please identfy a problem by asking why 5 techneque in RCA besed on the case study

involved have been notified of the work schedule. However, work authorization (permit to Department and Mr. Nail, a senior technician from the Maintenance Department without the knowledge of their respective department heads. Two employees from the Maintenance Department responsible for the repair work on the steam valve were Mr. Nail and Mr. Moktar. While the engineer who approved the work authorization was Mr. Joye. CASE SYNOPSIS An industrial accident has occurred at ABC Company on 16th June 2016. The company, which is located in an industrial area of Kota Kinabalu, Sabah began its operations in 1997 in the field of electric power generation. The company has been accredited with ISO 9001:2008 in 2000 and ISO 27001 in 2016. The electric generator machines used are gas turbine and steam turbine, which require high temperature as its main processing materials to produce its primary products. The accident involved two maintenance workers who were repairing a steam valve. The senior worker was exposed to excess steam in the pipe, which temperature exceeded 100C but his colleague survived the incident. He was given an initial treatment immediately after the accident by a trained first aid team in the company before he was rushed to the hospital. Fortunately, his injury was not critical and was treated as an outpatient. CASE CHRONOLOGY On 16th June 2016 at approximately 8:17 a.m., a Department Heads meeting involving Operation and Maintenance Departments was held to discuss a repair operation work on a steam valve. It was concluded during the meeting that the repair work would be performed at 8.00 p.m. when the steam temperature would reduce to approximately 50oC as the condition would be safer for the maintenance operation. Based on the company's Standard Operating Procedures, any work involving steam must be carried out at a temperature below 50C and the excess steam must be removed from the system. The risk of an accident is higher if the repair still in the equipment. The respective department together with the engineers and technicians 19 Restricted COPY