FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 26
APPENDIX 3
FISHBONE DIAGRAM | ENVIRONMENT
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
Affected worker
(unauthorized)
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
Inadequate
planning
Rushing
LEGEND:
ENVIRONMENT
