Corporate

FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 21 APPENDIX 3 FISHBONE DIAGRAM | FULL FISHBONE DIAGRAM Affected worker (unauthorized) Inadequate leadership commitment Inadequate contractor management 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 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 Not our WSIB premium 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 Liability not perceived 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 Production valued over safety Safety not integrated into production Production KPIs, targets, quotas Staff performance Bonuses Career advancement Inadequate LOTO specific metrics Training effectiveness LOTO compliance (audits) Near misses / incidents Equipment issues Inadequate monitoring & evaluation Competing KPIs Low perception of risk Time to enter / analyse Remote area / size of facility Dust Inadequate awareness signage End of shift (cleaning) Inadequate maintenance Inadequate changeover time High speed production Short-staffed Jams / blockages Quick fix Leave at end of shift Inadequate time Procrastination Overwhelmed Inadequate process Production pressure Production output Quick reaction Causes unaddressed Low risk perception Routine (non) Delayed authorized worker Production pressure Not reported short-staffed Location / access to LOTO point LOTO device not at point of use LOTO involving multiple workers Distant from machine Inadequate planning Communication barriers Facility / equipment design Exposure Access to LOTO point Inadequate maintenance of LOTO point Inadequate preventive maintenance Extreme temperature Thermal LOTO takes too long Skilled trade Complacency Overconfidence No incidents Organization perceives as safe Organizational structure New business Large corporation Small / family owned Production valued over safety Inadequate knowledge Inadequate resources Production valued over safety Information /resources not readily available Inadequate Leadership Fear Live work Risk not appreciated Underreporting of LOTO issues Quick fix Overconfidence Increased effort causes increased risk acceptance No LOTO incidents Complacency Practicality Workers (reprisal, embarassed) Increased with Temp workers Inadequate supervision Worker may leave for another workplace Worker may file harassment complaint Convenient Perception of only option Minor maintenance Troubleshooting Overconfidence Food safety requirement Reliance on other safeguarding devices Inadequate risk assessment for alternate measures Influence on organizational values Imbalanced priority Not utilizing system incentives (HSEP) Don't appreciate / understand legal requirements Inadequate training Perceived cost / benefit Inadequate metrics Not measuring rates Unsure of benchmark comparison Inadequate time / resources Cost outweighs benefits Not LOTO specific Inadequate planning Hectic workplace Procedure not followed Rushing Low risk perception / acceptable risk Inadequate Leadership commitment Lack of procedures (program) Inadequate knowledge Inadequate knowledge of requirement Everyone knows (oral) Change management Specific tasks unidentified Always that way Inadequate experience New to role Right people not included Cannot verify (show me) Complacency Group think LOTO need unidentified Inadequate risk assessment Inadequate procedure Unidentified roles & responsibilities Inadequate training Inadequate monitoring / enforcement No progressive discipline Not measured (KPIs) Inadequate supervision (overwhelmed) Fear staff may leave Perceived value Too many employees / space too large Inadequate training Economic issues short-staffed Inadequate knowledge transfer Logistics Applicability Inadequate content Complacency Mental health Inadequate Leadership Common practice Inadequate time spent Inadequate trainer Assume abilities Undefined skills Not expert Inadequate recruiting Theory only Generic Internal vs external Language Inadequate environment Information overload Inadequate verification Inadequate time / resources Not required Inadequate feedback Inadequate contractor communication (scope changes) Contractor coordinating with organization (oversight) Inadequate knowledge No legal requirement Competing risk consideration (food safety) Inadequate leadership Generic (not machine specific) Misunderstood Not in plain / common language No photos Missing steps All energies not identified LOTO devices not included Inadequate implementation LOTO point not maintained (defective) Inadequate preventive maintenance Inadequate LOTO point LOTO point not accessible LOTO point not identified Inadequate LOTO placard at machine Multiple LOTO points LOTO wrong point LOTO point not identified Stress / rushing / no verification Inadequate resources Inadequate LOTO Not legible / understood Not conspicuous Functional needs not assessed Language barrier Dirty / old Inadequate preventive maintenance Live work Complacency / overconfidence Reliance on other safeguarding devices Inadequate knowledge Unable to do partial LOTO LOTO point in electrical room Restricted / blocked Unlabeled panel Single LOTO point for multiple machines (electrical panel) Remove fuse to LOTO machine Functional needs not assessed Complacency / overconfidence Inadequate LOTO Inadequate knowledge Live work Reliance on other safeguarding devices Not at point of use Not compatible Missing / broken Functional needs not assessed Too many / uncontrolled keys Typically issued Not to safety standards Inadequate storage Inadequate preventive maintenance Inadequate knowledge Purchasing Change management Large distance between LOTO points Out of reach No LOTO point at machine (remote) Barriers to access (items in way) Inappropriate design / modification Layout / installation (floor plan, material storage) No defined design standard requirement Functional needs not assessed Inadequate housekeeping Inadequate PSR Change management Purchasing Inadequate knowledge Doesn't address LOTO Inadequate process Cost LEGEND KPI: Key performance indicator LOTO: Lock Out Tag Out PSR: Pre-Start Health and Safety Review Root causes: Primary cause Tertiary cause Quaternary cause Quintenary cause Secondary cause Top primary cause LEGEND KPI: Key performance indicator LOTO: Lock Out Tag Out PSR: Pre-Start Health and Safety Review Root causes: Primary cause Tertiary cause Quaternary cause Quintenary cause Secondary cause Top primary cause Not available Inadequate metrics (production rate, downtime, financial growth) Inadequate LOTO device PEOPLE PROCESS TOOLS AND MACHINES ENVIRONMENT CULTURE LEGEND:E MEASURES

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