FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 12
APPENDIX 1
PRIMARY CASUAL FACTORS
TOOLS AND MACHINES:
LOTO point not accessible
Inadequate LOTO device
LOTO point not identified
Inadequate LOTO point
Inadequate LOTO placard at machine
Multiple LOTO points
LOTO points not maintained (defective)
ENVIRONMENT:
Rushing
Remote area/size of facility
Dust
Inadequate awareness signage
Extreme temperature
CULTURE:
Skilled trade
Organizational structure
Low risk perception/acceptance of risk
Fear
Live work
Inadequate leadership commitment
PEOPLE:
Unfit for duty
Fatigue
Contractors
Procedures not followed
Mental Health
Temporary workers
PROCESSES:
Lack of procedures (program)
Inadequate procedures
Inadequate risk assessment
Unidentified roles & responsibilities
Inadequate training
Inadequate monitoring/enforcement
MEASURES:
Inadequate metrics (production rate,
downtime, financial growth)
Inadequate LOTO Metrics
