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Worksheet Summary
Contributing
Direct
Root
Problem/Deficiency Category
Cause
Cause
Cause
Equipment/
C
Material Problem
Operational
Procedure
Problem
Readiness Problem
Personnel
D
Error
Design
C
Problem
Management/Field
Training
Bridge Problem
Deficiency
Management Problem
R
External Phenomenon
Cause Description:
The direct cause was an untrained employee violated safety procedures by
tying out an interlock and using the wrong meter to test a high voltage fuse.
The root cause was the supervisor assigned an unqualified substitute to
work on high voltage.  Contributing causes were failure to maintain up-to-
date parts (fuse) and tolerance of an unsatisfactory operational system
(frequent fuse blowing).
Corrective Actions:
1.
Train supervision to verify qualifications when assigning personnel
to hazardous tasks.
2.
Evaluate parts inventory and procurement system and, where needed,
discard and replace outdated parts.
3.
Implement procedures and controls to report and correct malfunctioning
systems.
4.
Train employees, as needed, on high voltage systems.
C-12


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