GUIDANCE FOR ROOT CAUSE ANALYSIS

Specific Activity
0.-Clerical/Adm./Office Work 10.-Levee/Breakwater 20.-Painting 30.-Abrasive Blasting (Sand)
1.-Idle 11.-Jacket Fabrication 21.-Pipe Test 31.-Non Work Activity
2.-Laying Pipe 12.-Platform 22.-Keyway Work 32.-Not Determined
3.-Jetting 13.-Pipe Welding 23.-Repair Work 33.-Crane Operation
4.-Structural Work 14.-Loading Materials 24.-Yard Fabrication 34.-Rigging
5.-Rig Move 15.-Unloading Materials 25.-Yard/Barge General Cleaning 35.-Illness Not Job Activity Related
6.-Bulkhead Steel 16.-Ship Work 26.-Buffing/Grinding 36.-Administration Work Duties
7.-Bulkhead Pile/Wood 17.-Barge Work 27.-Service Equipment 37.-Pile Driving
8.-Land Clearing 18.-Stinger Work 28.-Riser Work 38.-Deck Fabrication
9.-Dredging 19.-Blasting 29.-Pipe Inspection 39.-QC-NDE Work
40.-Other (specify)
Wind
1. - 0-10 MPH 3. - 20 – 30 MPH 5. -.50 + MPH
2. - 10-20 MPH 4. - 30 + MPH 6. -.Not Applicable to Claim
Seas
1. - 0 – 5 FT 3. - 10-20 FT 5. - 50+ FT
2. - 5 – 10 FT 4. - 20+ FT 6. - Not Applicable to Claim
Length of Service
0. - Length of Service Unknown 3. - 3 – 6 Months 5. - 1 – 2 Years 7. - 4 – 10 Years
1. - 0 – 1 Month 4. - 6 Months – 1 Year 6. - 2 – 4 Years 8. - 10 + Years
2.- 1 – 3 Months 9. - 20 + Years
Incident Source
1. – Beams 11. – Terrain/work surface 21. – Riser 31. – Leads
2. – Brackets 12. – Tools (hand or power) 22. – Checking stinger/pipe 32. – Hammer
3. – Chemicals/Paints/Gases /Vapors 13. – Welding/burning – hose/flash/rod 23. – hand jetting 33. – Forming material
4. – Electrical equipment/lighting 14. – Machinery 24. – Checking jets-led/ditch 34. – Boat or vehicle
5. – Handrails/supports 15. – Materials/supplies/ equipment 25. – Buoy installation 35. – Concrete forms
6. – Hooks/booms/cranes/ cables/wire 16. – Vehicles 26. – Davit hook-up 36. – Elevators
7. – Ladders/step/stairs 17. – Insects/animals 27. – Salvage 37. – Weather conditions
8. – Particles/foreign bodies/slag 18. – Fire/heat/cold/explosion 28. – Other diving 38. – Food
9. – Pipe/bars 19. – Building fixture or facility 29. – Health Condition 39. – Other (specify)
10. – Scaffolds/boards 20. - Noise 30. – Not determined
Type of Incident
1. – Struck Against 9. – Contact w/Electricity/Acids/Etc. 17. – Saturation 26. – Company Sponsored Sports
2. – Struck By Falling Object 10. - Rubbing/Abrading 18. – Scuba injuries
3. – Caught In/On/Between 11. – Stung/Bitten/Scratched by Animal 19. – Non-Industrial 27. – Eye Injury / Ear Injury
4. – Fall-Same Level/Tripping/Slipping 12. – Inhalation/Absorption/ Ingestion 20. – Not Determined 28. – Illness not Job Related
5. – Fall-Different Level 13. – Struck By Flying Object 21. – Struck By Sliding Object 29. – Burns
6. – Bodily 14. – Air Dive 22. – Struck by Swinging Object 30. – Radiation Exposure
7.- Reaction/Overexertion 15. – Mixed Gas 23. – Fall-Slipped 31. – Weld Flash
8. – Contact w/Temperature Extremes 16. – Bell 24. – Other 32. – Chemical Contact
25. – Stepped into/or Onto 33. – Molten Metal Contact
34. - Other (specify)
Body Part
0. – N/A 9. – Chest 19. – Buttocks 29. – Not Determined
1. – Head 10. – Back 20. – Thigh 30. – Internal Injuries
2. – Ear 11. – Arm 21. – Knee 31. – Other
3. – Eye 12. – Elbow 22. – Calf 32. – Skin
4. – Nose 13. – Wrist 23. – Ankle 33. – Heart
5. – Mouth 14. – Hand 24. – Foot 34. – Lungs
6. – Face 15. – Finger 25. – Toe 35. – Illness not Job Related
7. – Neck 16. – Abdomen 26. – Trunk 36. – Tooth/Teeth Damage
8. – Shoulder 17. – Hip 27. – Leg 37. – Illness/Job Related
18. – Groin 28. – Multiple Injuries 38. – Other (specify)
Side of Body
1. – Anterior 3. – Left 5. - Right
2. – Both 4. - Posterior
Primary Diagnosis
1. – Amputation/Enucleating 11. – Dislocation 22. – Fatality 34. – Flash Burn
2. – Asphyxia/Strangulation/ 12. – Electric Shock 23. – Internal Injuries 35. – Crushed
Drowning 13. – Fracture – Crushed 24. – Not Determined 36. – Pain Only
3. – Burn or Scald (Heat) 14. – Hearing Loss/Impairment 25. – Non-Industrial Illness 37. – Infection
4. – Burn (Chemical) 15. – Hernia/Rupture 26. – Bends 38. – Herniated/Ruptured Disk
5. – Radiation/Sunburn 16. – Inflammation/Irritation-Not Strains 27. – Embolism 39. – Dental Injury
6. – Heat Stroke/Heat Exhaustion 17. – Poisoning (Systemic) 28. – Squeeze 40. – Eye (Rust Ring)
7. – Concussion 18. – Pneumoconiosis (Silicosis, etc) 29. – Other Diving/Pressure Injuries 41. – Foreign Body
8. – Contusion 19. – Scratch/Abrasion/Bite/Sting 30. – Frost Bite 42. – Corneal Abrasion
9. – Cut/Laceration/Puncture/ Open 20. – Sprain/Strain 31. – Multiple Injures 43. – Bite/Sting
Wound 21. – Nervous Disorder 32. – Embedded Object 44. – Other (specify)
10. – Dermatitis 33. – Non-Embedded
Severity
0. – First Aid/Non Recordable 2. – Restricted Work Case 4 – Other/Non-Industrial related 6 – Fatal Case
1. – Medical Treatment Case 3. – Lost Day Work Case 5 – Lost Days – Employee Term/Laid Off
Immediate/Direct Cause
UNSAFE ACTS UNSAFE CONDITIONS
1. Acting without authority 8. Improper loading or placement 17. Inadequate guard or barrier 32. Hazardous environmental
2. Failure to warn or signal 9. Unsafe body use and position 18. Inadequate safety device conditions
3. Failure to secure 9.1 Taking unsafe position 19. Fire and explosion hazard 33. Other unsafe condition (specify)
4. Making safety devices inoperable 9.2 Positioned in line of fire 20. Unexpected movement
5. Using defective equipment 9.3 Improper ascending or descending 21. Poor housekeeping
6. Failing to use PPE Properly 9.4 Eyes not on path 22. Projectile hazard
6.1 Ear protection 9.5 Body parts in pinch points 23. Congestion/Clearance hazard
6.2 Hand protection 9.6 Improper lifting 24. Hazardous atmosphere
6.3 Body protection 10. Servicing equipment in operation 25. Inadequate ventilation
6.4 Fall protection 11. Moving hazardous equipment 26. Failure of tools, equipment, or
6.5 Respiratory protection 12. Horseplay material
7. Tools and Equipment Selection 13. Substance abuse 27. Improper/hazardous placement or
and Use 14. Failure to follow procedure storage
7.1 Using wrong tool or equipment 15. Unauthorized abandonment or 28. Inadequate or excessive
7.2 Improper use of restraining device discharge of waste/housekeeping illumination
7.3 Improper stage/pre-job inspection 16. Other unsafe behavior (specify) 29. Excessive noise
7.4 Operating vehicle/equipment at 30. Hazardous personnel attire
unsafe speed (Bold indicates part of BBSM CBI 31. Temperature extremes
32. Radiation exposure
BASIC/UNDERLYING CAUSES
PERSONAL FACTORS JOB FACTORS
1. Inadequate Physical/Mental 2. Lack of Knowledge/Skill 4.0 Inadequate Leadership and/or 6.0 Inadequate Purchasing
Capability 2.1 Lack of experience Supervision 6.1 Inadequate
1.1 Inappropriate height, weight, 2.2 Inadequate orientation of job 4.1 Unclear or conflicting specifications on
size, strength, reach, etc. hazards reporting relationships requisitions
1.2 Restricted range of body 2.3 Inadequate review of work 4.2 Unclear or conflicting 6.2 Inadequate research on
movement instructions assignment of materials/equipment
1.3 Limited ability to sustain 2.4 Inadequate initial/refresher responsibility 6.3 Inadequate receiving
body positions training 4.3 Improper or insufficient inspection and
1.4 Substance sensitivities or 2.5 Misunderstood directions delegation acceptance
allergies 2.6 Inadequate practice 4.4 Giving inadequate policy, 6.4 Improper salvage and/or
1.5 Sensitivities to sensory 2.7 Infrequent performance procedure, practices waste disposal
extremes (temperature, 2.8 Inadequate hazard guidelines 6.5 Inadequate contractor
sound, etc.) recognition and response 4.5 Giving conflicting goals, selection
1.6 Sensory deficiency (vision, 3. Improper Motivation objectives, or standards 6.6 Inadequate identification
hearing, touch, taste, smell, 3.1 Improper conduct that is 4.6 Inadequate work planning of hazardous materials
balance) condoned/tolerated or programming 7.0 Inadequate Maintenance/
1.7 Respiratory incapacity 3.2 Improper conduct that is not 4.7 Inadequate instructions, Inspection
1.8 Temporary disabilities condoned orientation and/or timing 7.1 Inadequate preventative
1.9 Fears and phobias 3.3 Proper performance is 4.8 Inadequate reference maintenance
1.10 Emotional punished documents assessment
disturbance/overload 3.4 Lack of incentives 4.9 Inadequate 7.2 Inadequate lubrication or
1.11 Mental illness 3.5 Excessive frustration identification/evaluation of servicing
1.12 Intelligence level 3.6 Inappropriate aggression risk 7.3 Inadequate adjustment/
1.13 Poor judgment 3.7 Improper attempt to save time 4.10 Lack of assembly
1.14 Low mechanical aptitude or effort supervisory/management 7.4 Inadequate cleaning or
1.15 Memory failure 3.8 Improper attempt to avoid knowledge resurfacing
1.16 Fatigue discomfort 4.11 Inadequate matching of 7.5 Inadequate
1.17 Medical condition 3.9 Improper attempt to gain individual qualifications to communication of repair
1.18 Medication effect attention job needs
1.19 Atmospheric effects 3.10 Inadequate discipline 4.12 Inadequate performance 7.6 Inadequate scheduling
(temperature, oxygen, CO, 3.11 Inappropriate peer pressure measurement and of work
lead, etc.) 3.12 Improper supervisory evaluation 7.7 Inadequate repairs
1.20 Confused on example 4.13 Inadequate or incorrect made
directions/procedures 3.13 Inadequate performance performance feedback 7.8 Inadequate inspection
1.21 Extreme judgment/decision feedback 5.0 Inadequate Engineering and and/or monitoring
demands 3.14 Inadequate reinforcement of Controls 8.0 Inadequate Tools and
proper behavior 5.1 Inadequate consideration Equipment
3.15 Improper production of human 8.1 Inadequate availability of
incentives factors/ergonomics proper tool/equipment
5.2 Inadequate standards, 8.2 Inadequate assessment
specifications and/or of needs and risks
design criteria 8.3 Improper loading or rate
5.3 Inadequate monitoring of of use
operations 8.4 Improper extension of
5.4 Inadequate assessment of service life
operational readiness 9.0 Inadequate Work Standards
5.5 Inadequate or improper 9.1 Inadequate development
controls of standards
5.6 Inadequate evaluation of 9.2 Inadequate
changes communication of
5.7 Inadequate planning for standards
use 9.3 Inadequate updating of
standards
9.4 Inadequate monitoring
of compliance with
procedures
System Failures
1.0 Management Commitment & Planning 8.0 Equipment & Facility Maintenance
1.1 HS&E Philosophy 8.1 PM system includes critical HS&E equipment
1.2 HS&E Policy 8.2 Minimum HS&E Protective devices in place
1.3 HS&E Responsibilities defined 8.3 Hazardous Materials/waste have designated proper storage
1.4 HSE personnel assigned areas/containers
1.5 HSE Reporting responsibilities clear 8.4 Walk/Work areas properly maintained
1.6 Management support of HS&E 8.5 Good Housekeeping program in place
1.7 HSE Incentive program 8.6 Rigging system maintained with register
1.8 HSE Management system Action Plan maintained 8.7 Proper scaffold system in place
1.9 HSE Management Action Plan being reviewed by 8.8 Electrical system maintained
management 9.0 Health Management
2.0 HS&E Standards and Procedures 9.1 Industrial hygiene assessment performed
2.1 Level I HSE Management System Document 9.2 Evaluation of ventilation/respiratory needs being made
2.2 Level II HSE Operational Procedures 9.3 Medical exams performed
2.3 Level III Work Instructions 9.4 Food Preparation QC program in place
2.4 E&M procedures properly referenced/incorporated in 9.5 Wellness program in place
HSE procedures 9.6 Work related injuries reviewed by designated medical provider
2.5 Procedures clearly define roles/responsibilities, 9.7 Case management
objectives, controls, etc. 9.8 Temporary work assignments for injured personnel
2.6 Methods of communicating procedures identified 10.0 Preventive and Corrective Actions, Assessments, & Audits
2.7 HSE Handbook for employees 10.1 Routine HS&E inspections performed
2.8 Employee’s acknowledge receipt of handbook 10.2 Inspection protocols/procedures followed
2.9 HSE Policies/Procedures readily available 10.3 Internal HSE systems audits
3.0 Risk Identification, Assessments & Controls 10.4 External HSE systems audits
3.1 Performance of Hazard and Risk Assessments 10.5 Performance of root cause analysis
3.2 Risk assessment teams 10.6 Corrective action plan developed/maintained
3.3 Consideration of all hazards 10.7 Corrective actions completed
3.4 Methods of communicating job hazards to employees 11.0 Training
(verbally, JSA’s, HAZOP’s etc.) 11.1 HS&E Orientation provided to new personnel
3.5 Proper use of PPE identified in risk assessments 11.2 Orientation on safe offshore transfer provided
3.6 Hazard control systems identified/followed 11.3 Short service employee training/OJT program established
3.7 Correct methods used to reduce risk 11.4 Training matrix identifies all relevant training
4.0 Employee Participation 11.5 Initial/Refresher training program in place
4.1 BBSM process implementation properly 11.6 Supervisors training program in place
4.2 Right-to-refuse unsafe work policy used 11.7 Recurring training provided when required
4.3 Employee system for reporting hazards 11.8 Training programs evaluated
4.4 HS&E Council 11.9 Training matrix reviewed/updated
4.5 HS&E “tool box” meetings 11.10 Training records being tracked
4.6 Methods of communicating HS&E information 11.11 Supervisors made aware of employee training requirements
4.7 Employee recognition program 12.0 Emergency Preparedness and Response
5.0 Engineering & Change Management 12.1 Emergency assessments performed and based on probability
5.1 HS&E Personnel involvement in evaluation of projects, and severity of potential emergencies
processes, procedures, and facility changes 12.2 Emergency plan complete
5.2 HS&E personnel involvement in performing JSA’s & 12.3 Emergency command structure identified
HAZOPs 12.4 Arrangements made with external emergency response
5.3 HS&E personnel coordination with Project Management organizations
5.4 HS&E personnel monitoring of projects 12.5 Training performed to all personnel on emergency
5.5 HS&E personnel participation in evaluation of vendors responsibilities
5.6 List of qualified vendors/acceptable material maintained 12.6 Special training provided to internal emergency responders
6.0 Contractor HS&E Management 12.7 Vessels have specific emergency plans
6.1 Critical vendors/contractors identified 12.8 Emergency management and control assessment performed
6.2 HS&E Pre-Qualification of vendors/contractors 12.9 Internal/external emergency equipment and/or facilities identified
6.3 Use of qualified vendors/contractors and maintained
6.4 Vendor/contractor aware of HSE requirements 12.10 Routine inspections/maintenance/repair/replacement of
6.5 Vendor/contractor following HSE requirements emergency equipment
6.6 Critical vendors/contractors provide qualified supervisors 12.11 Primary/alternate command centers identified
for HSE management 12.12 Emergency equipment on board vessels maintained
6.7 Critical contractors evaluated/audited 12.13 Medical equipment/facilities available
7.0 Compliance Controls 12.14 Environmental cleanup equipment available
7.1 Government HSE laws/regulations/codes available 12.15 Emergency communication systems
7.2 Monitoring of changes to regulatory requirements 12.16 Security systems in place
performed 13.0 Control of Documents & Records
7.3 Outline of applicable laws maintained 13.1 HS&E related documents maintained
7.4 Procedures for regulatory inspections followed 13.2 Employee related health and safety records maintained/tracked
7.5 Employee job responsibilities/appraisals given 13.3 HSE policies/procedures distributed through controlled system
7.6 Disciplinary policy enforced including zero tolerance 13.4 Periodic review of policies/procedures made
programs 14.0 Performance Measures
7.7 Disciplinary policy enforced consistently 14.1 Completeness of HSE Management System measured
14.2 HSE Management System action plans maintained
14.3 Worker’s compensation costs measured
14.4 Environmental Self Assessment Program
O – System Failures
1.0 Management Commitment and Planning 15.0 Contracting Systems
2.0 Resource Allocations (Personnel, Equipment, and money) 16.0 Compliance Controls Systems (Permits, Regulatory Requirements, etc.)
3.0 Project Bidding and Review Systems 17.0 Equipment & Facility Maintenance/Repair Systems
4.0 Project Planning, Execution, and Management Systems 18.0 Property and Asset Management Systems
5.0 Engineering Analysis and Control Systems 19.0 Material Transport and Handling Systems
6.0 Construction and Installation Quality Systems 20.0 Health and Medical Management Systems
7.0 Standards and Procedures (standard work practices, administrative 21.0 Preventive and Corrective Action Systems
procedures, or work instructions) 22.0 Accountability Systems
8.0 Hazard and Risk Assessment Systems 23.0 Inspection Systems
9.0 Insurance and Risk Management Systems 24.0 Auditing Systems
10.0 HS&E Hazard Control Systems 25.0 Training and Competency Systems
11.0 Employee Participation Systems 26.0 Emergency Preparedness and Response
12.0 Communication of Information/Expectations Systems (verbal or written) 27.0 Security Systems
13.0 Management of Change Systems 28.0 Control of Documents & Records
14.0 Procurement Systems 29.0 Performance Measuring Systems
Choose the appropriate system category above that failed and then include a description of the specific procedure, practice and/or sub-system by name and/or document
number that failed because there was either nothing in place (N), no standard implemented (S), or a system/procedure that was not effective (E). Note that consideration
should be given to all business systems when identifying deficiencies (i.e. HR, HS&E, Quality, E&M, Project Management, Engineering, Vessel Operations, Materials and
Transportation, Procurement, Legal , etc.).