7/29/2019 17594 CLC Poster AW
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When an investigation team does notunderstand why a person acted
asthey did, an antecendent-behaviour-consequence analysis is useul
to
better understand those behaviours.This understanding provides a
qualitycause analysis in the CLC.
To be eective, the ABC analysisshould be done ater the evidence
isgathered, but prior to the start o thecause analysis.
To perorm an ABC analysis:
Identiy the behaviour(s) in thiscritical actor a behaviour is
an
observable action, i.e. what aperson does or doesnt do or
say.
Write a statement o behaviour,including who perormed
thebehaviour, the task they wereengaged in at the time, what
theydid or did not do, and what was theoutcome o that.
See A Guide to ABC Analysisor more detail.
There are two tools or analysis obehaviour and we determine
whichtool to use based on whether thebehaviour was intended or
unintended.Most behaviours are intentional, eveni the outcome o
that behaviour wasunintentional or undesired.
I the behaviour was intentional,proceed with the ABC
analysis.
I the behaviour was unintentional,consult with a master level
RootCause Specialist, who has specicexpertise in this area.
Unintentionalbehaviours are inrequent.
Antecedents are the things whichtrigger or promote a specic
behaviour.Some antecedents are necessaryor the behaviour to be
possible oreasible, but antecedents alone willnot guarantee the
behaviour will beperormed.
Some examples o commonantecedents at work are:
signs
knowledge
warning labels
expectations o others
training programs
expectations o your supervisor
policies
tools and equipment
rules
example set by others
procedures
sucient time
working environment
Identiy the antecedents present inthis instance prior to the
behaviour.
Rate each antecedent as present andeective, present and not
eective ornot relevant or absent.
Use this understanding to selectappropriate causes or the
critical
actor associated with this behaviour
Consequences are a more poweruldriver or behaviour than
antecedentsare, but to understand consequences,we must consider
them rom theperspective o the person perormingthat behaviour. What
did that personexpect to get rom perorming thatway? Remember two
key points:1) most behaviour is rational to theperson perorming it
and2) consequences can be bothpositive and negative.
Some examples o commonconsequences at work:
saves time or eort
get injured
saves money
get caught by supervisor
get approval rom a supervisor
get corrected by a co-worker
go home early
personal discomort
avoid embarrassment
For each expected consequence:
Rate each consequence as:1. either positive or negative,2.
immediate or uture and3. certain to occur, or uncertain.
Ater you have completed the ABCanalysis, the additional insights
youhave into the behaviours exhibited bythe people involved in the
incidentwill assist you in identiying theproper causes or each
critical actor.
Continue with the CLC processto identiy the causes o
eachcritical actor.
Comprehensive List o CausesA Tool or Root Cause Analysis
Finishing up
Assess existing barriers
Understand each barrierthat was either in place, or
thought to be in place,prior to the incident.
As part o your analysis, listeach barrier and describewhy it was
ineective.
Propose corrective actionsto x or strengthenexisting barriers
beorerecommending new ones.
Draft yourrecommendations
Corrective actions should bespecic and targeted to thecauses you
have identied
Each cause listed must becovered or addressed by acorrective
action.
Test yourthought process
The investigation team mustdiscuss and agree that itheir
corrective actions areproperly implemented, theywill be sucient to
prevent
recurrence. I not, you muststrengthen them.
There must be symmetrybetween the cause andthe corrective
action. Forexample, an engineeringcause must have anengineering
corrective actionand a behavioural causemust have a
behaviouralcorrective action. Behaviouralissues must consider
theorganizational and culturalissues which enable
thatbehaviour.
Quality Tip
This concept o symmetryshould be your nal qualitycheck beore
submittingyour report. A lack osymmetry between thecause and the
correctiveaction is inherentlyineective.
Quality Tip
Take care to properlydevelop each correctiveaction statement.
Reerto training materials ora urther discussion othe
characteristics otargeted, eectivecorrective actions.
Getting started
Organize a small team, withthe appropriate training
andinstruction.
Set terms o reerence orthe work.
Preserve the evidence priorto starting the investigation.
See the RCA website ormost recent
supportdocuments:https://rca.bpglobal.com.
Quality Tip
Good local preparationallows or a aster start tothe
investigation, whichyields a better investigation.
Gathering evidence
Visit the scene o theincident (positions).
Interview using properinterview techniques unnelling and
numerous5WH questions (people).
Examine relevant records paper or electronic (paper).
Inspect the equipmentinvolved (parts).
The our Ps: position, people,paper and parts
representevidence.
Quality Tip
A solid RCA investigationis dependent on actualinormation. The
more actsyou gather, the better yourinvestigation.
Using the CLC
Beore using the CLC,organize the evidenceinto a timeline.
Identiy and write the criticalactors short, specic andaction
oriented is best.
Then perorm an ABCanalysis as needed to betterunderstand
behavioursprior to using the CLC.
Ater the ABC analysisis complete, use theCLC with the Glossaryto
determine the causesor each critical actor.
Quality Tip
A concisely worded criticalactor allows the investigationteam to
ocus theirdiscussions and helps to tellthe story in the
incidentreport. Reer to trainingmaterials or a urtherdiscussion and
examples owell crated critical actors.
Quality Tip
Each cause you list must:1) be supported by evidenceand 2)
answer why thecritical actor existed. I acause does not meet botho
these elements, it shouldnot be used.
Possible immediate causes
Actions
1 Did not follow existingprocedures
1.1 Violation (by individual )
1.2 Violation (by group)1.3 Violation (by supervisor)
1.4 Procedure not available
1.5 Procedure was notunderstood
1.6 Other
2 Use of tools, plant/equipment or vehicle
2.1 Plant/equi pment or vehicleused in the wrong way
2.2 Tools used in the wrong way
2.3 Use o plant/equi pment orvehicle with known deect
2.4 Use o tools with a knowndeect
2.5 Incorrect placement o tools,equipment or materials
2.6 Operation o plant/equ ipmentor vehicle at improper speed
2.7 Other
3 Use of protectiv eequipment or methods
3.1 Need or protectiveequipment or methods notrecognized
3.2 Personal protectiveequipment or methods
not used3.3 Incorrect use o personal
protective equipment ormethods
3.4 Personal protectiveequipment or methodsnot available
3.5 Disabled guards, warningsystems or saety devices
3.6 Removal o guards, warningsystems or saety devices
3.7 Other
4 Lack of focus or inattention
4.1 Distracted by other concerns
4.2 Inattention to surroundings
4.3 Inappropriate workplacebehaviour
4.4 No warning provided
4.5 Unintentional human error
4.6 Routine activity withoutthought
4.7 Other
Conditions
5 Protective systems
5.1 Guards or protective devicesnot eective
5.2 Deective guards or protectivedevices
5.3 Incorrect personal protectiveequipment
5.4 Deective personal protectiveequipment
5.5 Warning systems not eective
5.6 Deective warning systems
5.7 Saety devices werenot eective
5.8 Deective saety devices
5.9 Other
6 Tools, plant/equipment& vehicles
6.1 Plant/equi pment malunction
6.2 Preparation o plant/equipment
6.3 Tool malunction
6.4 Preparation o tools
6.5 Vehicle malunction
6.6 Preparation o vehicle
6.7 Other
7 Unanticipated exposure to
7.1 Fire and explosion
7.2 Noise
7.3 Energized electrical systems
7.4 Energized sources other thanelectrical
7.5 Temperature extremes7.6 Hazardous chemicals
7.7 Mechanical hazards
7.8 Storms or acts o nature
7.9 Other
8 Workplace layout
8.1 Congestion
8.2 Illumination
8.3 Ventilation
8.4 Unprotected height
8.5 Workplace displays
8.6 Other
Possible system causes
Personal actors
9 Physical capabilitie s
9.1 Vision deciency
9.2 Hearing deciency
9.3 Other sensory deciency
9.4 Other permanent physicaldisabilities
9.5 Substance sensitivitiesor allergies
9.6 Size or strength limitations
9.7 Other
10 Physical condition
10.1 Previous injury or illness
10.2 Fatigue
10.3 Diminished perormance
10.4 Impairment due to drug,alcohol or medication
10.5 Other
11 Mental capability
11.1 Memory ailure
11.2 Poor co-ordination orreaction time
11.3 Emotional status
11.4 Fears or phobias
11.5 Low mechanical aptitude
11.6 Low learning aptitude
11.7 Incorrect judgment
11.8 Other
12 Mental stress
12.1 Preoccupation with problems
12.2 Frustration
12.3 Conusing directions/
demands12.4 Conficting directions/
demands
12.5 Extreme decision demands
12.6 Unusual concentration orperception demands
12.7 Other emotional overload
12.8 Other
13 Behaviour
13.1 Antecedent not present
13.2 Antecedent not eective
13.3 Incorrect behaviour reinorced
13.4 Incorrect behaviour notconronted
13.5 Proper behaviour notrewarded
13.6 Behavioural analysis processnot eective
13.7 Other
14 Skill level/compete ncy
14.1 Assessment o required skillsor competency not eective
14.2 Practice o skill not eective
14.3 No coaching on skill
14.4 Inrequent perormance
o skill14.5 Other
Job actors
15 Training/knowledge transfer
15.1 No training provided
15.2 Training eort not eective
15.3 Knowledge transer noteective
15.4 Training materials not recalled
15.5 Other
16 Management/supervision/employee leadership
16.1 Behaviours not reinorced
16.2 Participation in saety eortsnot eective
16.3 Consideration o saety instang not eective
16.4 Resourcing or saety noteective
16.5 Support o people noteective
16.6 Monitoring/auditing o saetyprocess not eective
16.7 Lessons learned notembedded
16.8 Leadership or accountability16.9 Employee involvement
not eective
16.10 Risk analysis or tolerancenot eective
16.11 Other
17 Contractor selection& oversight
17.1 No contractor pre-qualication process
17.2 Contractor pre-qualicationprocess not eective
17.3 Use o a non-approvedcontractor
17.4 Contractor selectionnot eective
17.5 No job oversight process
17.6 Job oversight not eective
17.7 Other
18 Engineering/design
18.1 Technical design not correct
18.2 Design standards,specications or criteria notcorrect
18.3 Incorrect ergonomic orhuman actor design
18.4 Monitoring o construction
not eective18.5 Assessment o operational
readiness not eective
18.6 Monitoring o initial operationnot eective
18.7 Technical analysis or risknot eective
18.8 Other
19 Control of Work (CoW)
19.1 No work planning or riskassessment perormed
19.2 Risk assessment not eective
19.3 Required permit not obtained
19.4 Specied controls notollowed
19.5 Change in job scope
19.6 Worksite not let sae
19.7 Other
20 Purchasing, materialhandling & material control
20.1 Incorrect item ordered
20.2 Incorrect item received
20.3 Handling or shippingnot eective
20.4 Storage o materialsnot eective
20.5 Labelling o materialsnot eective
20.6 Other
21 Tools & plant/equipment
21.1 Wrong tools or plant/equipment provided
21.2 Correct tools or plant/equipment not available
21.3 No inspection
21.4 Incorrect adjustment/repair/maintenance
21.5 Removal or replacement ounsuitable items not eective
21.6 No preventative maintenanceprogram
21.7 Testing o plant, tools orequipment not perormed
21.8 Other
22 Standards/Practices/Procedures (SPP)
22.1 Lack o SPP or the task
22.2 Development o SPPnot eective
22.3 Communication o SPPnot eective
22.4 Implementation o SPPnot eective
22.5 Enorcement o SPPnot eective
22.6 Other
23 Communication
23.1 Horizontal communicationbetween peers not eective
23.2 Vertical communicationbetween supervisor andperson not
eective
23.3 Communication betweendierent organizations noteective
23.4 Communication betweenwork groups not eective
23.5 Communication betweenshits not eective
23.6 Communication not received
23.7 Incorrect inormation
23.8 Inormation not understood
23.9 Other
Quality Tip
Once you have identiedsystem causes, recognize
you are likely not at the rootcause level. Continue to
askyoursel and your investigationteam why? until you aresatised you
have exhaustedall possibilities. Using the5 Why technique is
aneective way to drill deeper.
Quality Tip
A key responsibility o theinvestigation team leader is topush
the team to identiy whensystem causes are not yetroot causes, and
then speciyadditional causes not shown onthe chart.
Corrective actionsAntecedent-Behaviour-Consequence analysis
CausesPreliminaries
02. Choose the right tool
03. Consider antecedents
04. Consider expected consequences
Quality Tip
The more specic you are inidentiying the behaviour, the
more specic the ABC willbe. This will give you a
betterunderstanding o causes. Notethat there may be more thanone
behaviour in a speciccritical actor. Each behaviourshould be listed
and analysedseparately. For example, aworker and a supervisor
mightexhibit dierent behaviours ordierent reasons.
Quality Tip
To determine i a behaviourwas intentional, ocus onthe action,
not the outcome.or example, I was using amobile phone while
driving,became distracted and hadan accident. The behaviouris using
a mobile phone while
driving and it is intentional.The outcome was I becamedistracted
and had an accident.While that is an undesirableoutcome, it does
not changethe act the behaviour wasintentional.
Quality Tip
An antecedent can be presentand still not prevent an
undesiredbehaviour. For example, i awarning sign says do not
usethis equipment and a personignores that and uses theequipment,
the antecedentis present and eective itconveyed the right
inormationto the person. I an antecedentis rated as ineective, you
willneed to speciy a correctiveaction or it.
Quality Tip
Behaviour experts believethat consequences whichare positive,
immediate,certain and meaningul tothe individual are the
mostpowerul drivers o behaviour.
Colour key to references: People Plant Process
CLC is a tool which ensureswe have a consistent approachto
investigating incidentsand analyzing their rootcauses. Incident
investigationis an element o the OMS,BPs shared way o operatingto
promote continuousimprovement across the group.
01. Identify behaviours
BP_CLC_poster_AW_v4.indd 1 16/10/07 12:00:35 pm
