FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 6
Failure to control hazardous energy,
such as Inadequate LOTO of equipment,
can have serious consequences for
workers, organizations and the
supporting community.
Temp workers
Mental health
Contractors
Fatigue
Unfit for duty
Inadequate LOTO specific metrics
Remote area / size of facility
Dust
Inadequate awareness signage
Extreme temperature
Skilled trade
Organizational structure
Fear
Live work
Procedure not followed
Rushing
Low risk perception / acceptable risk
Inadequate Leadership commitment
Lack of procedures (program)
Inadequate risk
assessment
Inadequate procedure
Unidentified roles & responsibilities
Inadequate training
Inadequate monitoring / enforcement
LOTO point not maintained (defective)
Inadequate LOTO point
LOTO point not accessible
LOTO point not identified
Inadequate LOTO placard at machine
Multiple LOTO points
LEGEND
LOTO: Lock Out Tag Out
Primary cause
Top primary cause
LEGEND
LOTO: Lock Out Tag Out
Primary cause
Top primary cause
Inadequate metrics
(production rate, downtime,
financial growth)
Inadequate LOTO device
PEOPLE
TOOLS & MACHINES
The subject matter experts identified 32 primary causal factors, as depicted in the fishbone diagram below and listed in Appendix 1.
ENVIRONMENT CULTURE
MEASURES
PROCESS
LEGEND:
