FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 27
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
Inadequate
leadership
commitment
Production valued
over safety
Safety not integrated
into production
Production
KPIs, targets,
quotas
Staff performance
Bonuses
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
Inadequate
metrics
(production rate,
downtime,
financial growth)
APPENDIX 3
FISHBONE DIAGRAM | MEASURES
LEGEND:
MEASURES
