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ACCIDENT/INCIDENT ROOT CAUSE ANALYSIS: Date: Inc. Rep. No.

:
26-4-2011

Site: HLPE Site Jubail, KSA Incident Title: Unloading steel material from flatbed trailer 26-4-2011

KEY BEHAVIOURAL INDICES Inadequacies HAZARDOUS CONDITIONS Inadequacies


Operating Equipment without authority Inadequate guards or barriers
Failure to Warn Inadequate or improper PPE
Failure to Secure Defective tools, equipment or
materials
Operating at improper speed Congestion or restricted access
Making safety devices inoperable Inadequate warning system
Removing Safety Devices Fire & Explosion hazards
Using Defective Equipment Poor Housekeeping; disorder
Using equipment improperly No apreciation of dnamic shifting Hazardous environmental conditions
Failure to use PPE properly Noise exposures
Improper loading Improper unloading Radiation exposures Very hot day 40 deg C
Improper placement High/low temperature exposures
Improper lifting Inadequate or excess illumination
Improper position for task Yes should have been to one side Inadequate ventilation
Servicing equipment in operation No lockout/tagouts
Horseplay No Permit to Work
Under influence of alcohol/drugs Fall hazard
Behavioral / Personal Factors Inadequacies Job / Equipment Factors Inadequacies
No Safety Observations Conducted No Plant Risk Assessment conducted
Lack of skill Inadequate maintenance system
Lack of knowledge Inadequate engineering controls
Inadequate capability (physical) No Procedures Not for this specific task
Improper motivation Inadequate purchasing
Inadequate leadership/supervision No foreman or supervisor present Inadequate tools/equipment
Stress/morale Hot temperature Inadequate work standards
Abuse/misuse Inadequate design/labelling/signage
Lack of incentive to work safely Not under supervision Inadequate Inspections
Physiological deficiency Poor Records/Document Control
Improper attempt to save time Inadequate Training Yes must be improved
Communication (English skills) Lack of comms.amongst workers and Inadequate Emergency Systems/PPE
supervisory staff (in any language)
System Failures Recommendations System Failures Recommendations
Inadequate leadership/supervision yes Inadequate work standards Tool box and tarining to be given
Inadequate design/labelling/signage

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