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GasLog LNG Services Ltd. Comprehensive List of Causes CLC

Rev.: 0 Effective Date: 01.Nov.2012 COLLECTION OF EVIDENCE

PRIOR STARTING  Selection of Investigation Team: People taking part in the investigation team should be involved in the incident and have the appropriate qualifications  Secure evidence : Team should preserve the evidence prior starting the investigations

INCIDENT/ ACCIDENT

   

Position : take photos ,make sketches of the position of all participants from all angle Parts : Evidence on the scene (equipment, tools, materials) People : Conduct Interviews no more than 24 hrs after the incident Paper: Relevant documentation (permits, certificates, training records etc.)

IMMEDIATE CAUSES UNSAFE ACTS i. Failure to follow rules and regulations ii. Failure to use personal protective equipment properly iii. Operating equipment or machinery without authority

iv. Incorrect use of equipment or machinery v. Using defective equipment or machinery vi. Failure to follow repair/maintenance instructions vii. Incorrect navigation of ship handling

viii. Failure to warn ix. Failure to secure x. Making safety devices inoperable xi. Improper position for task xii. Improper lifting, handling or storage xiii. Inappropriate behavior

UNSAFE CONDITIONS xiv. Under influence of alcohol and/or other drugs xv. Sabotage, willful damage xvi. Suicide/Homicide xvii. Other substandard acts xviii. Failure to focus on the conducted task xix. Inappropriate pace

i. Inadequate guards or barriers ii. Inadequate or defective personal protective equipment iii. Defective equipment, machinery or tools iv. Hull and structural conditions

v. vi. vii. viii. ix. x.

Inadequate warning system Adverse weather conditions Adverse sea conditions Poor housekeeping Congestion or restricted action Inadequate or excessive illumination

xi. xii. xiii. xiv. xv. xvi.

Fire and explosion hazards Noise or temperature Radiation exposure Inadequate ventilation Environmental conditions Outdated charts, publications or other documentations

xvii. Bunkers and/or lub oils xviii. Port and berthing facilities xix. Cargo xx. Other substandard conditions xxi. Condition of Fire / Emergency equipment

ROOT CAUSES

 Physical incapacity Hearing deficiency Inappropriate height, weight, size, strength, reach etc. Limited ability to sustain body positions Other permanent physical disabilities Others sensory deficiency (tooth, taste, smell, balance) Respiratory Incapacity Restricted range of body movement Sensitivities to sensory extremes (temperature, sound etc) Substance sensitivities or allergies Temporary disabilities Vision deficiency

 Mental/psychological incapacity Emotional disturbance Fears & phobias Inability to comprehend Intelligence level Low hearing aptitude Low mechanical aptitude Memory failure Mental illness Poor co-ordination Poor judgment Slow reaction time Physical stress

 Physical Stress Atmospheric pressure variations Blood sugar insufficiency Constrained movement Drugs Exposure to health hazards Exposure to temperature extremes Fatigue due to Circadian rhythm disturbance Fatigue due to lack of rest Fatigue due to sensory overload Fatigue due to task load or duration

Injury or illness Oxygen deficiency

 Mental or psychological stress Conflict demands Confusing directions Emotional overload Extreme concentration/ perception demands Fatigue due to mental task load or speed Frustration Meaningless or “disregarding” activities Mental illness Preoccupation with problems Routine, monotony, demand of uneventful vigilance

 Lack of knowledge/ skill / competence Inadequate Competence Assessment Inadequate induction training Inadequate initial task specific training Inadequate orientation Inadequate update training Infrequent performance / Practices Lack of Coaching / Toolbox talks Lack of experience Misunderstood directions

 Improper Behavior / motivation Improper attempt to avoid discomfort Improper attempt to gain attention Improper attempt to save time or effort Improper performance rewarding Improper production intensives Improper supervisory example Inadequate intervention for incorrect behavior Inadequate reinforcement of correct behavior Inappropriate aggression Inappropriate peer pressure Lack of incentives

JOB FACTORS  Inadequate leadership or/and supervision Consideration of HSSE in staffing not effective Giving inadequate policy, procedure, practices or guidelines Giving objectives, goals or standards that conflict Improper or insufficient delegation Inadequate Hazard and/or Risk Assessment Inadequate matching of individual qualifications and job/task requirements Inadequate or incorrect performance feedback Inadequate performance measurement and evaluation Inadequate reinforcement of correct behaviors Lack of supervisory/management job knowledge Monitoring/Auditing of HSSE not effective Support of people not effective Unclear or conflict assignment of responsibilities Unclear or conflict reporting relationships

 Inadequate engineering Inadequate assessment of operational readiness Inadequate consideration of human factors/ergonomics Inadequate evaluation of changes Inadequate hazard and risk assessment Inadequate monitoring of construction Inadequate monitoring of initial operation Inadequate standards, specification and /or design criteria Incorrect technical design

 Inadequate Purchasing Improper handling of materials Improper salvage and/or waste disposal Improper storage of materials Improper transporting of material Inadequate communication of safety and health data Inadequate identification of hazardous items Inadequate mode or route of shipment Inadequate receiving inspection and acceptance

CORRECTIVE & PREVENTIVE ACTIONS

Inadequate research on materials / equipment Inadequate specification on requisitions Inadequate specifications to vendors

 Inadequate maintenance Inadequate preventative o Adjustment / assembly o Assessment of needs o Cleaning or resurfacing o Lubrication and servicing Inadequate repetitive o Communication of needs o Examination of units o Part substitution o Scheduling of work

 Inadequate Tools and Equipment Inadequate adjustment / repair / maintenance Inadequate assessment of needs and risks Inadequate availability Inadequate human factors / ergonomics considerations Inadequate inspections of the tool, equipment or vehicle before use Inadequate removal and replacement of unsuitable item Inadequate salvage and reclamation Inadequate standards and specifications

 Inadequate work standards Inadequate communications of standards/ procedures o Distribution o Publication o Reinforcing with signs, color codes and job aids o Translation to appropriate languages Inadequate development of standards / procedures o Coordination with process design o Employee involvement o Inconsistent standards/procedures/rules o Inventory and evaluation of exposures and needs

Inadequate implementation of work standards/procedures Inadequate maintenance of standards o Monitoring use of standards/procedures/rules o Updating Inadequate management of change controls in place

 Excessive wear and tear Improper extension of service life Improper loading or rate of use Inadequate inspection and/or monitoring Inadequate maintenance Inadequate planning of use Use by unqualified or untrained people

 Abuse or misuse Controlled by supervision o Intentional o Unintentional No condoned by supervision

 Contractor selection and oversight Contractor oversight not effective Contractor Pre-qualification process not effective No contractor oversight process No contractor pre-qualification Use of non-approved contractor

 Inadequate Training / Knowledge Transfer Competency not assessed Inadequate instructions, orientation and /or training Lessons Learnt not applied Training not effective

ROOT CAUSE ANALYSIS

PERSONAL FACTORS