FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 22
APPENDIX 3
FISHBONE DIAGRAM | TOOLS AND MACHINES
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
LOTO device
LEGEND:
TOOLS & MACHINES
