FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 9
ROOT CAUSE ANALYSIS WORKSHOP
DAY 2
On Day 2 of the workshop, the results of the voting were shared with all participants who then discussed
possible solutions and controls for the top 10 identified primary causal factors.
LIST OF TOP PRIMARY CAUSAL FACTORS
PRIORITY CATEGORY PRIMARY CASUAL FACTOR AVERAGE
1 Culture
Leadership commitment 6.6
2 Processes
Lack of procedures (program) 6.525
3 People
Inadequate training 6.35
4 Culture
Low risk perception/acceptance of risk 6.25
5 Environment
Rushing 6.225
6 People
Procedures not followed 6.1
7
Process
Inadequate monitoring and enforcement 6.025
Culture
Inadequate LOTO devices 6.025
8 Tools & Machines
Lockout point not accessible 6
9 Processes
Inadequate Procedure 5.975
10 Measures
Inadequate metrics (production rate, downtime,
financial growth)
5.85
11 Tools & Machines
LOTO point not identified 5.65
Note: Due to ties in the formal voting process and changes in votes during validation, the list consists of
more than 10 items.
Note: Score is out of seven as per the voting scale (page 7).
Respective recommended solutions and controls for each primary causal factor can be accessed through
the hyperlinks in the table above. A full list of recommendations and controls can be found in Appendix 2.
