FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 25
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
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
Low risk perception
/ acceptable risk
Inadequate
Leadership
commitment
Common practice
Skilled trade
Complacency
Overconfidence
No incidents
Organization
perceives as safe
Inadequate
Leadership
APPENDIX 3
FISHBONE DIAGRAM | CULTURE
LEGEND:
CULTURE
