Analisis de Causas PDF

Causal Analysis Tree Rev.
0
START
HERE
A1 Design / Engineering A2 Equipment / Material A3 Human PerformanceLTA A4 Management Problem A5 Communications LTA A6 Training Deficiency
Problem Problem
B1 MANAGEMENT METHODS B3 WORK ORGANIZATION & PLANNING LTA B1 NO TRAINING
B1 DESIGN INPUT LTA B1 CALIBRATION FOR B1 SKILL BASED ERROR B1 WRITTEN
C01 Check of work was LTA LTA C01 Insufficient time for worker to prepare task PROVIDED
C01 Design input cannot INSTRUMENTS LTA COMMUNICATIONS
C01 Management policy guidance/ C02 Insufficient time allotted for task C01 Decision not to train
be met C01 Calibration LTA C02 Step was omitted due to METHOD OF
expectations not well-defined, C03 Duties not well-distributed among personnel C02 Training requirements not
C02 Design input obsolete C02 Equipment found distraction PRESENTATION LTA
understood or enforced C04 Too few workers assigned to task identified
C03 Design input not outside acceptance criteria C03 Incorrect performance due to C01 Format deficiencies
C02 Job performance standards not C05 Insufficient number of trained or experienced workers C03 Work incorrectly
correct mental lapse C02 Improper referencing or
B2 PERIODIC / adequately defined assigned to task considered skill of the craft
C04 Necessary design C04 Infrequently performed steps branching
input not available CORRECTIVE were performed incorrectly C03 Management direction created C06 Planning not coordinated with inputs from C03 Checklist LTA
MAINTENANCE LTA B2 TRAINING METHODS
C05 Delay in time cause d LTA insufficient awareness of impact of Walk downs/ task analysis C04 Deficiencies in user aids LTA
B2 DESIGN OUTPUT LTA C01 Preventive actions actions on safety / reliability C07 Job scoping did not identify potential task interruptions (charts, etc.) C01 Practice or hands -on
C01 Design output scope maintenance for equipment C06 Wrong action selected based C04 Management follow-up or and / or environmental stress C05 Recent changes not made experience LTA
LTA LTA on similarity with other actions monitoring of activities did not C08 Job scoping did not identify special circumstances apparent to user
C02 Predictive maintenance C02 Testing LTA
C02 Design output not C07 Omission / repeating of steps identify problems and / or conditions C06 Instruction step / C03 Refresher training LTA
clear LTA due to assumptions for C05 Management assessment did not C09 Work planning not coordinated with all departments information in wrong
C03 Corrective C04 Inadequate presentation
C03 Design output not completion determine cause s of previous event or involved in task sequence
correct maintenance LTA known problem C10 Problem performing repetitive tasks and / or subtasks C07 Unclear / complex wording B3 TRAINING
C04 Inconsistent design C04 Equipment history B2 RULE BASED ERROR C06 Previous industry or in-house C11 Inadequate work package preparation or grammar MATERIAL LTA
output LTA C01 Strong rule incorrectly experience was not effectively used C01 Training objectives LTA
B4 SUPERVISORY METHODS LTA B2 WRITTEN
C05 Design input not chosen over other rules to prevent recurrence C02 Inadequate content
B3 INSPECTION / TESTING C01 Tasks and individual accountability not made clear to COMMUNICATION
addressed in design output C02 Signs to stop were ignored C07 Responsibility of personnel not C03 Training on new work
LTA worker CONTENT LTA
C06 Drawing, and step performed incorrectly well-defined or personnel not held methods LTA
C01 Start-up testing LTA C02 Progress / status of task not adequately tracked C01 Limit inaccuracies
specification, or data error C03 Too much activity was accountable C04 Performance standards
C02 Inspection / testing LTA C03 Appropriate level of in-task supervision not determined C02 Difficult to implement
C07 Error in equipment or occurring and error made in C08 Corrective action responses to a LTA
C03 Post-maintenance / Post- prior to task C03 Data / computations
material selection problem solving known or repetitive problem was
modification testing LTA C04 Direct supervisory involvement in task interfered with wrong / incomplete
C08 Errors not detectable C04 Previous success in use of untimely
rule reinforce d continued use of
overview role C04 Equipment identification A7 Other Problem
C09 Errors not recoverable B4 MATERIAL CONTROL C09 Corrective action for previously C05 Emphasis on schedule exceeded emphasis on LTA
LTA rule identified problem or event was not
B3 DESIGN / methods / doing a good job C05 Ambiguous instructions / B1 EXTERNAL PHENOMENA
C01 Material handling LTA C05 Situation incorrectly adequate to prevent recurrence
DOCUMENTATION LTA C06 Job performance and self-checking standards not requirements C01 Weather or ambient conditions LTA
C02 Material storage LTA identified or represented result ing
C01 Design / documentation B2 RESOURCE MANAGEMENT properly communicated C06 Typographical error C02 Power failure or transient
C03 Material packaging in wrong rule used
not complete LTA C07 Too many concurrent tasks assigned to worker C07 Facts wrong / requirements C03 External fire or explosion
LTA
C02 Design / documentation B3 KNOWLEDGE BASED C01 Too many administrative duties C08 Frequent job or task shuffling not correct C04 Other natural phenomena LTA
C04 Material shipping LTA
not up-to-date ERROR assigned to immediate supervisor C09 Assignment did not consider workers need to use C08 Incomplete / situation not
C05 Shelf life exceeded
C03 Design / documentation C01 Attention was given to wrong C02 Insufficient supervisory resources higher-order skills covered B2 RADIOLOGICAL / HAZARDOUS
C06 Unauthorized material
not controlled issues to provide necessary supervision C10 Assignment did not consider workers previous task C09 Wrong revision used MATERIAL PROBLEM
substitution
C02 LTA Conclusion based on C03 Insufficient manpower to support C11 Assignment did not consider workers ingrained work C01 Legacy contamination
C07 Marking / labeling LTA B3 WRITTEN
B4 DESIGN / sequencing of facts identified goal / objective patterns C02 Source unknown
INSTALLATION B5 PROCUREMENT C03 Individual justifie d action by C04 Resources not provided to assure C12 Contact with personnel too infrequent to detect work COMMUNICATION
VERIFICATION LTA CONTROL LTA focusing on biased evidence adequate training was provided / habit/attitude changes NOT USED
C01 Independent review of C01 Control of changes to C04 LTA review based on maintained C13 Provided feedback on negative performance but not on C01 Lack of written
design / documentation procurement specifications / assumption that process will not C05 Needed resource changes not positive performance communication
LTA purchase order LTA change approved / funded C02 Not available or Level A nodes are
B5 CHANGE MANAGEMENT LTA inconvenient for use
C02 Testing of design / C02 Fabricated item did C05 Incorrect assumption that a C06 Means not provided to assure underlined.
installation LTA not meet requirements correlation existed between two or procedures / documents / records were C01 Problem identification did not identify need for change
C03 Independent C03 Incorrect item received of adequate quality and up -to-date C02 Change not implemented in timely manner
B4 VERBAL Level B nodes are in
more facts COMMUNICATION LTA
inspection of design / C04 Product acceptance C06 Individual underestimated the C07 Means not provided for assuring C03 Inadequate vendor support of change
C01 Communication between
ALLCAPS.
installation LTA requirements LTA problem by using past events as adequate availability of appropriate C04 Risks / consequences associated with change not Level C nodes are in
work groups LTA
C04 Acceptance of basis materials / tools adequately reviewed / assessed
design / installation LTA B6 DEFECTIVE, FAILED C08 Means not provided for assuring C05 System interactions not considered
C02 Shift communications sentence case.
OR CONTAMINATED LTA
B4 WORK PRACTICES LTA adequate equipment quality, C06 Personnel / department interactions not considered
C03 Correct terminology not
LTA = Less than adequate
B5 OPERABILITY C01 Defective or failed part C01 Individual s capability to reliability, or operability C07 Effects of change on schedules not adequately addressed
C02 Defective or failed used
OF DESIGN / perform work LTA [Examples C09 Personnel selection did not assure C08 Change-related training / retraining not performed or not
ENVIRONMENT LTA material C04 Verification / repeat back
include: Sensory / perceptual match of worker motivations / job adequate
C01 Ergonomics LTA C03 Defective weld, braze not used
capabilities LTA, Motor / physical descriptions C09 Change-related documents not developed or revised
or soldering joint C05 Information sent but not
C02 Physical environment capabilities LTA, and Attitude / C10 Means / method not provided for C10 Change-related equipment not provided or not revised
LTA C04 End of life failure understood
psychological profile LTA.] assuring adequate quality of contract C11 Changes not adequately communicated
C05 Electrical or instrument C06 Suspected problems not
C03 Natural environment C02 Deliberate violation services C12 Change not identifiable during task
LTA noise communicated to supervision
C13 Accuracy / effectiveness of change not verified or not
C06 Contaminant C07 No communication
validated
method available

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