Causal factors analysis

The allocation of ‘causal factors’ to fatal incidents and high potential events was requested for the 2011 data reported to OGP. This request was first made in 2010, therefore, a comparison of two years of data is possible.

A list of causal factors and their descriptions were supplied to those providing data for this document to ensure stand-ardised responses.

The causal factors list is divided into two sections:

• People (acts) classifications usually involve either the actions of a person or actions which were required but not carried out or were incorrectly performed. There are four major categories of actions, with an additional level of detail under each of the major categories.

• Process (conditions) classifications usually involve some type of physical hazard or organisational aspect out of the control of the individual. There are five major clas-sification categories, with an additional level of detail under each of the major categories.

The causal factors assigned to fatal incidents are shown below. The highlighted content indicates the top 10 causal factors assigned to fatal incidents in 2011 compared to 2010; eight of the ten were the same for both years.

Additional information on the fatal incidents reported by region can be found on the OGP Safety Zone website:

http://info.ogp.org.uk/Safety/. The information provided includes a narrative description of the incident, the corrective actions and recommendations and the causal factors assigned by the reporting company.

• 42 of the 50 fatal incidents reported were assigned causal factors (51 of 58 in 2010)

• 203 causal factors were assigned for the 50 fatal inci-dents

ê81 were People (Aacts) (109 in 2010) ê122 were Process (conditions) (133 in 2010)

• Between 1 and 12 causal factors were assigned per inci-dent (1 to 18 in 2010)

2.11.1 Fatal Incident Causal Factors

Causal factors assigned for fatal incidents 2011 2010

Process (conditions): Organisational: Inadequate supervision 18 18

People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment 16 14 Process (conditions): Organisational: Inadequate hazard identification or risk assessment 15 30 Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers 11 7

Process (conditions): Organisational: Inadequate training/competence 10 13

Process (conditions): Organisational: Inadequate communication 9 12

People (acts): Following Procedures: Violation unintentional (by individual or group) 9 12

People (acts): Following Procedures: Improper position (in the line of fire) 9 16

People (acts): Use of Protective Methods: Failure to warn of hazard 8 7

Process (conditions): Organisational: Inadequate work standards/procedures 8 10

Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads 7 1 People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress 7 5 People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly 6 1 People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/materials/

products 6 9

Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing 6 4 Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices 6 5 Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of change 5 10 Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/products 5 4

Process (conditions): Work Place Hazards: Storms or acts of nature 5 2

Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment 5 0

People (acts): Use of Protective Methods: Equipment or materials not secured 4 6

People (acts): Use of Protective Methods: Inadequate use of safety systems 4 5

People (acts): Following Procedures: Violation intentional (by individual or group) 4 12

Process (conditions): Organisational: Poor leadership/organisational culture 4 9

Process (conditions): Work Place Hazards: Congestion, clutter or restricted motion 4 2 Process (conditions): Protective Systems: Inadequate security provisions or systems 2 2

People (acts): Following Procedures: Work or motion at improper speed 2 0

People (acts): Following Procedures: Improper lifting or loading 2 8

People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices 2 2

People (acts): Inattention/Lack of Awareness: Acts of violence 1 6

People (acts): Inattention/Lack of Awareness: Fatigue 1 0

Process (conditions): Work Place Hazards: Hazardous atmosphere (explosive/toxic/asphyxiant) 1 1

Process (conditions): Organisational: Failure to report/learn from events 1 3

People (acts): Following Procedures: Overexertion or improper position/posture for task 0 3 People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate energy

isolation 0 3

• 69 of the 76 high potential incidents were assigned causal factors (97 of 98 in 2010)

• 317 causal factors were assigned for the 76 high poten-tial events (400 in 2010)

ê131 were People (Acts) (134 in 2010) ê186 were Process (Conditions) (266 in 2010)

• Between 1 and 19 causal factors were assigned per event (1 to 11 in 2010)

2.11.2 High Potential Event Causal Factors

Causal Factors assigned for high potential events 2011 2010

Process (conditions): Organisational: Inadequate hazard identification or risk assessment 24 47 People (acts): Inattention/Lack of Awareness: Improper decision making or lack of judgment 21 23

Process (conditions): Organisational: Inadequate work standards/procedures 20 37

Process (conditions): Organisational: Inadequate supervision 18 31

Process (conditions): Tools, Equipment, Materials & Products: Inadequate design/specification/management of change 18 13 People (acts): Use of Tools, Equipment, Materials and Products: Improper use/position of tools/equipment/materials/

products 17 9

People (acts): Following Procedures: Violation unintentional (by individual or group) 15 27

Process (conditions): Organisational: Inadequate communication 15 19

Process (conditions): Organisational: Inadequate training/competence 15 22

Process (conditions): Protective Systems: Inadequate/defective warning systems/safety devices 15 13

People (acts): Use of Protective Methods: Failure to warn of hazard 13 9

Process (conditions): Tools, Equipment, Materials & Products: Inadequate/defective tools/equipment/materials/products 13 16

People (acts): Use of Protective Methods: Inadequate use of safety systems 12 2

Process (conditions): Tools, Equipment, Materials & Products: Inadequate maintenance/inspection/testing 12 21

People (acts): Following Procedures: Improper lifting or loading 9 5

People (acts): Use of Protective Methods: Equipment or materials not secured 9 3

Process (conditions): Organisational: Poor leadership/organisational culture 9 15

Process (conditions): Protective Systems: Inadequate/defective guards or protective barriers 9 10 People (acts): Inattention/Lack of Awareness: Lack of attention/distracted by other concerns/stress 8 15 People (acts): Following Procedures: Violation intentional (by individual or group) 6 9 Process (conditions): Work Place Hazards: Hazardous atmosphere (explosive/toxic/asphyxiant) 5 6

People (acts): Inattention/Lack of Awareness: Fatigue 4 4

People (acts): Following Procedures: Improper position (in the line of fire) 3 9

People (acts): Following Procedures: Work or motion at improper speed 3 3

People (acts): Use of Protective Methods: Disabled or removed guards, warning systems or safety devices 3 1 People (acts): Use of Protective Methods: Personal Protective Equipment not used or used improperly 3 6 People (acts): Use of Tools, Equipment, Materials and Products: Servicing of energized equipment/inadequate energy

isolation 3 6

Process (conditions): Protective Systems: Inadequate security provisions or systems 3 1 Process (conditions): Work Place Hazards: Congestion, clutter or restricted motion 3 3

Process (conditions): Organisational: Failure to report/learn from events 2 4

Process (conditions): Work Place Hazards: Inadequate surfaces, floors, walkways or roads 2 5

Process (conditions): Work Place Hazards: Storms or acts of nature 2 0

People (acts): Following Procedures: Overexertion or improper position/posture for task 1 3

People (acts): Inattention/Lack of Awareness: Acts of violence 1 0

Process (conditions): Protective Systems: Inadequate/defective Personal Protective Equipment 1 3

The causal factors assigned to fatal incidents are shown below. The highlighted content indicates the top 10 causal factors assigned to fatal incidents in 2011 compared to 2010, seven of the ten were the same for both years.

Note: the top 11 causal factors have been shown for 2010, as two of the causal factors were each assigned 15 times.

Additional information on high potential events reported by region can be found on the OGP Safety Zone website:

http://info.ogp.org.uk/Safety/. The information provided includes a narrative description of the event, the corrective actions and recommendations, and the causal factors assigned by the reporting company.