Purpose + Introduction

This tool/checklist is designed to assist teams carrying out a Root Cause Failure Analysis by providing a
standardized way, and a common language, to analyse the elements of the Human Cause, in particular what is
often referred to as a “Human Error”. This then leads into the identification of the underlying system causes.

The intention is not to “blame“ individuals, but to understand what has happened and why it has happened
It is assumed that:
• All people make mistakes! … and will continue to do so!
• Mistake-afflicted situations and bad organizational design cause mistakes
• The focus lies on all contributing factors, not only on individual activities or superficial symptoms
• The processes and the systems of the organization must be changed to improve the situation

The Human cause why tree provided here is:

• Based on DuPont template used for safety investigations
• Input from a various people based on real-life experience
• An Excel® spread sheet file, formatted to copy/paste to PowerPoint® with 3 sections:
• unwise acts
• underlying personal factors
• potential system causes
The appropriate cells should be highlighted to indicate all those that can apply. Comments can be added
to explain in more detail what is meant for a specific investigation.

Before use of this tool it may be necessary to obtain approval from local employee representatives (unions,
Works Council etc.).

system causes

human causes

physical causes

visible failure

Respect for People Reminder

“We must remember not to judge any public servant by any one act, and especially should we beware of
attacking the men who are merely the occasions and not the cause of disaster. ”
Theodore Roosevelt, 26th President of the USA

“People who are out to find fault seldom find anything else. It is a waste of time, no matter how much you find
fault, it is not going to change anything. It's better to find a remedy.”
James Dye, American writer

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 Possible human cause
â
Did the person try to follow the correct procedure?
Procedure = overall instructions for perfoming the task
â â
Yes (intention correct) No (intention at fault)

Was the correct procedure deliberately not followed, or was an incorrect

In what way was the correct action not performed? (execution at fault) procedure mistakenly followed instead?
â â â â
Incorrect action performed - replaced by another Correct action not performed Yes - deliberately not followed No - incorrect procedure mistakenly followed
(skill based failure) (skill based failure) (rule based failure) (knowledge based failure)

â â â â

Slip Lapse Deviation Mistake

Identify all that apply:

Distracted Distracted "New" knowledge Manipulation

"what went wrong"
UNWISE ACTS

Interrupted Early Exit / Lost Count "Strong but wrong" Misdiagnosis

Mistimed Interrupted Routine - cutting of corners Misperception

Repeated Strong Habit Routine - lack of ownership Over simplification

Strong Habit Rush to meet deadline Selection

"Strong but wrong"

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 Slip / Lapse / Deviation / Mistake
Identify all that apply: â â â â
Don’t see the job as worth my attention, not
a high priority Lack of engagement, bored Lack of sense of responsibility

Proprietary attitude – “don’t tell me how to Lack of motivation Unconcern - Assumed that the systems will
Attitude do my job, I already know" catch any errors
“This is waste, not value-added” Frustrated Over motivated - mistaken priorities
Personal relationships with the people they
Emotional No brother-keeper mentality
work with or for
Response/approach exists but person doesn’t
Misleading or incorrect information Cultural differences
UNDERLYING PERSONAL FACTORS

know it

Missing information Requirements not properly described Language barrier

Communication /
"why they acted incorrectly"

information No documented response/approach exists Requirements not understood Status not documented

Mistaken priorities

Loss of focus Multi-tasking Excessive workload

Distracted Distracted Shift breaks Information overload
Interrupted Surprise or unexpected event
Perception that risk is low Out of Practice - no recent training Lack of experience

Earlier successes Assumed process is correct, in spite of evidence Only a few experienced people are able to
showing it wasn't make the process work correctly
Experience and
Insufficient appreciation of the consequences Assumed other
system steps and/or personnel Operator not familiar with newer process,
Judgement would catch any errors tools, etc.
Out of Practice - Uncommon or infrequent
activity
Inadequate sense capability (sight, smell, Change of sense capability, muscle conrol or
etc.) dexterity Affected by alcohol, narcotics, etc.

Inadequate muscle control, dexterity Attention span Forgetting - Occasional

Physical / Mental Ability Physical size (e.g., too large or small for Inherently limited cognitive ability in relation to Forgetting - Recurring
working space) task / Overtaxes abilities

Illness, disease Affected by medications

Rush job / time pressure / rapid response Uncomfortable or unpleasant work Mental fatigue – long shift, complex
Pressure and stress required environment activities, etc.
High visibility Physical fatigue – overload

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 UNDERLYING PERSON
"why they acted in

Deviation (only) Misconduct Deliberate Misconduct Recklessness

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 Slip Lapse Deviation Mistake
Identify all that apply: â â â â

Inappropriate equipment design Communication failure Communication failure ‘Group-think’

"what is the underlying issue"

Obsolete equipment design Organisational failure – no-one tasked Incompatible goals Unusual requirements
Potential System Causes

Poor working environment Poor working environment Organisational failure - lack of Inadequate training
involvement

Poor layout of working environment Poor layout of working environment Poor tasking/scheduling Poor procedure format

Poor procedure design: insufficient Poor procedure design: insufficient Complex procedure design: too many
checks checks Quality culture rules

Poor procedure design: not robust Poor procedure design: not robust Poor information availability

Complex procedure design: too time- Complex procedure design: too time-
Organisational failure - mismatched
consuming consuming

Complex procedure design: too many Complex procedure design: too many
rules rules

Poor tasking/scheduling Poor tasking/scheduling

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 UNWISE ACTS
"what went wrong"
"New" knowledge Person had 'new' knowledge saying that the correct procedure did not need to be followed.
"Strong but wrong" Person had the opinion that it was better not to follow the correct procedure or that the incorrect procedure was correct.
Distracted The person's attention was diverted to something not directly related to the task
Early Exit / Lost Count Completed or moved onto next stage of the task, before current part of task was complete
Interrupted The person's attention was demanded by someone or something not directly related to the task
Manipulation Incorrectly seeking a particular desired result
Misdiagnosis Wrongly interpreted what are the key elements from the task to determine which procedure should be used
Misperception Did not understand the task/situation correctly
Mistimed An action from elsewhere in the task was performed rather than the correct action.
Over simplification The situation was complex and was over-simplified in order to decide which procedure should be followed (Bounded rationality)
Repeated A previous (correct) action was repeated rather than the correct action.
Routine - cutting of corners It was an tolerated (within the immediate environment) working practice that the procedure was not followed 100% correctly.
Routine - lack of ownership There was no commitment (within the immediate environment) that the procedure should be used.
Selection Failure of judgement in selecting correct rule/procedure/task
Strong Habit Slipping into another, very similar, sequence of actions, Failure to carry out any checks in well-practised sequences

UNDERLYING PERSONAL FACTORS

"why they acted incorrectly"
Don’t see the job as worth my attention, not a
high priority

Proprietary attitude – “don’t tell me how to do my

job, I already know"

“This is waste, not value-added” Employee does not think the task adds value and should not need to be done.

Emotional The employee was in an overly-emotional state - that had an impact on their work.

Lack of engagement, bored Employee did not get fully involved in the task, were not interested in the task
Employee lacked motivation, possibly because they were close to retirement, had tenure (job
Attitude Lack of motivation
security) or are senior, or are a temporary worker
Frustrated Employee is frustrated with the task or working environment
Personal relationships with the people they work Personal relationships between the employee and other people they work with (supervisors, co-
with or for workers, customers, suppliers etc.)
Lack of sense of responsibility
Unconcern - Assumed that the systems will
catch any errors
Over motivated - mistaken priorities

No brother-keeper mentality Employee(s) do not look after their co-workers, pointing out potential issues and trying to help them.

Misleading or incorrect information The information the employee was using was misleading or incorrect

Missing information The employee did not have some information needed to perform the task correctly.

No documented response/approach exists

Mistaken priorities Incorrect priorities were communicated to the employee or wrongly interpreted by the employee
Response/approach exists but person doesn’t
Communication / know it
information Requirements not properly described
Requirements are correctly described but the employee did not understand them correctly. This could
Requirements not understood
be due to language issues, intellectual ability/complexity of task.
Differences due to culture between individuals ot groups. Cultural differences can come from
Cultural difference
nationality, geography, background, departmental/functional environment etc.
Language barrier Language skills were a factor, for example not correctly understanding a foreign language.
The actual situation of the task has not been documented - for example information not conveyed at
Status not documented
task handoff.
Loss of focus Employee was not paying 100% attention to the task.
Something external to the employee passively attracted their attention, causing a loss of focus on the
Distracted
task.
Something external to the employee actively attracted their attention, causing a loss of focus on the
Interrupted
task.
Multi-tasking Employee was carrying out more than one task at a time, causing a loss of focus on the task.
Distracted Shift breaks A shift-break interupted the task.

Surprise or unexpected event An unexpected event impacted the task directly, or the employee performing the task.
Employee has too many tasks, meaning they cannot gove the actual task the time and/or attention it
Excessive workload
needs to be performed correctly.
Information overload Employee is receiving to much information to be properly read and understood
Perception that risk is low Employee thought that it was impossible, or very unlikely, that something would go wrong.
Previously there have been no problems when the task was performed in the same way that caused
Earlier successes
a problem this time.
Insufficient appreciation of the consequences Employee was not aware of what would happen, and how serious this would be.
Out of Practice - Uncommon or infrequent
The task was not performed correctly because the employee had not been doing it regularly.
activity
Out of Practice - no recent training The employee had not perforemd the task recently, and had received no recent training.
Experience and
Judgement
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 Experience and
Assumed process is correct, in spite of evidence
Judgement showing it wasn't
Assumed other system steps and/or personnel
would catch any errors
Lack of experience
Only a few experienced people are able to make
the process work correctly
Operator not familiar with newer process, tools, Something had chenged about the process / equipment and the employee had little or no experience
etc. with the changes.

449107100.xls/Definitions Page 7 / 8 11/26/2019


Physical / Mental Ability
Pressure and stress
‘Group-think’
Communication failure
Complex procedure design: too many rules
Complex procedure design: too time-consuming Procedure design has a lack of procedurised “short-cuts”, making it time-consuming and difficult to follow correctly
Inadequate training
Inappropriate equipment design
Incompatible goals
Obsolete equipment design
Organisational failure - lack of involvement
Organisational failure - mismatched
Organisational failure – no-one tasked
Poor information availability
Poor layout of working environment
Poor procedure design, insufficient checks
Poor procedure design: not robust
Poor procedure format
Poor tasking/scheduling
Poor working environment
Quality culture
Unusual requirements
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Inadequate sense capability (sight, smell, etc.)
Inadequate muscle control, dexterity
Physical size (e.g., too large or small for working
space)
Illness, disease
Change of sense capability, muscle control or
dexterity
Attention span
Inherently limited cognitive ability in relation to
task / Overtaxes abilities
Affected by medications Medications = medicines used to treat illness etc
Affected by alcohol, narcotics, etc. Employee is affected by substances unrelated to treating medical conditions
Forgetting - Occasional
Forgetting - Recurring
Rush job / time pressure / rapid response
required
High visibility The outcome of the task is clear to either a large number of colleagues, or to senior management
Uncomfortable or unpleasant work environment
Physical fatigue – overload Employee was physically tired due to an excessive amount of physical tasks.
Mental fatigue – long shift, complex activities,
Employee was mentally tired due to an excessive amount of thinking tasks.
etc.
Potential System Causes
"what is the underlying issue"
Following the behaviour and input from colleagues rather than assessing the individual situation.
Communication failure
Procedure design has too many rules (often to allow for too many unknowns) leading to easily confusable requirements or frequency dominating
selection, making it difficult to follow correctly
Inadequate training and education (esp. in technical professional skills)
Designs which allow hardware to be rebuilt in more than one way
Incompatible goals
Old process or tools are no longer fit for purpose, no longer supported or maintained
Lack of involvement in development, review and upgrade of procedures and monitoring of their effectiveness
Mismatch between what should have been done and the organization (resources, skills) to actually do it.
Organisational failure – no-one tasked to perform the action
Limited access to information
Layout of controls, buttons, switches etc.
Procedure design does not include enough checks or error-proofing
Inappropriate design – not forgiving or tolerant of failure / human fallibility
Layout of procedures makes them hard to follow or select correct one
Poor tasking / scheduling
Temperature, humidity, noise, light , comfort, posture ergonomic etc.
’Weak’ quality culture – lack of shared values
Having to perform work outside of normal requirements
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