1. RCAF
Contractor Training T
First Tool In LPS

2. Organizational Factors
Questionable Item,
Near Loss, Loss Occurs
WHY?
Personal Factors
External Factors
Organizational Factors

3. Root Cause Analysis Flowchart (RCAF)
Questionable Item, Near Loss, Loss Occurs WHY?
Personal Factors
Organizational Factors
8. External Factors
Did not follow procedures or
acceptable practices because . . .
5. Lack of or inadequate procedures
6. Inadequate communication of
expectations regarding procedures
or acceptable practices.
1. Lack of skill or knowledge
2. Doing the job according to procedures or acceptable practices takes more time/effort
7. Inadequate tools or equipment
3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated
4. In past, did not follow procedures or acceptable practices and no incident occurred
(injury, product quality incident, equip damage, regulatory
assessment or production delay).
Development of solutions
Implementation of solutions
Verification and validation of solutions

4. When to Use RCAF JHA and SAI Level 3’s Observations and Walkthroughs
Near Loss Incidents (NLIs) when IRAT <400
Loss Incidents when IRAT <400

5. STEP #1 - Use 5-Why Process to Identify Logical Root Causes
Questionable Item,
Near Loss, Loss Occurs
WHY?
Root Causes
Incident: Worker’s hand was cut by a fan on running rig welder

6. Organizational Factors
STEP #2 – Use RCAF Flowchart to Determine Factors
Questionable Item,
Near Loss, Loss Occurs
WHY?
Personal Factors
External Factors
Organizational Factors
Because we didn’t have an inspection checklist to verify that rig welders’ equipment is in safe operating condition before being allowed into the plant.

7. Factors and Solutions Flowchart
Personal Factors
Did not follow procedures or
acceptable practices because . . .
In past, did not follow procedures or acceptable practices and no incident occurred
(injury, product quality incident, equipment damage,
regulatory assessment or production delay).
Doing the job according to procedures or acceptable practices takes more time/effort.
Short-cutting procedures or acceptable practices is positively reinforced or tolerated.
Lack of skill
or knowledge

8. Factors and Solutions Flowchart
Lack of or inadequate procedures
Inadequate tools or equipment (available, operable &
safely maintained; proper task & workplace design)
Inadequate communication of expectations
regarding procedures or acceptable practices
Development of solutions
Implementation of solutions
Organizational Factors
External Factors
Verification and validation of solutions

9. STEP #3 – Develop Solutions to Address Factor
Factor Identified
Solution(s)
Develop procedure with checklist form to inspect all rig welders as they come into the plant to ensure they are in safe working condition before being sent to the jobsite
Communicate new procedure to the affected workforce
Train personnel that will be performing the inspections
STEP #4 – Implement Solutions
Track solutions to completion, ensure they are implemented in agreed upon timeframe
STEP #5 – Verify and Validate Solutions
Must verify that the Solution(s) worked. Test it to be sure it is fully implemented and doing what it was supposed to do.

10. Decision Support Tools Personal Factors
1 - Lack of Skill or Knowledge
Training not conducted or not available
Worker missed required training
Training completed but not understood (no validation)
Task completed/attempted by unqualified worker
Training inadequate or ineffective
Training not required but is necessary to do job properly
2 - Doing the job according to accepted practice takes more time/effort
Worker took unapproved shortcut in order to save time or effort
PPE available but not utilized in order to save time, make task simpler, or for worker comfort
Work team(s) did not adequately discuss job roles or requirements in an effort to save time (includes shift turnover)
Worker(s) did not prepare for task in order to save time (includes LPSA, SJHA's, Daily Addendum, Permits, Safety standards, other work planning)
3 - Deviating from accepted practices is reinforced or tolerated (short cutting)
Supervisor implied need for shortcut
Supervisor or peer influence for "friendly competition" including the use of shortcuts or deviations from procedures
Inadequate reinforcement or compliance with policy or procedure by the supervisor, even though management expectations are clear
Inadequate verification of proper use of policy or procedure by supervisor (management presence in the field)
Required job supervision and/or intervention not provided
Supervisor allowed unqualified or impaired worker(s) to perform task, despite indications of worker deficiencies
4 - Past deviations from procedures or acceptable practices produced no negative results
SPSA not performed regularly
Procedures and/or work standards not consulted regularly
Job habits/common practices have deviated from procedures or acceptable standards
Routine task performed without prior planning or preparation
SHE risks, and decision to not minimize them, were understood and accepted by worker(s)
Worker(s) knowingly deviated from accepted practice based on similar instances in the past that yielded favorable results

11. Decision Support Tools Operational /External Factors
5 - Lack of/or inadequate Procedures/Policies
Policy/Procedure is needed; but does not exist or is not available
Policy/Procedure not required; but should be
Policy/Procedure not updated when changes made
Policy/Procedure content does not address hazards leading to incident
Policy/Procedure is confusing, incomplete, or incorrect
Policy/Procedure contains errors (sequence wrong, typos, wrong calculations/conversions, wrong names/identifications…)
No way to implement Policy/Procedure as written
Policy/Procedure creates unnecessary risks, difficulties, or inefficiencies (ergonomics, fatigue, repetition, etc.)
6 - Inadequate Communication of Critical Information or Expectations
Inadequate communication of expectations by management
Management actions appear to contradict stated expectations
New or modified Policy/Procedure or job standard not received by worker (not communicated by management or central staff)
Special task requirements (procedure, SJHA, work permit, PPE, etc.) identified, but not communicated to workers
Inadequate communication between work teams or key individuals
Communications incorrect or misunderstood
7 - Inadequate Tools, Equipment, Facilities
Correct tools, equipment, or PPE not available or inadequate (includes communication equipment)
Inadequate human/machine interface (alarms,displays,controls,layout)
Labeling, signs, or identification non-existent or incorrect
Inadequate work environment (lights, noise, housekeeping, barriers)
Ergonomics of task need improvement (excessive physical activity,etc)
Task too complex (too many actions or decisions required))
Inadequate design or specification of equipment for purpose
Defective equipment fabrication/construction
Equipment damaged prior to installation/use
Wrong equipment ordered or installed
Inadequate inspection and/or preventive maintenance
Hazards or errors not detectable prior to incident
Equipment repaired, but failure repeated
Fault identified but not yet repaired
8 - External Factors
Natural disaster
Act of vandalism
War/Sabotage
Other

12. What is the Root Cause & Factor?
Incident: Worker was observed running impact w/o a faceshield
Using the 5-Why Process it was determined that:
Worker had started task with faceshield on
He was in a very tight congested area
When he repositioned his body, the faceshield was knocked off and fell 30’ to grade
He had less than a minute left to finish tightening one nut and the task was complete
Incident: Worker was observed transitioning w/o maintaining 100% tie-off
Using the 5-Why Process it was determined that:
Job had been in progress for ~ 2hours
Worker had all proper fall arrest equipment on, dismantling scaffold
Workcrew was on the next to last level, they had already dismantled 3 levels
When moving on the same level the worker often moved w/o 100% tie-off
The Crew’s Foreman had been on the jobsite all morning observing the work

13. Root Cause Analysis Flowchart (RCAF)
Questionable Item, Near Loss, Loss Occurs WHY?
Personal Factors
Organizational Factors
8. External Factors
Did not follow procedures or
acceptable practices because . . .
5. Lack of or inadequate procedures
6. Inadequate communication of
expectations regarding procedures
or acceptable practices.
1. Lack of skill or knowledge
2. Doing the job according to procedures or acceptable practices takes more time/effort
7. Inadequate tools or equipment
3. Short-cutting procedures or acceptable practices is positively reinforced or tolerated
4. In past, did not follow procedures or acceptable practices and no incident occurred
(injury, product quality incident, equip damage, regulatory
assessment or production delay).
Development of solutions
Implementation of solutions
Verification and validation of solutions