2: Equipment/Software Issue Front-line Personnel Issue External Factors Tolerable Risk Cause Cannot Be Determined Process/Manufacturing Equipment Issue Software Issue Material/Product Issue Utility/Support Equipment Issue Other Equipment Issue Company Personnel Issue Contract Personnel Issue Third-party Personnel Issue Natural Phenomena External Events External Sabotage and Other Criminal Activity Design Issue Equipment Reliability Program Issue Documentation and Records Issue Material/Parts and Product Issue Hazard/Defect Identification and Analysis Issue Procedure Issue Human Factors Issue Training/Personnel Qualification Issue Supervision Issue Verbal and Informal Written Communication Issue Personnel Performance Issue Design Input Issue Design Scope Issue Design Input Data Issue Design Output Issue Design Output Incorrect Design Output Unclear or Inconsistent Design Review/Verification Issue No Review/Verification Review/Verification Issue Enter here with each intermediate cause Company Standards, Policies and Administrative Controls (SPAC) Issue No SPAC or Issue Not Addressed in SPAC SPAC Not Strict Enough SPAC Confusing or Contradictory SPAC Incorrect Company Standards, Policies and Administrative Controls (SPAC) Not Used Unaware of SPAC SPAC Recently Changed SPAC Enforcement Issue Equipment Reliability Program Design Issue Critical Equipment Not Identified No or Inappropriate Maintenance Selected Risk Acceptance Issue Periodic Maintenance Issue Scope Issue Frequency Specification Issue Implementation Issue Event-based Maintenance Issue Scope Issue Event Specification Issue Monitoring Issue Implementation Issue Condition-based Maintenance Issue Scope Issue Detection Method Issue Monitoring Issue Data Interpretation Issue Fault-finding Maintenance and Inspection Issue Scope Issue Scheduling/Frequency Issue Implementation Issue Corrective Maintenance Issue Troubleshooting/Corrective Action Issue Repair Implementation Issue Routine Inspection and Servicing Issue Scope Issue Scheduling/Frequency Issue Troubleshooting/Corrective Action Issue Equipment Records and Manuals Issue Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date Documents Used Operational and Maintenance History Issue Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date Documents Used Risk Assessment Records Issue Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date Documents Used Personnel Records Issue Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date Documents Used Other Documents and Records Issue Documentation Content Inaccurate or Incomplete Documents Not Available or Missing Out-of-date Documents Used Material/Parts Issue Purchasing Specification Issue Packaging/Transportation Issue Acceptance Criteria Issue Acceptance Testing Implementation Issue Handling and Storage Issue Inventory Level Issue Product Control and Acceptance Issue Product Specification Issue Product Acceptance Criteria Issue Inspection Issue Packaging, Handling, Transportation Issue Storage Issue Inventory Level Issue Readiness Review Issue Review Not Performed Implementation Issue Change Control Issue Change Identification Issue No Change Assessment Performed Change Assessment Issue Change Assessment Timing Issue Risk Acceptance Issue Proactive Risk/Safety/Reliability/Quality/Security Analysis Issue Analysis Not Performed Analysis Issue Recommendation Identification Issue Recommendation Implementation Issue Risk Acceptance Issue Reactive Risk/Safety/Reliability/Quality/Security Analysis Issue Problem/Incident Reporting/Identification Issue Investigation Issue Recommendation Identification Issue Recommendation Implementation Issue Risk Acceptance Issue Inspection/Audit/Measurement Issue Requirements Not Identified Implementation Issue Recommendation Identification Issue Issue Tracking/Implementation Issue Risk Acceptance Issue Correct Procedure for Task/Operation No Procedure for Task/Operation Procedure Difficult to Obtain Procedure Use Discouraged Procedure Difficult to Use Language Issue Procedure Difficult to Identify Wrong Revision Used Correct Procedure Used Incorrectly Format Inappropriate Confusing/Complex/Difficult to Use More than One Action Per Step Inadequate Checklist Graphics/Drawing Issue Language/Wording Issue Insufficient or Excessive References Too Much/Too Little Detail Appropriate Procedure Incorrect/Incomplete Wrong Action Sequence/Ordering Facts Wrong, Requirements Incorrect, or Content Not Updated Inconsistent Procedural Requirements Missing Steps/Content/Situation Not Covered Overlap or Gaps Between Procedures Tools/Equipment Issue Appropriate Tools/Equipment Not Used Tools/Equipment Not Functioning Properly Workplace Layout Issue Individual Control/Display/Alarm Issue Control/Display/Alarm Integration/Arrangement Issue Awkward/Inconvenient/Inaccessible Location of Control/Display/Alarm Awkward/Inconvenient/Inaccessible Equipment Location Poor/Illegible Labeling of Control/Display/Alarm or Equipment Work Environment Issue Housekeeping Issue Ambient Conditions Issue Protective Clothing/Equipment Issue Physical Workload Issue Sustained High Workload/Fatigue High Transient Workload Mental Workload Issue Knowledge-based Behavior Issue Rule-based Behavior Issue Skill-based Behavior Issue Unrealistic Monitoring Requirement Error Mitigation Issue Errors Not Detectable Errors Could Not Be Corrected/Mitigated No Training Decision Not to Train Training Need Not Identified Training Requirements Not Completed Training Implementation Issue Training Program Design/Development Issue Classroom Training Issue Laboratory/Practical Training Issue On-the-job Training Issue Self Study and Computer-based Training Issue Continuing Training Issue Training Resources Issue Qualification Issue Preparation Issue Job Plan/Instructions to Workers Issue Ineffective Walkthrough Job Scheduling Issue Personnel Selection/Assignment/Scheduling Issue Responsibility/Authority Issue Supervision During Work Issue Improper Performance Not Corrected Teamwork/Coordination Issue Too Much/Too Little Supervision No Communication or Not Timely Method Unavailable or Inadequate Communication Not Timely/Not Performed Communication Misunderstood/Incorrect Standard Terminology Not Used Language/Translation Issue Verification/Repeat-back Not Used Long Message Other Misunderstood Communications Wrong Instructions Company Issue Personnel Hiring Issue Resource/Staffing Issue Rewards/Incentives Issue Detection of Individual Performance Problem Issue Individual Issue Sensory/Perceptual Abilities Issue Mental Capabilities Issue Physical Capabilities Issue Personal Problem Prescribed Drug Interaction Issue Horseplay Off-the-job Rest/Sleep (Fatigue) Issue Disregard for Company Procedures/Policies Drug/Alcohol Abuse Internal Sabotage or Criminal Activity