FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 24
APPENDIX 3
FISHBONE DIAGRAM | PEOPLE
LEGEND
Root causes:
Primary cause
Tertiary cause
Quaternary cause
Quintenary cause
Secondary cause
Top primary cause
LEGEND
Root causes:
Primary cause
Tertiary cause
Quaternary cause
Quintenary cause
Secondary cause
Top primary cause
Temp
workers
Mental health
Contractors
Fatigue
Unfit for duty
Inadequate
training
Agency selection
Misinformation
task / duties
Perform tasks untrained for
No follow up from agency
Lower cost for labourer
Language barrier
Assumed agency trained (generic)
Don't want to invest
Short term
Not responsible
Occupational stress
Personal stress
Pandemic
Burnout
Essential worker
Rapid / drastic changes
Unclear reporting structure
Speed of line
New worker
Production pressure
Inadequate procedure & devices
Inadequate enforcement / supervision
Keep line running
Company procedure
not followed
Assume contractor
competency
Inadequate
monitoring
Different person
every time
Subcontracted
Off hours
Assumptions
Long hours
Shift work
Night
Rotational
Short-staffed (absenteeism)
Collective agreement requirement
Inadequate time management policy
Family issues
Medical issues
Distracted
Drugs & alcohol
Two jobs
Hectic workplace
Procedure not followed
Complacency
Mental health
Liability not
perceived
Inadequate
contractor
management
LEGEND:
PEOPLE
