SCAT - Systematic Cause Analysis Technique

TYPE OF EVENT

See Immediate Causes
1
Struck against (running or bumping into) Struck by (hit by moving object)

1, 2, 4, 5, 6, 9, 11, 12, 13, 14,15, 16, 17,18,19,20,21, 22, 23, 24, 25, 27, 31, 39, 40
2
Fall from elevation to lower level fall on same level (slip and fall, trip over)

3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 21, 22, 23, 26, 27,31, 33, 36, 40
3
Caught in (pinch and nip points) Caught on (snagged, hung) Caught between or under (crushed or amputated)

4, 5, 6, 9, 10, 11, 12, 15, 16, 17, 18, 19, 21, 22, 23, 24 35
4
Contact with (electricity, heat, cold, radiation, ignition source, caustics, toxics, biological, noise, plant and equipment.

2, 3, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 40
5
Abnormal Operating conditions, following temporary instructions

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
6
Product Contamination, process systems, storage tank, shipping, external stakeholder

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
7
Overstress (over-exertion, overload, over-exposure, ergonomic, human factor man and machine interface

3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 24, 25, 35, 37, 40
8
Equipment failure, instrument, piping, pump, vessel, etc

1, 4, 6, 8, 16, 18, 23, 25, 30, 32, 33, 34, 35, 37, 38, 40, 41, 42, 43, 44, 45
9
Environmental pollution, inside of site boundary

1, 2, 3, 5, 6, 8, 9, 12, 15, 16, 17, 18, 19, 20, 23, 25, 26, 30, 32, 33, 34, 35, 36, 38, 41, 42, 43, 44, 45
10
Environmental pollution, outside of site boundary

1, 2, 3, 5, 6, 8, 9, 12, 15, 16, 17, 18, 19, 20, 23, 25, 26, 30, 32, 33, 34, 35, 36, 38, 41, 42, 43, 44, 45
11
Loss of containment - any classified substance

1, 4, 5, 6, 8, 9, 10, 12, 13,14, 15, 16, 17, 18, 20, 25, 31, 34, 35, 36, 41, 42, 43, 44, 45
12
Release of substances to a closed system via a relief valve or over pressure protection system

1, 4, 5, 6, 8, 9, 10, 12, 13,14, 15, 16, 17, 18, 20, 25, 31, 34, 35, 36, 41, 42, 43, 44, 45
13
Mobile plant or equipment - road traffic vehicle – contact with operating plant or equipment

1, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 21, 23, 24, 27, 28, 31, 33, 36, 37, 39, 40, 41, 42, 43, 44, 45

IMMEDIATE CAUSES
SUBSTANDARD ACTS

See Basic Causes

SUBSTANDARD ACTS

See Basic Causes
SUBSTANDARD CONDITIONS

See Basic Causes

SUBSTANDARD CONDITIONS

See Basic Causes
1
Operating equipment without authority

2, 4, 5, 7, 8, 9, 13, 14, 16
18
Failure to check/monitor

2, 3, 4, 5, 6, 7, 9, 10, 12, 13, 14, 15, 16
21
Inadequate guards or barriers

5, 9, 10, 11, 12, 13, 15
38
Inadequate communications hardware/ software process

7, 9, 10, 11, 12, 13, 15, 16
2
Failure to warn

1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 15, 16
19
Failure to react/correct

1, 2, 3, 4, 5, 6, 7, 9, 13, 14, 16
22
Inadequate or improper protective equipment

5, 7, 8, 9, 10, 11, 12, 13, 15

3
Failure to secure

1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 14
20
Failure to communicate/ coordinate

3, 4, 5, 7, 9, 10, 16
23
Defective tools, equipment or materials

8, 9, 10, 11, 12, 13, 15
39
Road conditions

5, 7, 8, 9, 10, 12, 13, 14, 15
4
Operating at improper speed

2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14,
41
Failed to respond to an alarm

3, 4, 5, 6, 7, 8, 9, 14, 16,
24
Congestion or restricted action

9, 10, 11, 14
40
Weather conditions

5, 7, 9, 13, 14, 16
5
Making safety devices inoperative

2, 3, 4, 5, 6, 7, 8, 9, 10,
42
Failed to respect a safety warning notice

3, 4, 5, 6, 7, 8, 9, 14, 16,
25
Inadequate warning system

8, 9, 10, 11, 12, 13, 14, 15, 16
45
Biological hazards

5, 6, 7, 9, 10, 14
6
Using defective equipment

2,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16
43
Individual was not following good / best practice procedures or methods

5, 6, 7, 9, 14, 16
26
Fire and explosion hazards

5, 6, 7, 8, 9, 10, 11, 12, 13, 15
46
Poor illumination or ventilation

5, 6, 7, 9, 10, 14
7
Failing to use PPE properly

1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 13, 14, 15, 16
44
Failed to follow guidance / instruction from supervision

5, 6, 7, 9, 14, 16
27
Poor housekeeping disorder

7, 8, 9, 10, 12, 14, 15
47
Defective tools – equipment - infrastructure

5, 6, 7, 9, 10, 14
8
Improper loading

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14

28
Noise exposure

5, 7, 8, 9, 10, 11, 12, 13, 14, 16

9
Improper placement

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14

29
Radiation exposure

5, 7, 8, 9, 10, 11, 12, 13, 14, 16

10
Improper lifting

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14,

30
Temperature extremes

5, 7, 9, 10, 14

11
Improper position for task

1, 2, 3, 4, 5, 6, 7, 9, 10, 13, 14, 16

31
Inadequate or excess illumination

5, 7, 9, 10, 11, 12, 13, 15

12
Servicing equipment in operation

3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16

32
Inadequate ventilation

5, 7, 9, 10, 12, 13, 15

13
Horseplay

2, 3, 4, 5, 7, 8, 9, 14

33
Presence of harmful materials

5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16

14
Under influence alcohol and/or other drugs

1, 2, 3, 4, 5, 7, 8, 9, 14

34
Inadequate instructions/procedures

5, 6, 7, 9, 10, 14, 16

15
Using equipment improperly

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16

35
Inadequate information/data

5, 6, 9, 10, 11, 12, 16

16
Failure to follow procedure/policy/practice

1, 2, 3, 4, 5, 6, 7, 8, 9, 14, 16

36
Inadequate preparation/planning

5, 6, 7, 9, 14, 16

17
Failure to identify hazard/risk

3, 4, 5, 6, 7, 9, 14

37
Inadequate support/assistance

7, 9, 11, 12,16

ROOT/UNDERLYING CAUSES
PERSONAL FACTORS
JOB FACTORS
1
Inadequate Physical/Physiological Capability

4.6
“Meaningless” or “degrading” activities

9
Inadequate Leadership and/or Supervision

12.2
Inadequate reparative

16
Inadequate Communications

1.1
Inappropriate height, weight, size, strength, reach etc.

4.7
Confusing directions/demands

9.1
Unclear or conflicting reporting relationships

12.2.1
Communication of needs

16.1
Inadequate horizontal communication between peers

1.2
Restricted range of body movement

4.8
Conflicting demands/directions

9.2
Unclear or conflicting assignment of responsibility

12.2.2
Scheduling of work

1.3
Limited ability to sustain body positions

4.9
Preoccupation with problems

9.3
Improper or insufficient delegation

12.2.3
Examination of units

16.2
Inadequate vertical communication between supervisor and person

1.4
Substance sensitivities or allergies

4.10
Frustration

9.4
Giving inadequate policy, procedure, practices or guidelines

12.2.4
Part substitution

1.5
Sensitivities to sensory extremes (temperature, sound etc)

4.11
Mental illness

9.5
Giving objectives, goals or standard that conflict

16.3
Inadequate communication between different organisations

1.6
Vision deficiency

9.6
Inadequate work planning or programming

13
Inadequate Tools and Equipment

1.7
Hearing deficiency

5
Lack of Knowledge

9.7
Inadequate instructions, orientation and/or training

13.1
Inadequate assessment of needs and risks

16.4
Inadequate communication between work groups

1.8
Other sensory deficiency (touch, taste, smell, balance)

5.1
Lack of experience

9.8
Providing inadequate reference documents

13.2
Inadequate human factors/ergonomic considerations

1.9
Respiratory incapacity

5.2
Inadequate orientation

9.9
Inadequate identification and evaluation of loss exposures

13.3
Inadequate standards or specifications

16.5
Inadequate communication between shifts

1.10
Other permanent physical capabilities

5.3
Inadequate initial training

9.10
Lack of supervisory / management job knowledge

13.4
Inadequate availability

1.11
Temporary disabilities

5.4
Inadequate update training

9.11
Inadequate matching of individual qualifications and job/task requirements

13.5
Inadequate adjustment/repair/maintenance

16.6
Inadequate communication methods

5.5
Misunderstood directions

9.12
Inadequate performance measurement and evaluation

13.6
Inadequate salvage and reclamation

16.7
No communication method available

2
Inadequate Mental/Psychological Capability

9.13
Inadequate or incorrect performance feedback

13.7
Inadequate removal and replacement of unsuitable items

16.8
Incorrect instructions

2.1
Fears and phobias

6
Lack of Skill

16.9
Inadequate communication due to job turnover

2.2
Emotional disturbance

6.1
Inadequate initial instruction

10
Inadequate Engineering (Either in design or construction)

14
Inadequate Work Standards

2.3
Mental illness

6.2
Inadequate practice

10.1
Inadequate assessment of loss exposures

14.1
Inadequate development of standards for

16.10
Inadequate communication of safety and health data, regulations or guidelines

2.4
Intelligence level

6.3
Infrequent performance

10.2
Inadequate consideration of human factors/ergonomics

14.1.1
Inventory & evaluation of exposures & needs

2.5
Inability to comprehend

6.4
Lack of coaching

10.3
Inadequate standards, specifications and/or design criteria

14.1.2
Coordination with process design

16.11
Standard terminology not used

2.6
Poor coordination

6.5
Inadequate review instructions

10.4
Inadequate monitoring of construction

14.1.3
Employee involvement

16.12
Verification/repeat feedback techniques not used

2.7
Slow reaction time

10.5
Inadequate assessment of operational readiness

14.1.4
Procedures/practices/rules

2.8
Low mechanical aptitude

7
Improper Motivation

10.6
Inadequate or improper controls

14.2
Inadequate communication of standards for

16.13
Messages too long

2.9
Low learning aptitude

7.1
Improper performance is rewarded (tolerated)

10.7
Inadequate monitoring or initial operation

14.2.1
Publication

16.14
Speech interference

2.10
Memory failure

7.2
Proper performance is punished

10.8
Inadequate evaluation of changes

14.2.2
Distribution

7.3
Lack of incentives

14.2.3
Translation of appropriate languages

3
Physical or Physiological Stress

7.4
Excessive frustration

11
Inadequate Purchasing

14.2.4
Training

3.1
Injury or illness

7.5
Inappropriate aggression

11.1
Inadequate specifications on requisitions

14.2.5
Reinforcing with sings, colour codes and job aids

3.2
Fatigue due to task of load or duration

7.6
Improper attempt to save time or effort

11.2
Inadequate research on materials/equipment

14.3
Inadequate maintenance of standards for

3.3
Fatigue due to lack of rest

7.7
Improper attempt to avoid discomfort

11.3
Inadequate specifications to vendors

14.3.1
Tracking of work flow

3.4
Fatigue due to sensory overload

7.8
Improper attempt to gain attention

11.4
Inadequate mode or route of shipment

14.3.2
Updating

3.5
Exposure to health hazards

7.9
Inadequate discipline

11.5
Inadequate receiving inspection and acceptance

14.3.3
Monitoring use of procedures/ practices/ rules

3.6
Exposure to temperature extremes

7.10
Inappropriate peer pressure

11.6
Inadequate communication of safety and health data

14.4
Inadequate monitoring of compliance

3.7
Oxygen deficiency

7.11
Improper supervisory example

11.7
Improper handling of materials

3.8
Atmospheric pressure variation

7.12
Inadequate performance feedback

11.8
Improper storage of materials

15
Excessive Wear and Tear

3.9
Constrained movement

7.13
Inadequate reinforcement of proper behaviour

11.9
Improper transporting of materials

15.1
Inadequate planning of use

3.10
Blood sugar insufficiency

7.14
Improper production incentives

11.10
Inadequate identification of hazardous materials

15.2
Improper extension of service life

3.11
Drugs

11.11
Improper salvage and/or waste disposal

15.3
Inadequate inspection and/or monitoring

8
Abuse or Misuse

11.12
Inadequate contractor selection

15.4
Improper loading or rate of use

4
Mental or Psychological Stress

8.1
Improper conduct that is condoned

12
Inadequate Maintenance

15.5
Inadequate maintenance

4.1
Emotional overload

8.1.1
Intentional

12.1
Inadequate preventive

15.6
Use by unqualified or untrained people

4.2
Fatigue due to mental task load or speed

8.1.2
Unintentional

12.1.1

15.7
Use for wrong purpose

4.3
Extreme judgement/decision demands

8.2
Improper conduct that is not condoned

12.1.2
Lubrication and servicing

4.4
Routine, monotony, demand for uneventful vigilance

8.2.1
Intentional

12.1.3
Adjustment/assembly

4.5
Extreme concentration / perception demands

8.2.2
Unintentional

12.1.4
Cleaning or resurfacing