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y <br /> Root Cause Analysis Flow Chart <br /> Incident, Near Miss or Questionable <br /> Ilem Occurs Why? <br /> Personal Factor Joh Factor Uncontrollable (3 <br /> Factor <br /> Lack of Skill Lack of Motivation i Lack of or 2 <br /> or Knowledge I Inadequate <br /> Operational <br /> Procedures or <br /> Correct Way Takes Work Standards <br /> More Tune and/or 5 <br /> Requires More <br /> Effort Inadequnte 13" <br /> COITIMUnication of <br /> Expectations j <br /> Regarding <br /> Short-cutting Procedures or <br /> StandardE! Work Standards <br /> Procedures is B <br /> Positively <br /> Reinforced or Inadequate Tools ! a <br /> Tolerated I or Equiprnent <br /> Person Thinks <br /> There is No 7; <br /> Personal Benefit s` <br /> to Always Doing <br /> the Job According .._._.... ........... <br /> ..............._._.._..........._._._.._.__...._....__- <br /> to Standards <br /> Sol ution/Recotnrnendation <br /> Implementation of <br /> Solution/Recommendation <br /> f3c:fore Segit�M1lir1[g. Arty Act:ivityIT.-isRJJcs , After an <br /> _._..__-........_ tllClfjf.'i11•_ or- f+ o-rtc M isf., --my LI11M11SIA.-Il IiC:M1..f1331�':9i7r7CE:.=r: <br /> r " <br /> i <br /> the t1{iM:S <br /> : hnt coulcd 9P v:rGrtfi r biro# if, the +�.•c,r §t thing#Ft�1. r;raul�+ >�..�� -.n it' <br /> l:-16E«dP-05 i*L V.rCtlmk� ? <br /> >;'_ 1 s '�t� Z~'� fTC.A."10 r'r:ciuc;c tho risk!. <br /> On 1 hrivst al th.i r;uce.: zar�,, nijel time a✓di dem 4uclo illis jr-,la sal CIVY e <br /> l Do I all the prai.aer " acts .ancl .?rrci conal prc?cec.ev* oquiprnent'a <br /> "t"oko neci?ssnry -Actf>rr to cn* urs actio$,A.,-is dot a-aq€;:V <br /> t - ---_ Fcll;svt v,6tie ie pen cauures? Ank.trra5519111"r4i, Itne(+ dtlbI <br />