentph%sic$lc$p$bilities

'rovidingin$de*u$tereferencedocuments2directives2$ndguid$ncepublic$tions

Authori6edmodific$tionnotimplemented

Tempor$r%dis$bilities

n$de*u$teidentific$tion$ndev$lu$tionoflosse0posures

Schedulingof1or5

Fe$rs$ndphobi$s

L$c5ofsupervisor%(m$n$gement:ob5noledge

'$rts!epl$cement

Emotion$ldisturb$nce

n$de*u$tecommunic$tion(implement$tion oflessonsle$rned

Ad:ustment($ssembl%

#ent$lillness

n$de*u$tem$tchingofindividu$l*u$lific$tions$nd:ob(t$s5re*uirements

nt elli gencelevel n$bil it%t o comprehend 'oorcoordin$tion Slore$ctiontime Lomech$nic$l$ptitude Lole$rning$ptitude

n$de*u$t eperf orm$nceme$surement $ndev$l u$t ion n$de*u$t eorincorrect perform$ncefeedb$c5

Ina%equate Enginee!ing*&anu "actu!ing

E ng in ee ri ng

n$de*u$tedesign$ccept$ncecriteri$

n$de*u$tedesigncommerci$li6$tion(l$unch n$de*u$tecustomerorderi nf orm$ti onor processi ng n$de*u$teproductionpl$nning(flo n$de*u$teproductionlinetools(e*uipment(s%stems n$de*u$tereceivinginspection$nd$ccept$nce n$de*u$ter$ m$teri$ls n$de*u$tecomponentp$rtsf$bric$tion(m$chining n$de*u$teinventor%(stoc5control

Constr$inedmovement 7loodSug$rinsufficienc%

n$de*u$tecontrolof$ste n$de*u$tem$nuf$cturingdocument$tion+p$rtslists($ssembl% instructions(dr$ings. n$de*u$te$ssembl% n$de*u$tetesting n$de*u$teuserinstructions(m$nu$ls

Ina%equate P!cu!ement*Pu!c hasing

Ina%equate Cnt!acting

L$c5ofe0perience n$de*u$teorient$tion n$de*u$teiniti$ltr$ining n$de*u$teupd$tetr$ining #isunderstooddirections L$c5ofsitu$tion$l$$reness n$de*u$teiniti$linstruction n$de*u$tepr$ctice nfre*uentperform$nce L$c5ofco$ching

 n$ de* u$t eco mmu ni c$ ti on of s$ fe t%$ nd he$ lt hd $t $  n$ de *u $t ei de nt if ic $t io no fh $6 $r do us m$ te ri $l s Client

Contr$ctors(Suppliers

n$de*u$tedentific$tionofneeds  n$ de *u$ tet en de ri ng pr oc ess n$de*u$tebid

n$de*u$te st$nd$rds or specific$tions  n$d e*u $t e s$ lv$g e $ nd r ecl $m$ ti on  n$d e * u$t e re mov $l $ nd r ep l$ ce men t of un su it $b le i tems n$de*u$teretirement(remov$l(repl$cementof unsuit$ble(deterior$teditems

Ina%equate Stan%a!%s*P!ce%u!e s*,!-Inst!uctins

n$de*u$tedevelopmentofst$nd$rds(procedures(or5 instructions

n$de*u$tecommunic$tionof st$nd$rds(procedures(or5instructions'ublic$tion

 

n$de*u$tem$inten$nceofst$nd$rds(procedures(or5 instructions

nventor%$ndev$lu$tionofe0posures$ndneeds Coordin$tionithprocessdesign Emplo%eeinvolvement 'rocedures(pr$ctices(rules ,istribution  

 

 

Tr$nsl$tionof$ppropri$tel$ngu$ges Tr$ining !einforcingithsigns2colorcodes$nd:ob$ids Tr$c5ingofor5flo Upd$ting #onitoringuseofprocedures(pr$ctices(rules

n$de*u$temonitoringofcompli$nceithst$nd$rds(procedures(or5instructions  

E.cessi#e,ea!an%   Tea! 

Ina%equate   Cmmunicatins

n$de*u$tepl$nningofuse mpropere0tensionofservicelife

n$de*u$tecommunic$tionbeteenorg$ni6$tions n$de*u$tecommunic$tionbeteenor5groups n$de*u$tecommunic$tionbeteenshifts  n$d e*u $t eho ri 6on t$ lco mmun ic $t io nbe te en pee rs n$de*u$tevertic$lcommunic$tionbeteensupervisor$ndperson

 

n$de*u $tecontr$ctithclient n$de*u $tepre-contr$ctmeetings n$de*u$temobili6$tion n$de*u$tee0ecution(compli$nceithcontr$ct n$de*u$teperform$ncemonitoring n$de*u$teroutinest$tusmeetings n$de*u$tedemobili6$tion n$de*u$tepost-contr$ctmeeting n$de*u$tedentific$tionofneeds n$de*u$tepre-*u$lific$tion n$de*u$tetenderingprocess n$de*u$tecontr$ctorselection n$de*u$tecontr$ctithcontr$ctor(supplier n$de*u$tepre-contr$ctmeetings n$de*u$temobili6$tion n$de*u$tee0ecution(compli$nceithcontr$ct n$de*u$teperform$ncemonitoring n$de*u$teroutinest$tusmeetings

mproper$ttemptto g$in$ttention n$de*u$tediscipline

n$de*u$tedemobili6$tion n$de*u$tepost-contr$ctmeeting

mproperconductth$tisnot condoned

n$de*u$te$ssessmentof:obneeds$ndris5s n$de*u$te hum$n f$ctors(ergonomicsconsider$tions

n$de*u$teinspection$nd(ormonitoring mproperlo$dingofr$teofuse n$de*u$tem$inten$nce Useb%un*u$lifiedoruntr$inedpeople

mproperperform$nceisre$rded+toler$ted. 'roperperform$nceispunished L$c5ofincentives E0cessivefrustr$tion n$ppropri$te$ggression mproper$ttemptto s$vetimeor effort mproper$ttemptto $voiddiscomfort

mproperconductth$tis condoned

Assessmentofneeds

Cle$ningorresurf$cing   Ina%equate Tls*Equi+ment*Sy stems

n$de*u$terese$rchon m$teri$ls(e*uipment n$de*u$tespecific$tionsonre*uisitionorders n$de*u$tere*uisition(orderings%stems n$de*u$tespecific$tionsto vendors

n$de*u$terevieinstruction

n$ppropri$tepeerpressure mpropersupervisor%e0$mple n$de*u$teperform$ncefeedb$c5 n$de*u$tereinforcementofproper beh$vior  

 n$ de *u $t ed es ig n2 st $n d$ rd s2 pr oc ed ur es 2g ui de li ne s  n$ de* u$t ed esi gnc ri te ri $( spe ci fi c$ ti on s  n$ de* u$t ed esi gn de ve lo pme nt n$de*u$tedesignrevie

E0posureto temper$turee0tremes "0%gendeficienc%  Atmosphericpressurev$ri$tion

Con fu si ng di rec ti ons ( de m$n ds C on fl ic ti ng de m$ nd s( d ir ec ti on s 'reoccup$tionithproblems Frustr$tion #ent$lillness

A'use!&isuse

n$de*u$teprevent$tive

n$de*u$tedesign*u$lific$tiontesting #$nuf $cturi ng

E0treme:udgment( decisiondem$nds !outine2monoton%2dem$ndforuneventfulvigil$nce E0tremeconcentr$tion( perceptiondem$nds