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DNV SYSTEMATIC CAUSE ANALYSIS TECHNIQUE (SCAT®)

DESCRIPTION OF ACCIDENT OR INCIDENT  People  Process/Operation  Property  Environmental EVALUATION OF
DESCRIPTION OF ACCIDENT OR INCIDENT
 People
 Process/Operation
 Property
 Environmental
EVALUATION OF LOSS POTENTIAL IF NOT CONTROLLED
Loss Severity Potential
Probability of Recurrence
Frequency of Exposure
 Major (A)
 Serious (B)
 Minor (C)
 High (A)
 Moderate (B)
 Low (C)
 Extensive (A)
 Moderate (B)
 Low (C)
Type of Event
1. Struck Against (Running or Bumping Into)
(See ICs: 1, 2, 4, 5, 6, 11, 14, 15, 16, 21, 22, 23, 24, 25, 27, 31, 39,
(See ICs: 4, 9, 11, 13, 14, 15, 16, 17, 19, 23, 26, 27, 31, 33)
25, 27, 31, 34, 35, 36, 37, 38)
40)
5. Caught In (Pinch and Nip Points)
(See ICs: 5, 6, 11, 15, 16, 17, 19, 21, 22, 23, 34)
2. Struck By (Hit By Moving Object)
(See ICs: 1, 2, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21, 22, 23, 24, 25, 27, 31, 39, 40)
6. Caught On (Snagged, Hung)
(See ICs: 4, 5, 6, 9, 10, 11, 12, 15, 16, 17, 18, 21, 23, 35)
8. Contact With (Electricity, Heat, Cold, Radiation, Caustics, Toxics,
Biological, Noise)
(See ICs: 2, 3, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 40)
11. Overstress, Overpressure, Overexertion, Ergonomic
(See ICs: 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 24, 25,
35, 37, 40)
12. Equipment Failure
(See ICs: 1, 4, 6, 8, 16, 18, 23, 25, 30, 32, 33, 34, 35, 37, 38, 40)
3. Fall from Elevation to Lower Level
(See ICs: 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 21, 22, 23, 27, 33, 36,
40)
4. Fall on Same Level (Slip and Fall, Trip Over)
7. Caught Between or Under (Crushed or Amputated)
(See ICs: 2, 3, 5, 6, 8, 9, 11, 12, 15, 16, 17, 18, 19, 20, 21, 24, 25,
34, 36, 37)
9. Abnormal Operation
(See ICs: 1, 2, 3, 6, 9, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25,
27, 31, 33, 34, 35, 36, 37, 38)
10. Product Contamination
(See ICs: 1, 2, 3, 5, 6, 9, 11, 12, 14, 15, 16, 17, 18, 19, 20, 23, 24,
13. Environmental Release
(See ICs: 1, 2, 3, 5, 6, 8, 9, 12, 15, 16, 17, 18, 19, 20, 23, 25, 26, 30,
32, 33, 34, 35, 36, 38)
Immediate/Direct Causes
SUBSTANDARD ACTS
12. Servicing Equipment in Operation
(See BCs: 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16)
(See BCs: 5, 7, 8, 9, 10, 11, 12, 13, 15)
1. Operating Equipment Without Authority
(See BCs: 2, 4, 5, 7, 8, 9, 13, 14, 16)
13. Horseplay
(See BCs: 2, 3, 4, 5, 7, 8, 9, 14)
23. Defective Tools, Equipment or Materials
(See BCs: 8, 9, 10, 11, 12, 13, 15)
33. Presence of Harmful Materials
(See BCs: 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
2. Failure to Warn
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 14, 15, 16)
14. Under In uence of Alcohol and/or Other Drugs
(See BCs: 1, 2, 3, 4, 5, 7, 8, 9, 14)
24. Congestion or Restricted Action
(See BCs: 9, 10, 11, 14)
34. Inadequate Instructions/Procedures
(See BCs: 5, 6, 7, 9, 10, 14, 16)
3. Failure to Secure
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 14)
15. Using Equipment Improperly
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16)
25. Inadequate Warning System
(See BCs: 8, 9, 10, 11, 12, 13, 15, 16)
35. Inadequate Information/Data
(See BCs: 5, 6, 9, 10, 11, 12, 16)
4. Operating at Improper Speed
(See BCs: 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14)
16. Failure to Follow Procedure/Policy/Practice
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 14, 16)
26. Fire & Explosion Hazards
(See BCs: 5, 6, 7, 8, 9, 10, 11, 12, 13, 15)
36. Inadequate Preparation/Planning
(See BCs: 5, 6, 7, 9, 14, 16)
5. Making Safety Devices Inoperative
(See BCs: 2, 4, 5, 6, 7, 8, 9, 10)
17. Failure to Identify Hazard/Risk
(See BCs: 3, 4, 5, 6, 7, 9, 14)
6. Using Defective Equipment
(See BCs: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
27. Poor Housekeeping/Disorder
(See BCs: 7, 8, 9, 10, 12, 14, 16)
37. Inadequate Support/Assistance
(See BCs: 7, 9, 11, 12, 16)
18. Failure to Check/Monitor
(See BCs: 2, 3, 4, 5, 6, 7, 9, 10, 12, 13, 14, 15, 16)
7. Failing to Use PPE Properly
(See BCs: 1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 13, 14, 15, 16)
28. Noise Exposure
(See BCs: 5, 7, 8, 9, 10, 11, 12, 13, 14, 16)
38. Inadequate Communications Hardware/Software/Process
(See BCs: 7, 9, 10, 11, 12, 13, 15, 16)
19. Failure to React/Correct
(See BCs: 1, 2, 3, 4, 5, 6, 7, 9, 13, 14, 16)
8. Improper Loading
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
29. Radiation Exposure
(See BCs: 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
39. Road Conditions
(See BCs: 5, 7, 8, 9, 10, 12, 13, 14, 15)
20. Failure to Communicate/Coordinate
(See BCs: 3, 4, 5, 7, 9, 10, 16)
30. Temperature Extremes
(See BCs: 5, 7, 9, 10, 14)
40. Weather Conditions
(See BCs: 5, 7, 9, 13, 14, 16)
9. Improper Placement
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14)
SUBSTANDARD CONDITIONS
10. Improper Lifting
(See BCs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14)
31. Inadequate or Excess Illumination
(See BCs: 5, 7, 9, 10, 11, 12, 13, 15)
11. Improper Position for Task
(See BCs: 1, 2, 3, 4, 5, 6, 7, 9, 10, 13, 14, 16)
21. Inadequate Guards or Barriers
(See BCs: 5, 9, 10, 11, 12, 13, 15)
32. Inadequate Ventilation
(See BCs: 5, 7, 9, 10, 12, 13, 15)
22. Inadequate or Improper Protective Equipment
Basic/Root Causes
PERSONAL FACTORS
5. Lack of Knowledge
(See CAs: 2, 4, 5, 6, 8, 9, 10, 11, 14, 15, 16, 17, 18, 21, 22)
9.11. Inadequate matching of individual quali cations and
job/task requirements
9.12.
22)
14.1. Inadequate development of standards
14.1.1.
Inadequate orientation
5.3.
5.1. Lack of experience
5.2.
Inadequate performance measurement and
evaluation
Inventory and evaluation of
exposures and needs
1. Inadequate (See CAs: 4, 6, Physical/Physiological 11, 12, 13, 15, 18) Capability
9.13. Inadequate or incorrect performance feedback
1.1. Inappropriate height, weight, size,
strength, reach, etc.
1.2.
Inadequate initial training
5.4.
Inadequate update training
10. Inadequate Engineering
5.5. Misunderstood directions
5.6. Lack of situational awareness
(See CAs: 1, 3, 4, 12, 13, 14, 19, 21, 22)
Employee involvement
14.1.4.
14.1.2. Coordination with process design
14.1.3.
Procedures/practices/rules
Restricted range of body movement
10.1.
Inadequate assessment of loss exposures
14.2. Inadequate communication of standards
1.3. Limited ability to sustain body positions
10.2.
Publication
1.4. Substance sensitivities or allergies
6. Lack of Skill
(See CAs: 2, 4, 6, 7, 9, 10, 13, 15, 16, 18, 21, 22)
Inadequate consideration of human
factors/ergonomics
14.2.1.
14.2.2. Distribution
1.5. Sensitivities to sensory extremes
(temperature, sound, etc.)
1.6.
6.1.
Inadequate initial instruction
10.3.
6.2.
Inadequate practice
Vision de ciency
1.7.
6.3.
Infrequent performance
Inadequate standards, speci cations and/or design
criteria
14.2.3. Translation of appropriate languages
14.2.4.
10.4.
Inadequate monitoring of construction
Training
14.2.5.
Hearing de ciency
6.4.
Lack of coaching
10.5.
Inadequate assessment of operational
readiness
Reinforcing with signs, color codes
and job aids
1.8. Other sensory de ciency (touch, taste,
smell, balance)
6.5.
Inadequate review instruction
14.3. Inadequate maintenance of standards
7. Improper Motivation
10.6.
Inadequate or improper controls
14.3.1.
1.9. Respiratory incapacity
(See CAs: 1, 2, 4, 5, 6, 8, 10, 11, 13, 15, 16, 17, 20, 21, 22)
10.7.
Inadequate monitoring of initial operation
Tracking of work ow
14.3.2.
Updating
1.10. Other permanent physical capabilities
7.1.
Improper performance is rewarded (tolerated)
10.8.
Inadequate evaluation of changes
14.3.3. Monitoring use of procedures/
1.11. Temporary disabilities
7.2.
Proper performance is punished
11. Inadequate Purchasing
practices/rules
7.3.
Lack of incentives
2. Inadequate (See CAs: 1, 4, Mental/Psychological 6, 8, 12, 13, 15, 18, 20) Capability
14.4. Inadequate monitoring of compliance
7.4.
Excessive frustration
(See CAs: 1, 3, 6, 11, 12, 13, 14, 19, 21, 22)
11.1.
Inadequate speci cations on requisitions
2.1. Fears and phobias
2.2.
7.5.
Inappropriate aggression
15. Excessive Wear and Tear
11.2.
Inadequate research on materials/equipment
Emotional disturbance
7.6.
Improper attempt to save time or e ort
(See CAs: 3, 4, 6, 9, 11, 12, 13, 14, 19, 21, 22)
11.3.
Inadequate speci cations to vendors
2.3. Mental illness
7.7.
Improper attempt to avoid discomfort
15.1.
Inadequate planning of use
Improper attempt to gain attention
11.4.
Inadequate mode or route of shipment
2.4. Intelligence level
2.5.
7.8.
15.2.
Improper extension of service life
11.5.
Inadequate receiving inspection and acceptance
Inability to comprehend
7.9.
Inadequate discipline
15.3.
Inadequate inspection and/or monitoring
11.6.
Inadequate communication of safety and health data
2.6. Poor coordination
7.10.
Inappropriate peer pressure
15.4.
Improper loading or rate of use
11.7.
Improper handling of materials
2.7. Slow reaction time
7.11.
Improper supervisory example
15.5.
Inadequate maintenance
11.8.
Improper storage of materials
2.8. Low mechanical aptitude
7.12.
Inadequate performance feedback
15.6.
Use by unquali ed or untrained people
11.9.
Improper transporting of materials
2.9. Low learning aptitude
7.13.
Inadequate reinforcement of proper behavior
15.7.
Use for wrong purpose
2.10. Memory failure
7.14.
Improper production incentives
11.10.
Inadequate identi cation of hazardous
materials
16. Inadequate Communications
8. Abuse or Misuse
(See CAs: 1, 2, 3, 4, 5, 6, 8, 10, 13, 14, 15, 21, 22)
11.11.
Improper salvage and/or waste disposal
(See CAs: 1, 2, 4, 5, 6, 7, 9, 10, 12, 14, 15, 16, 17, 19, 21, 22)
3. (See Physical CAs: or 4, Physiological 5, 6, 7, 9, 11, 12, Stress 15, 18, 20, 22)
11.12.
Inadequate contractor selection
16.1.
Inadequate horizontal communication between peers
3.1. Injury or illness
3.2.
8.1. Improper conduct that is condoned
16.2.
Fatigue due to task load or duration
12. Inadequate Maintenance
8.1.1.
Intentional
Inadequate vertical communication between
supervisor and person
3.3. Fatigue due to lack of rest
(See CAs: 3, 4, 6, 8, 10, 13, 14, 19, 21, 22)
8.1.2. Unintentional
16.3.
3.4. Fatigue due to sensory overload
12.1. Inadequate preventive
8.2. Improper conduct that is not condoned
3.5. Exposure to health hazards
12.1.1.
Assessment of needs
Inadequate communication between di erent
organizations
8.2.1.
Intentional
16.4.
Inadequate communication between work groups
3.6. Exposure to temperature extremes
12.1.2. Lubrication and servicing
8.2.2. Unintentional
16.5.
Inadequate communication between shifts
3.7. Oxygen de ciency
16.6.
Inadequate communication methods
3.8. Atmospheric pressure variation
3.9.
12.1.3. Adjustment/assembly
12.1.4.
Cleaning or resurfacing
16.7.
No communication method available
Constrained movement
JOB/SYSTEM FACTORS
12.2. Inadequate reparative
16.8.
Incorrect instructions
3.10. Blood sugar insu ciency
12.2.1.
Communication of needs
16.9.
Inadequate communication due to job turnover
3.11. Drugs
9. Inadequate Leadership and/or Supervision
(See CAs: 1, 2, 3, 5, 6, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21, 22)
12.2.2. Scheduling of work
12.2.3.
Examination of units
16.10.
12.2.4. Part substitution
Inadequate communication of safety and health data,
regulations or guidelines
16.11.
Standard terminology not used
4. Mental or Psychological Stress
13. Inadequate Tools and Equipment
9.1.
Unclear or con icting reporting relationships
16.12.
Veri cation/repeat feedback techniques not used
(See CAs: 1, 4, 5, 6, 7, 9, 10, 12, 13, 15, 16, 18, 20, 21, 22)
(See CAs: 1, 3, 4, 6, 7, 8, 11, 12, 13, 19, 21, 22)
9.2.
Unclear or con icting assignment of responsibility
16.13.
Messages too long
4.1. Emotional overload
13.1.
Inadequate assessment of needs and risks
9.3.
Improper or insu cient delegation
16.14.
Speech interference
4.2. Fatigue due to mental task load or speed
4.3.
13.2.
9.4.
Extreme judgment/decision demands
Giving inadequate policy, procedure, practices or
guidelines
Inadequate human factors/ergonomics
considerations
4.4. Routine, monotony, demand for uneventful vigilance
13.3.
Inadequate standards or speci cations
9.5.
Giving objectives, goals or standards that con ict
4.5. Extreme concentration/perception demands
13.4.
Inadequate availability
9.6.
Inadequate work planning or programming
4.6. “Meaningless” or “degrading” activities
4.7.
13.5.
Inadequate adjustment/repair/maintenance
9.7.
Inadequate instructions, orientation and/or training
Confusing directions/demands
13.6.
Inadequate salvage and reclamation
9.8.
4.8. Con icting demands/directions
4.9.
Providing inadequate reference documents, directives
and guidance publications
13.7.
Inadequate removal and replacement of
Preoccupation with problems
unsuitable items
9.9.
4.10. Frustration
4.11. Mental illness
Inadequate identi cation and evaluation of loss
exposures
14. Inadequate Work Standards
(See CAs: 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 21,
9.10.
Lack of supervisory/management job knowledge
Areas for Corrective Action
1. LEADERSHIP AND ADMINISTRATION
P
S
C
c. Critical task observations performed
P
S C
h. Internal communications
P
S
C
P
S
C
a. General policy statement
d. Follow-up system
22.
QUALITY MANAGEMENT
b. Loss control coordinator quali cations
13. SYSTEM EVALUATION
c. Senior and middle management participation in loss
control activities
7. EMERGENCY PREPAREDNESS
a. Assessment of loss control requirements
a. Identi cation of potential emergencies
b. Regular loss control system monitoring
d. Loss control performance standards for all personnel
b. Emergency plan
e. Loss control reference manual
c. O -site emergencies
c. Evaluation of compliance with loss control system
standards
f. Annual loss control objectives established
d. Employee perception surveys
d. Sources of energy controls
P
S
C
g. Joint safety and health committees and/or representatives
e. Protective and rescue systems
P
S C
h. Policy on refusal to work due to hazards
f. Emergency teams
14. ENGINEERING AND CHANGE MANAGEMENT
i. Applicable regulations, codes and standards identi ed
g. Lessons learned system
a. Hazard identi cation and risk assessment
j. Communication with external parties
h. First aid
b. Project review and change management
P
S
C
i. Organized outside help and mutual aid
c. Operational and work process change management
2. LEADERSHIP TRAINING
j. Post-event planning
P
S
C
a. Training needs analysis
k. Emergency communication
15. PERSONAL COMMUNICATIONS
b. Loss control orientation/induction for new
leaders/managers
l. Communications with the community
a. Training in personal communication techniques
LEGEND
P
S
C
P
S
C
b. Individual job orientation/induction
P - Not a part of our system
S - Inadequate standards
c. Initial training of senior management
8. RULES AND WORK PERMITS
c. Task instruction
C - Inadequate compliance with our standards
d. Update training of senior management
a. General loss control rules
d. Planned personal contacts
e. Initial loss control training for leaders/managers
b. Specialized work rules
P
S
C
f. Update loss control training for leaders/managers
c. Specialized work permit systems
16. GROUP COMMUNICATIONS
g. Formal training of loss control coordinator
d. Regulatory permit-to-operate systems
a. Quantity and quality of group loss control meetings
e. Rule education and review
b. Management involvement
3. PLANNED INSPECTIONS AND MAINTENANCE
f. Rule compliance and recognition
a. Planned general inspections
g. Use of educational signs and color codes
b. Follow-up system
P
S
C
P
S
C
c. Critical parts/items inspection
9. INCIDENT ANALYSIS
17. GENERAL PROMOTION
d. Preventive maintenance system
a. Consequence measurements
a. Loss control bulletin boards
e. Special systems inspections
P
S
C
b. Cause and control analysis
b. Use of incident statistics
f. Pre-use equipment inspections
c. Property damage/process loss identi cation and analysis
c. Critical topic promotion
g. System for employees to report substandard conditions in
writing
d. Individual awards and recognition
P
S
C
d. Near-miss analysis
e. Problem-solving project teams
e. Loss control information publications
h. Compliance with regulatory requirements for inspections
P
S
C
f. Group awards and recognition
P
S
C
g. Housekeeping promotion systems
P
S
C
4. CRITICAL TASK ANALYSIS AND PROCEDURES
h. Communications with the public about loss control
a. Task analysis system established
10. KNOWLEDGE AND SKILL TRAINING
b. Critical tasks identi ed
a. Training needs analysis
18. HIRING AND PLACEMENT
c. Controls developed for potential losses
b. Instructor quali cations
a. Job capability requirements established
d. Controls incorporated into procedures and practices
c. Training systems
b. Medical examination
e. Critical task procedures/practices updated
d. Training system evaluation and follow-up
c. General orientation/induction
P
S C
d. Pre-employment/pre-placement quali cation checks
11. PERSONAL PROTECTIVE EQUIPMENT
P
S C
a. Identi cation of personal protective equipment needs
19. MATERIALS AND SERVICES MANAGEMENT
P
S C
b. Personal protective equipment available
a. Procurement of goods
5. INCIDENT INVESTIGATION
c. Enforcement of standards
b. Contractor selection
a. Incident investigation system
c. Management of contractors
b. Operating management participation
12. HEALTH AND HYGIENE CONTROL
P
S
C
c. Review of major and high-potential accidents/incidents
a. Health hazard identi cation and evaluation
20. OFF-THE-JOB SAFETY
d. Remedial action and follow-up
b. Health hazard control
a. Problem identi cation and analysis
e. Near-miss reporting and investigation
c. Occupational health and industrial hygiene monitoring
b. O -the-job safety education
d. Information and training
6. TASK OBSERVATION
e. Healthcare system
a. System for partial/spot task observations
f. Ergonomic program
b. System for complete task observations
g. Professional assistance
21. ENVIRONMENTAL MANAGEMENT

DNV SCAT PRODUCTS IMPROVE INVESTIGATIONS AND MANAGEMENT’S KNOWLEDGE OF ACCIDENT CONTROL. The SCAT training manual will enable you to teach your leadership team how to e ectively and systematically track actual and potential loss from occurrence to de ciencies in their system. It is also an excellent package to use in update training on causes and e ects of accidents/loss. Each manual contains a complete lesson plan, a section devoted to stimulating participation with a variety of suggested exercises. A set of black and white 8-1/2 x 11" paper masters for making transparencies and a pad of 20 SCAT charts are also included. Additional SCAT pads of 20 charts are available. Contact your nearest DNV Training Solutions Center.

SCAT_ISRS.R04