Corporate

32 Lack of process to measure Near misses are not reported Don't understand what a near miss is Fear of reprisal culture Lack of refresher training Employer doesn't invest/not interested in knowing Cost to implement/ maintain Lack of resources (money, time, people) Supervisor ignores/ doesn't resolve the complaint Workers lost trust Inconsistent buy-ins for each location Different priority due to products Job rotation or job variance LEGEND Root causes: Primary cause Tertiary cause Quaternary cause Quintenary cause Secondary cause Top primary cause Operating in silos Reactive process instead of proactive (design) Inconsistent implementation Reporting (severity differs) Subjective nature of pain (qualitative) Specialized skill sets Time for training Increase exposure to other hazards Mandatory certification Lack of cross training Seniority Lack of effective rotation No other tasks available Business operation design Understaffed Too complex to implement rotation Pay differences Maximize efficiency Lack of job variety at the workplace Personal choice Age/seniority Inadequate training Lack of training Poor quality Inconsistent implementati on of training Cost Risk not evaluated Lack of internal expertise Lack of priority No audit/ evaluation Training design flow Ineffective/ inactive JHSC Outdated training method/ system Lack of system information resources Inconsistent trainer qualification Lack of industry standards Inadequate supervision Lack of training Lack of resources Not held accountable Emphasis on production over safety High turnover of supervisors High turnover of supervisors Not part of KPI or individual performance Lack of management of change program Lack of understanding Varying risk acceptance Lack of KPIs Time consuming exercise Resource heavy process (time+people+$$) Delays operations Working in silos with different priorities

• Slide Number 1
• Disclaimer
• Table of Contents
• RA RCA project overview
• Introduction
• Industry Selection
• A Bipartite and Collective Process
• Risk Assessment Workshop
• WSPS Communications – Risk Assessment Results
• Communications Campaign for Industry Stakeholders
• RCA workshop Results
• Risk Statement
• Participant List: Subject Matter Experts
• Identified Primary Causal Factors
• Slide Number 15
• Category Breakdown – 35 Primary Causal Factors
• Voting Process – Level of Importance
• Top 10 Primary Causal Factors
• Employer vs. Workshop Results
• Worker vs. Workshop Results
• Employer vs. Worker Results
• Top 10 Comparison
• Final Workshop Recommendations and Conclusions
• Acknowledgements – Thank You!
• Appendix A – Fishbone diagrams
• Primary Causal Factors
• Slide Number 30
• Slide Number 31
• Slide Number 32
• Slide Number 33
• Slide Number 34
• Slide Number 35
• Appendix B – Controls/Solutions for top primary causal factors
• 1. Category: Culture – Leadership Commitment
• 1. Category: Culture – Leadership Commitment (1)
• 1. Category: Culture – Leadership Commitment (2)
• 2. Category: Process – Inadequate training
• 2. Category: Process – Inadequate training (1)
• 3. Category: Process – Inadequate supervision
• 3. Category: Process – Inadequate supervision (1)
• 4. Category: Environment – Load being handled (dimensions)
• 5. Category: People – Improper postures
• 5. Category: People – Improper postures (1)
• 6. Category: Environment – Inadequate workplace design
• 7. Category: Process – Lack of management of change program
• 8. Category: Measures – Lack of/Improper use of Hazard Identification and Risk Assessment (HIRA)
• Slide Number 50
• 9. Category: Tools and Machines – Inadequate equipment selection
• 10. Category: Culture – Inadequate reporting
• Appendix c – workshop contacts
• Workshop Contacts
• Slide Number 55