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    2018 Root Cause Categories

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    Ridwan Arief
    The document outlines categories for root cause analysis in 2018. It includes 4 main categories: 1) Organizational Influences, which covers organizational climate, processes, and resource management. 2) Preconditions for Unsafe Acts, such as crew resource management, personal readiness, physical environment, and psychological factors. 3) Unsafe Acts like decision errors, violations, perception errors, and skill-based errors. 4) Unsafe Supervision such as failure to correct known problems, inadequate supervision, planned inappropriate activities, and supervisory violations. Each category contains multiple sub-categories for more specific root causes.

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    2018 Root Cause Categories

    Uploaded by

    Ridwan Arief
    237 views3 pages
    The document outlines categories for root cause analysis in 2018. It includes 4 main categories: 1) Organizational Influences, which covers organizational climate, processes, and resource management. 2) Preconditions for Unsafe Acts, such as crew resource management, personal readiness, physical environment, and psychological factors. 3) Unsafe Acts like decision errors, violations, perception errors, and skill-based errors. 4) Unsafe Supervision such as failure to correct known problems, inadequate supervision, planned inappropriate activities, and supervisory violations. Each category contains multiple sub-categories for more specific root causes.

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    ISAGO Root Cause Categories in 2018

    Original Title

    2018 ROOT CAUSE CATEGORIES

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    The document outlines categories for root cause analysis in 2018. It includes 4 main categories: 1) Organizational Influences, which covers organizational climate, processes, and resource management. 2) Preconditions for Unsafe Acts, such as crew resource management, personal readiness, physical environment, and psychological factors. 3) Unsafe Acts like decision errors, violations, perception errors, and skill-based errors. 4) Unsafe Supervision such as failure to correct known problems, inadequate supervision, planned inappropriate activities, and supervisory violations. Each category contains multiple sub-categories for more specific root causes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    237 views3 pages

    2018 Root Cause Categories

    Uploaded by

    Ridwan Arief
    The document outlines categories for root cause analysis in 2018. It includes 4 main categories: 1) Organizational Influences, which covers organizational climate, processes, and resource management. 2) Preconditions for Unsafe Acts, such as crew resource management, personal readiness, physical environment, and psychological factors. 3) Unsafe Acts like decision errors, violations, perception errors, and skill-based errors. 4) Unsafe Supervision such as failure to correct known problems, inadequate supervision, planned inappropriate activities, and supervisory violations. Each category contains multiple sub-categories for more specific root causes.

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    2018 ROOT CAUSE CATEGORIES

    1 ORAGANIZATIONAL INFLUENCES
    1 Organizational Climate
    1 OC01 Inadequate company culture
    2 OC02 Inadequate HR policies
    3 OC03 Inadequate organizational structure
    4 OC04 Other (description to be provided by Auditee)
    2 Organizational Processes
    1 OP01 Inadequate oversight resources
    2 OP02 Unclear/unavailable/inadequate regulations, standard procedures
    3 OP03 Inadequate operations
    4 OP04 Inadequate training
    5 OP05 Other (description to be provided by Auditee)
    3 Resource Management
    1 RM01 Insufficient human resources
    2 RM02 Insufficient / defective equipment / facilities available
    3 RM03 Insufficient financial / budget resources, excessive cost cutting
    4 RM04 Insufficient selection process / qualification
    5 RM05 Poor planning, prioritization
    6 RM06 Other (description to be provided by Auditee)

    2 PRECONDITIONS FOR UNSAFE ACTS


    1 CRM
    1 CM01 Lack of assertiveness or leadership
    2 CM02 Lack of planning or preparation, inadequate briefing, insufficient re-planning
    3 CM03 Poor workload management or task delegation
    4 CM04 Authority gradient, poor teamwork
    5 CM05 Poor communication of critical information and poor decision making
    6 CM06 Lack of cross-monitoring performance, supportive feedback or acknowledgement
    7 CM07 Other (description to be provided by Auditee)
    2 Personal Readiness
    1 PR01 Inadequate Rest
    2 PR02 Inadequate physical firmness, Insufficient diet, nutrition
    3 PR03 Self-medication and, unreported medical conditions
    4 PR04 Inadequate personal preparation
    5 PR05 Other (description to be provided by Auditee)
    3 Physical Environment
    1 PN01 Restricted visibility, altitude, terrain, weather conditions
    2 PN02 Inadequate lighting, noise, vibration
    3 PN03 Inadequate cleanliness, surface conditions
    4 PN04 Inadequate facilities / walk / road layout, signing, marking
    5 PN05 Other (description to be provided by Auditee)
    4 Psychological and Physical Conditions
    1 PC01 Inattention, apathy, complacency, boredom, distraction, stress, exhaustion (Burnout)
    2 PC02 Channelized attention and action, confusion, disorientation
    3 PC03 Personality style
    4 PC04 Illness, sickness
    5 PC05 Effects of alcohol, drugs (before or while on duty)
    6 PC06 Inadequate experience for situation, insufficient reaction time
    7 PC07 Misperception of operational conditions, incorrect interpretation and understanding
    8 PC08 Other (description to be provided by Auditee)

    3 PRECODNDITIONS FOR UNSAFE ACTS


    1 Technological Environment
    1 TN01 Inappropriate / poor design of equipment, tool, parts, material
    2 TN02 Inappropriate automation, function, reliability
    3 TN03 Inappropriate interface design
    4 TN04 Inappropriate communication system
    5 TN05 Other (description to be provided by Auditee)

    3 Unsafe Acts
    1 Decision Errors
    1 DE01 Inadequate risk evaluation during operation, misjudging
    2 DE02 Ignored caution, warning
    3 DE03 Task misprioritization
    4 DE04 Other (description to be provided by Auditee)
    2 Exceptional Violations
    1 EV01 Lack of discipline
    2 EV02 Rules, regulations, procedures not follow
    3 EV03 Intentional bending the rules, procedures, policies by individual or team without cause or need
    4 EV04 Other (description to be provided by Auditee)
    3 Perception Errors
    1 PE01 Error due to misperception, illusion, disorientation, misjudgment
    2 PE02 Spatial disorientation, vertigo, visual illusion
    3 PE03 Other (description to be provided by Auditee)
    4 Routine violations
    1 RV01 Widespread, routine, systemic, habitual violation by individual or team
    2 RV02 Violation based on Risk Assessment
    3 RV03 Other (description to be provided by Auditee)
    5 Skill Based Errors
    1 SE01 Incorrect operations / handling of equipment / inappropriate use of automation
    2 SE02 Incorrect operations / handling equipment
    3 SE03 Inadvertently activating or deactivating equipment, controls or switches
    4 SE04 Failure to see and react / fail
    5 SE05 Other (description to be provided by Auditee)

    4 UNSAFE SUPERVISION
    1 Fail to Correct a Known Problem
    1 FP01 Supervision failed to identify and correct inappropriate behavior or unsafe tendencies
    2 FP02 Supervisor failed to correct known hazard / problem / error / inefficiency
    3 FP03 Supervisor failed to report a hazard or unsafe tendencies
    4 FP04 Other (description to be provide by Auditee)
    2 Inadequate Supervision
    1 IS01 Failed to provide leadership and guidance
    2 IS02 Failed to track performance
    3 IS03 Failed to track qualification
    4 IS04 Failed to provide / ensure adequate training
    5 IS05 Other (description to be provide by Auditee)
    3 Planned Inappropriate Activities
    1 PA01 Inappropriate employee scheduling / assigning / manning
    2 PA02 Inadequate Risk Assessment
    3 PA03 Authorization to take unnecessary risks
    4 PA04 Other (description to be provide by Auditee)
    4 Supervisory Violations
    1 SV01 Supervisor failed to enforce rules and regulations
    2 SV02 Supervisor directed / authorized subordinates to violate existing rules
    3 SV03 Supervisor authorized unqualified person for work
    4 SV04 Other (description to be provide by Auditee)

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