Comprehensive List of Causes (CLC)

– Before using the CLC, organize the evidence into a timeline.
– Identify and write the critical factors – short, specific and action oriented is best.
– Then perform an ABC analysis as needed to better understand behaviours prior to using the CLC.
– After the ABC analysis is complete, use the CLC with the Glossary to determine the causes for each critical factor.
The four P’s: position, people, paper and parts represent evidence.
1. Visit the scene of the incident (positions).
2. Interview using proper interviewing techniques - funnelling and
numerous 5WH questions (people).
3. Inspect the equipment involved (parts).
4. Examine relevant records – paper or electronic (paper).
- Organize a small team, with the appropriate training and
instruction.
- Set terms of reference for the work.
- Preserve the evidence prior to starting the investigation
Comprehensive
List of Causes (CLC)
USING THE CLC
GATHERING EVIDENCE
GETTING STARTED
Quality Tip
Good local preparation allows for a faster start to the
investigation, which yields a better investigation.
Quality Tip
A concisely worded critical factor allows the investigation team to focus their discussions and helps to tell the story in
the incident report. Refer to training materials for a further discussion and examples of well crafted critical factors.
Each cause you list must: 1) be supported by evidence and 2) answer why the critical factor existed. If a cause does
not meet both of these elements, it should not be used.
Quality Tip
A solid RCA investigation is dependent on factual information. The more
facts you gather, the better your investigation.
A tool for Root Cause Analysis
ANTECEDENT-BEHAVIOUR-CONSEQUENCE ANALYSIS
1. IDENTIFY BEHAVIOURS
When an investigation team does not understand why a person acted as
they did, an antecedent-behaviour-consequence (ABC) analysis is useful
to better understand those behaviours. This understanding provides a
quality cause analysis in the CLC.
To be effective, the ABC analysis should be done after the evidence is
gathered, but prior to the start of the cause analysis.
To perform an ABC analysis:
- Identify the behaviour(s) in this critical factor - a behaviour is an
observable action, i.e. what a person does or doesn’t do or say.
- Write a statement of behaviour, including who performed the behaviour,
the task they were engaged in at the time, what they did or did not do,
and what was the outcome of that.
- See “A guide to Human Factors in Incident Investigation” for more detail.
Quality Tip
The more specific you are in identifying the behaviour, the more specific the
ABC will be. This will give you a better understanding of causes. Note that
there may be more than one behaviour in a specific critical factor. Each
behaviour should be listed and analysed separately. For example, a worker
and a supervisor might exhibit different behaviours for different reasons.
4. CONSIDER EXPECTED CONSEQUENCES
3. CONSIDER ANTECEDENTS
2. CHOOSE THE RIGHT TOOL
Consequences are a more powerful driver for behaviour than antecedents are, but to understand consequences, we must
consider them from the perspective of the person performing that behaviour. What did that person expect to get from
performing that way? Remember two key points: 1) most behaviour is rational to the person performing it and 2)
consequences can be both positive and negative.
Some examples of common consequences at work:
- saves time or effort / go home early
- get injured
- saves money
- get caught by supervisor / get approval from a supervisor
- get corrected by a co-worker
- personal discomfort
- avoid embarrassment
For each expected consequence, rate each consequence as:
1. either positive or negative, 2. immediate or future and 3. certain to occur, or uncertain.
- After you have completed the ABC analysis, the additional insights you have into the behaviours exhibited by the
people involved in the incident will assist you in identifying the proper causes for each critical factor.
- Continue with the CLC process to identify the causes of each critical factor.
Antecedents are the things which trigger or promote a specific behaviour. Some antecedents are
necessary for the behaviour to be possible or feasible, but antecedents alone will not guarantee the
behaviour will be performed. Some examples of common antecedents at work are:
- signs and warning labels
- knowledge / training programs
- expectations of others / expectations of your supervisor
- policies
- tools and equipment / working environment
- rules / procedures
- example set by others
- sufficient time
Identify the antecedents present in this instance prior to the behaviour.
- Rate each antecedent as present and effective, present and not effective or not relevant or absent.
- Use this understanding to select appropriate causes for the critical factor associated with this
behaviour
There are two tools for analysis of behaviour and we determine
which tool to use based on whether the behaviour was intended or
unintended. Most behaviours are intentional, even if the outcome of
that behaviour was unintentional or undesired.
- If the behaviour was intentional, proceed with the ABC analysis.
- If the behaviour was unintentional, proceed with the Human
Error Analysis tool.
- Unintentional behaviours are infrequent.
Quality Tip
To determine if a behaviour was intentional, focus on the action, not
the outcome. for example, “I was using a mobile phone while driving,
became distracted and had an accident.” The behaviour is using a
mobile phone while driving – and it is intentional. The outcome was I
became distracted and had an accident. While that is an undesirable
outcome, it does not change the fact the behaviour was intentional.
Quality Tip
An antecedent can be present and still not prevent an undesired behaviour. For example, if a warning sign
says ’do not use this equipment’ and a person ignores that and uses the equipment, the antecedent is
present and effective – it conveyed the right information to the person. If an antecedent is rated as
ineffective, you will need to specify a corrective action for it.
Quality Tip
Behaviour experts believe that consequences which are positive, immediate, certain and meaningful to the individual are the
most powerful drivers of behaviour.
POSSIBLE IMMEDIATE CAUSES
UNSAFE ACTIONS
1
1.1
1.2
1.3
1.4
1.5
1.6
Did not follow existing
procedures
Violation by individual
Violation by group
Violation by supervisor
Performing task without access
to procedure
Performing task without
understanding procedure
Other (please specify)
2
2.1
2.2
2.3
2.4
2.5
2.6
2.6
2.7
2.7
Use of tools, plant/equipment or vehicle
Use of plant/equipment or vehicle in the wrong way
Use of tools used in wrong way
Use of plant/equipment or vehicle with known defect
Use of tools with a known defect
Incorrect placement of tools, equipment or materials
Operation of plant/equipment or vehicle without
authority
Operation of plant/equipment or vehicle at improper
speed
Servicing/adjusting of energized plant or equipment
Other (please specify)
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
Use of protective equipment or methods
Need for protective equipment or methods
not recognized
PPE or protective methods not used
Incorrect use of PPE or protective methods
PPE or protective methods not available
Disabling guards, warning systems or
safety devices
Removing guards, warning systems or
safety devices
Other (please specify)
UNSAFE CONDITIONS
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Lack of focus or inattention
Distracted by other concerns
Inattention to surroundings
Inappropriate workplace behaviour
Not warning others
Unintentional human error
Routine activity without thought
Other (please specify)
5
5.1
Protective systems
Guards or protective devices present or not
effective
5.2 Defective guards or protective devices
5.3 Plant, equipment or materials not secured
5.4 Incorrect personal protective equipment
5.5 Defective personal protective equipment
5.6 Warning systems not effective
5.7 Defective warning systems
5.8 Safety devices not effective
5.9 Defective safety devices
5.10 Other (please specify)
6
6.1
6.2
6.3
Tools, plant/equipment & vehicles
Plant/equipment malfunction
Incorrect plant/equipment
Incorrect preparation of
plant/equipment
6.4 Tool malfunction
6.5 Incorrect tool
6.6 Incorrect preparation of tool
6.7 Vehicle malfunction
6.8 Incorrect vehicle
6.9 Incorrect preparation of vehicle
6.10 Other (please specify)
7
7.1
7.2
7.3
7.4
Unanticipated exposure to
Fire and explosion
Noise
Energised electrical systems
Energised sources other than
electrical
7.5 Temperature extremes
7.6 Hazardous chemicals
7.7 Mechanical hazards
7.8 Storms or acts of nature
7.9 Adverse road conditions
7.10 Other (please specify)
8
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.6
Workplace layout
Congestion/workplace layout
Insufficient or excessive Illumination
Insufficient ventilation
Unprotected height
Inadequate workplace displays
Inadequate workplace ergonomics
Inadequate housekeeping
Slippery floors or walkways
Inadequate separation of vehicles
and people
Other (please specify)
POSSIBLE SYSTEM CAUSES
PERSONAL FACTORS
9
9.1
9.2
9.3
9.4
9.5
9.6
9.7
Physical
capabilities
Vision deficiency
Hearing deficiency
Other sensory
deficiency
Other permanent
physical disabilities
Substance
sensitivities or
allergies
Size or strength
limitations
Other (please
specify)
10
10.1
10.2
10.3
10.4
10.5
Colour key to references
Physical
condition
Previous injury
or illness
Fatigue
Diminished
performance
Impairment due
to drug, alcohol
or medication
Other (please
specify)
People
11 Mental capability
11.1 Memory failure
11.2 Poor co-ordination
or reaction time
11.3 Emotional status
11.4 Fears or phobias
11.5 Low mechanical
aptitude
11.6 Low learning
aptitude
11.7 Incorrect judgment
11.8 Other (please
specify)
Plant
JOB FACTORS
12 Mental stress
13 Behaviour
14 Skill level/
15 Training/
13.1 Antecedent not
12.1 Preoccupation with
competency
knowledge
problems
present
14.1 Assessment of
transfer
13.2 Antecedent not
12.2 Frustration
required skills or 15.1 No training
12.3 Confusing
effective
competency not
provided
directions/demands 13.3 Incorrect behaviour
effective
15.2 Training effort
12.4 Conflicting
reinforced
14.2 Practice of skill
not effective
directions/demands 13.4 Incorrect behaviour
not effective
15.3 Knowledge
not confronted
12.5 Extreme decision
14.3 No coaching on
transfer not
demands
13.5 Proper behaviour
skill
effective
12.6 Unusual
not rewarded
14.4 Infrequent
15.4 Training
13.6 Behavioural analysis
concentration or
performance of
materials not
perception
process not
skill
recalled
demands
effective
14.5 Other (please
15.5 Other (please
12.7 Other emotional
13.7 Other (please
specify)
specify)
overload
specify)
12.8 Other (please
specify)
Quality Tip
Once you have identified system causes, recognize you are likely not at
the root cause level. Continue to ask yourself and your investigation
team “why?” until you are satisfied you have exhausted all possibilities.
Process
Using the ‘5 Why’ technique is an effective way to drill deeper.
16
Management/supervision
/employee leadership
16.1 Incorrect reinforcement of
safe/unsafe behaviours
16.2 Participation in safety
efforts not effective
16.3 Consideration of safety in
staffing not effective
16.4 Resourcing for safety not
effective
16.5 Support of people not
effective
16.6 Monitoring/auditing of
safety process not effective
16.7 Lessons learned not
embedded
16.8 Leadership or
accountability
16.9 Employee involvement not
effective
16.10 Risk analysis or tolerance
not effective
16.11 Other (please specify)
17
17.1
17.2
17.3
17.4
17.5
17.6
17.7
Contractor
selection &
oversight
No contractor
prequalification
process
Contractor prequalification
process not
effective
Use of a nonapproved
contractor
Contractor
selection not
effective
No contractor job
oversight process
Contractor job
oversight process
not effective
Other (please
specify)
18 Engineering/ design
18.1 Technical design not
correct
18.2 Design standards,
specifications or
criteria not correct
18.3 Incorrect ergonomic
or human factor
design
18.4 Monitoring of
construction not
effective
18.5 Assessment of
operational readiness
not effective
18.6 Monitoring of initial
operation not
effective
18.7 Design risk analysis
not effective
18.8 Other (please specify)
19
19.1
19.2
19.3
19.4
19.5
19.6
19.7
Control of Work
(CoW)
No work planning
or risk assessment
performed
Risk assessment
not effective
Required permit
not obtained
Specified controls
not followed
Change in job
scope
Worksite not left
safe
Other (please
specify)
20
20.1
20.2
20.3
20.4
20.5
20.6
Purchasing,
material
handling &
material
control
Incorrect item
ordered
Incorrect item
received
Handling or
shipping not
effective
Storage of
materials not
effective
Labelling of
materials not
effective
Other (please
specify)
21
21.1
21.2
21.3
21.4
21.5
21.6
21.7
21.8
Tools & plant/
equipment
Wrong tools or plant/
equipment provided
Correct tools or plant/
equipment not
available
No pre-use inspection
Incorrect adjustment/
repair/ maintenance
Removal or replacement of unsuitable
items not effective
No preventative
maintenance
programme
Incorrect or no testing
of tools or plant/
equipment
Other (please specify)
22
22.1
22.2
22.3
22.4
22.5
22.6
Standards/
Practices/
Procedures (SPP)
Lack of SPP for the
task
Development of
SPP not effective
Communication of
SPP not effective
Implementation of
SPP not effective
Enforcement of
SPP not effective
Other (please
specify)
23 Communication
23.1 Horizontal
communication between
peers not effective
23.2 Vertical communication
between supervisor and
person not effective
23.3 Communication between
organizations not
effective
23.4 Communication between
work groups not effective
23.5 Communication between
shifts not effective
23.6 Communication not
received
23.7 Incorrect information
received
23.8 Information not
understood
23.9 Other (please specify)
CORRECTIVE ACTIONS
CORRECTIVE ACTIONS NEED TO…
ASSESS EXISTING BARRIERS…
TEST YOUR THOUGHT PROCESS…
- address or cover each cause listed.
- be S.M.A.R.T. : Specific-Measurable-Achievable-Relevant-Time-bound
- clearly identify responsibility for implementation.
- Understand each barrier (Safe System of Work) that was either in place, or
thought to be in place, prior to the incident.
- As part of your analysis, list each barrier and describe why it was ineffective.
- Propose corrective actions to fix or strengthen existing barriers before
recommending new ones.
- The investigation team must discuss and agree that if their corrective actions are properly implemented, they
will be sufficient to prevent recurrence. If not, you must strengthen them.
- There must be symmetry between the cause and the corrective action. For example, an engineering cause
must have an engineering corrective action and a behavioural cause must have a behavioural corrective
action. Behavioural issues must consider the organisational and cultural issues which enable that behaviour.
Quality Tip
This concept of symmetry should be your final
quality check before submitting your report. A
lack of symmetry between the cause and the
corrective action is inherently ineffective.
Quality Tip
Take care to properly develop each corrective
action statement. Refer to training materials for a
further discussion of the characteristics of
targeted, effective corrective actions.

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