FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 23
APPENDIX 3
FISHBONE DIAGRAM | PROCESSES
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
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 (2 way)
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
LEGEND
LOTO: Lock Out Tag Out
Root causes:
Primary cause
Tertiary cause
Quaternary cause
Quintenary cause
Secondary cause
Top primary cause
LEGEND
LOTO: Lock Out Tag Out
Root causes:
Primary cause
Tertiary cause
Quaternary cause
Quintenary cause
Secondary cause
Top primary cause
LEGEND:
PROCESS
