TABLE OF CONTENTS
Introduction and Background....................................................................3
Risk Assessment Workshop .......................................................................3
Root Cause Analysis Workshop Day 1 | Lockout/Tag Out............. 4
The Root-Cause Workshop Fishbone Exercise ...................................5
Primary Causal Factors Voting ..................................................................7
Management and Worker Voting Results .............................................7
Root Cause Analysis Workshop | Day 2 ............................................... 9
List of Top Primary Causal Factors ......................................................... 9
Final Workshop Industry Recommendations and Conclusions ..10
Appendix 1: Primary Causal Factors ..................................................... 12
Appendix 2: Controls/Solutions for Top Primary
Causal Factors ............................................................................................... 13
Appendix 3: Fishbone Diagrams ............................................................ 21
Appendix 4: The Swiss Cheese Model of Accident Causation .. 28
