Systematic root causes were classified in following areas:
Training/Competency: Training exists but inadequate ; Catering crew have been trained but not specific with task
Risk Management/JSA: Hazard not recognized; The hazard, putting the plastic basket near handrail was occurred in the past but never been reported as a hazard
Supervision/Work Direction: Inadequate work oversight or enforcement of work standards ; Catering crew never been observed and feedback at risk behavior when performed this job (material transferring to Dry store)