SCAT
Systematic
Cause
Analysis
Technique
Prepared by :
Engr. Rency A. Zapanta
ECE lic# 30116
OSH Practitioner C/A -1033-100517-0054
Objectives
Attendees will understand a simple technique
valuable in determining if an investigation of
an accident or incident has been thorough.
Reasons for Poor Causal Identification
1. Failure to do a good investigation
2. Failure to take enough time
3. Failure to use a systematic approach
4. Forgetting previous training
5. Improper motivation
6. Lack of method for checking results
Sources of Loss and Control
People
Equipment
Material
Environment
Principle of Multiple Causes
Accidents and other problems are seldom, if
ever, the result of a single cause.
DNV Loss Causation Model
LACK
LACK OF
OF BASIC
BASIC IMMEDIATE
IMMEDIATE
CONTROL
CONTROL CAUSES
CAUSES CAUSES
CAUSES INCIDENT LOSS
Inadequate
Inadequate Personal Substandard Event
Event Unintended
Unintended
Factors Acts / Harm
Harm
•• System
System
Practices
•• Standards
Standards Or
Or
•• System
System Job
Job // System
System Substandard
Substandard •• Compliance
Compliance Damage
Factors
Factors Conditions
Conditions Damage
•• Standards
•• Compliance
LOSS
Lack of Basic Immediate Incident Loss
Control Causes Causes
People
Environment
Property
Process
INCIDENT
Lack of Basic Immediate Incident Loss
Control Causes Causes
Contact with Energy or Substance
Struck against Caught in
Struck by Caught on
Fall to Caught between
Fall on Contact with
Overstress
IMMEDIATE CAUSES
Lack of Basic Immediate Incident Loss
Control Causes Causes
Substandard Acts / Practices Substandard Conditions
Failure to warn Inadequate guards / barriers
Failure to obey rules Inadequate PPE
Failure to follow procedures Defective tools / equipment
Removing safety devices Congestion
Improper lifting Inadequate warning system
Failure to use PPE Disorder
Servicing operating equipment Excessive exposures
Horseplay Inadequate ventilation
Inadequate illumination
BASIC CAUSES
Lack of Basic Immediate Incident Loss
Control Causes Causes
Job Factors Personal Factors
Inadequate leadership Inadequate capability
Inadequate engineering Lack of knowledge
Inadequate purchasing Lack of skill
Inadequate tools and equipment Stress
Inadequate maintenance Improper motivation
Inadequate work standards
Wear and tear
Abuse and misuse
LACK OF CONTROL
Lack of Basic Immediate Incident Loss
Control Causes Causes
INADEQUATE
System
Standards
Compliance
System Standards
• What is to be done?
• How often is to be done?
• What quality is required?
• Who is to do it?
• Where is it to be done?
• When is it to be done?
• What records are kept?
• What reviews are done?
Hazards Control Measure Hierarchy
• Hazard Elimination
• Product/Process Substitution
• Engineering Control
• Administrative Control
• Personal Protective Equipment (PPE)
“The end is that workers shall live to enjoy the
fruits of their labor; that parents shall have the
comfort of children in their old age; that children
shall have parents; and that disabled persons
who were once strong shall no longer be a by-
product of employment.”
Accident Investigation
Workshop
