VMTC Incident Investigation Presentation PDF

Incident
Investigation
and
Root Cause
Analysis
Page 1
Objectives:
Participants who will successfully complete this course will be able to:
 Initiate an investigation and gather evidence;

 Apply powerful techniques to identify causal factors and root causes of
an incident;
 Avoid future incidents of a similar type by developing appropriate
recommendations to address root causes;
 And prepare investigation reports and communicate results among the
investigation team and to all concerned.
Page 2
Incident Investigation Background
The marine industry experiences incidents that range

from major accidents to near misses. These incidents should
be investigated since many flag administration regulations
require it; international agreements mandate it (such as the
IMO “International Safety Management Code”) and industry
initiatives encourage it. Incident investigation is a process
that is designed to help organizations learn from past
performance and develop strategies to improve safety.
Page 3
Purpose of the Course
 To introduce you to the philosophy, processes, and procedures required to

support a marine casualty investigation in accordance with IMO Assembly
Resolution A.849(20) and the Code for the Investigation of Marine Casualties
and Incidents.
 The Code seeks to introduce to the international shipping community

uniform objectives and procedures for investigating casualties which occur
in this most international of industries.
 The international aviation industry has subscribed to such a code (Annex 13

of the International Civil Aviation Organization Convention) for some years
and the systems approach into air accidents is credited with contributing to
the safety of the civil aviation industry.
Page 4
Purpose of the Course
 The IMO Code is aimed at a safety outcome to identify the circumstances

under which a casualty occurred and to determine the causes of such an
accident.
 The course is designed to introduce the investigators with an introduction

to accident investigations and accident investigation methodology.
 The course also provide administrators with an insight into what is required
in conducting a casualty investigation, supporting the investigator in the
field and what an investigation should achieve.
Page 5
Ship Casualties and Public
Perception
 Marine accidents as seen by public and media
 Shipping was once perceived as the safest and most environmentally friendly way to
transport goods
 Shipping accidents bring into question the safety of the industry
 Incidents causing pollution raise doubts about the quality of ships, their operators
and crew
 News media are quick to focus public attention on shipping accidents
 Ship safety issues
 IMO response to bulk carrier losses as well as ferry losses. Remember that risk is
attached to every voyage by a vessel. Ships operate in an unfriendly environment and
are likely to encounter storms, rough seas, etc.
Page 6
Ship Casualties and Public
Perception
 Triangle or iceberg of accident.
 Most hazards are actually those which are not directly observed and hidden.
Accidents can be seen as the part of an iceberg above the sea surface. Beneath the
surface there are a myriad of minor accidents and near misses which are largely
unreported and whether they are investigated or not may rely on the company safety
culture and ethic. In comparing the severity of accidents a study shows that for every
reported major injury (death, disability, lost time or medical treatment) there were 9.8
minor injuries requiring first aid (Frank E. Bird Jr and Geroge L Germain). For each
major injury there were 30.2 property damage accidents and 600 incidents. It was
pointed out that to prevent the major accident it would be more productive to attack
the lesser incidents.
Page 7
Incident Investigation
 In the past, accident investigations have generally aimed to find fault or blame.
 Disciplinary action, well publicized, was expected to deter people from
causing a recurrence.
 This approach rarely discovers the real cause of an incident, therefore it
cannot prevent a similar incident from happening again.
 The result is always superficial, and often leads to important facts being
hidden by people anxious to avoid blame.
Page 8
The Modern Method of Incident Investigation gives emphasis to:
 Ensure that all causes are identified.
 Remove reluctance to reveal all facts, by eliminating the “blame culture”.
 Identify problem areas early enough to allow preventive action.
Page 9
International conventions,
requirements and recommendations
 Protection of seafarers and the environment – IMO, ILO and UNCLOS
 UNCLOS
 ILO Maritime convention
 IMO Conventions
 IMO Resolutions and Circular
 Resolution A 849 (20) – the code
Page 10
International Convention, Regulation
and Recommendation
UNCLOS articles:
 Article 27 – Criminal jurisdiction is severely limited unless crime committed in coastal

state, or master/flag state requests help, or illicit drugs are involved.
 Article 28 – Coastal state shall not stop or divert a ship to exercise civil jurisdiction
 Article 94 – Duties of flag state noting that 94(7) states that each state shall cause an
inquiry to be held by or before a suitably qualified person or persons into every
marine casualty or incident of navigation on the high seas.
 Article 97 – In the case of collision or other incident, the master or any other person
can only be prosecuted/disciplined by the flag state or state to which the person is
national.
 Article 98 – All Masters have a duty to render assistance to other ships in distress
Page 11
and Recommendation
 ILO Convention 134:
 deals with the prevention of occupational accidents to seafarers:
 - requiring accidents to be investigated - statistics to be kept
 - research undertaken into general trends - action taken to prevent accidents.

 Only 21 countries have ratified the convention
 ILO 147 concerns the minimum standards in merchant ships and requires member States to have:
 • laws covering safety standards • exercise of jurisdiction
 • tripartite consultation (owners, administration, unions) • rules covering the qualification of seafarers
 • an inspection regime
 • Article 2.4 requires that the competent authority undertake an investigation into causes and circumstances of
occupational accidents resulting in loss of life or serious personal injury, and such other accidents as may be
specified in national laws and regulations: to hold inquiries into serious marine casualties
 • ILO Convention 147, Article 3 (g), requires serious marine casualties, such as those involving injury and/or loss
of life, to be the subject of an official inquiry, the final report of such inquiry normally being made public Note that
only 18 countries have ratified ILO 147.
 Recommendation 142 of 1970
 makes recommendations in respect of ILO 134, in publicity of occupational accidents, investigation and analysis
of why they occur
Page 12
and Recommendation
 IMO conventions
 IMO was establish to provide machinery for cooperation among Governments in the
field regulation and practices affecting shipping trade. It was created in 1948 and
there are a lot of conventions created by IMO to safeguard human lives, properties
and environment. These are SOLAS, MARPOL, Loadline, STCW among others.
 SOLAS Chapter 1, Part C, Regulation 21
 International Convention on Loadlines, 1966 Article 23
 International Convention for the Prevention of Pollution from Ships 1973, as amended
by the Protocol of 1978, Article 8, Article 12, Regulation I/5
Page 13
and Recommendation
 IMO Resolutions and circulars
 IMO Conventions have been supported and amplified by Resolutions and

circulars. Various aspects of marine casualty investigation, recording and
reporting, not specified by Convention have been formulated as
recommendations by the IMO Assembly, the Maritime Safety Committee and
the Marine Environment Protection Committee.
 Resolution A.847(20)
 The flag State should provide qualified investigators, to carry out

investigations following a marine casualty or pollution incident. The flag
State should ensure that individual investigators have working knowledge
and practical experience in subject areas pertaining to their normal duties
 The flag State should also ensure, in order to assist individual investigators
in performing duties outside their normal assignments, ready access to
expertise in navigation and Colregs, flag State regulations on certificates of
competency, causes of marine pollution, and interviewing techniques
Page 14
and Recommendation
 IMO Requirements, Reports to IMO and Data Base on Casualties, MSCICirc.B27-MEPCICirc.433
 As described earlier, investigation by Administrations of casualties to any of their ships are to be

reported to the IMO under the SOLAS and Loadline Conventions, as well as MARPOL
 IMO Resolution A.322(IX) draws the attention of Governments to the SOLAS and Loadline
Conventions and to the need to investigate casualties and provide IMO with information on
findings. This Resolution requests the Maritime Safety Committee to examine the reports and
recommend action as necessary IMO MSC Circ.433 provides a Marine Casualty Report Form
enabling causes of casualties to be classified, and sent by Administrations to IMO, assisting with
establishment and maintenance of a database.
 Resolution A 849(20)
 The aim of the Code is to promote a common approach to safety investigations into maritime
casualties and promote cooperation between the States
 To create a process for the systematic investigation of marine casualties, to establish and
publicise causes and make recommendations
 The objective of any maritime casualty investigation is to prevent similar casualties in the future.
Page 15
and Recommendation
 Resolution A 884 (21)
 The purpose of the guidelines is to provide practical guidelines for systematic

investigation of human factors in maritime casualties and to allow the development of
effective analysis and preventive action
 The contents of the guidelines are:
 1. The introduction
 2. Investigation procedures and techniques
 3. Reporting procedures
 4. Qualifications and training of casualty investigators
 The guidelines are a useful framework around which to frame a report and
they will be used extensively throughout the course.
Page 16
Fundamental Concepts
The Human Element
 Is a complex multi-dimensional issue that affects maritime safety &

environmental protection.
 Involves the entire spectrum of activities performed by ship's crew, shore

management, regulatory bodies, recognized organizations, shipyards,
legislators, etc.
 In considering human contribution to disasters, we must distinguish

between 'active' errors that surface immediately & 'latent' errors that lie
dormant for a long time.
Page 17
THE HUMAN FACTORS ON BOARD
Culture Ability/Situation Awareness

Employer’s Policies Knowledge & Skills
Nationalities Communication
Recruitment Qualifications
Loyalty Education
Health Trust Training
Social
Strengths
Working Conditions
Fatigue Human
Interaction
Job Content/Stress
Factors Morale
Food
Leadership/Support
Accommodation
Team Work
Manning Levels Design IMO
Confidence
Technology Port State
Construction Flag State
Q/A Verification Unions
Maintenance
Ship Condition Legislation
Page 18
MAIN CAUSES OF MAJOR
INSURANCE CLAIMS
Unlicensed Crew Error

Pilot Error
Equipment Failure
26.50% 12.70%5.90%
Mechanical Failure
8.80%
Shore error
6.90% Structural error
26.50% 12.70% Under Investigation
5.90% 4.90% 11.80%
Other
Deck Officer error
Engineer Officer Error
Page 19
CLAIMS – (SOME POINTS TO NOTE)
 Human error direct or indirect accounts for about 80% of the incidents
 Structural & equipment failure cause about 20% of incidents
 Major claims tend to have the same causes as minor claims
 1.4% of the claims account for 71.8% of the costs
 10-14 yr old ships have highest Incidence of human error
 Bulk & Dry Cargo Ship oil spill claims are about 27% of total
 Major injury claims tend to peak in ships 5 to 9 years old
 Over 50% of the collisions took place in good visibility & 75% in calm or slights
seas
 The message that permeates the analysis of most P&I Club claims is that a
majority of the accidents clearly should not have happened
Page 20
Incident – Direct Costs
 Death
 Hospital, etc treatment
 Permanent disability
 Sick pay
 Legal costs
 Insurance claims
 Damage to buildings, vehicles, machinery, etc.
 Product loses and or damage
 Material loses and or damage
 Overtime working
Page 21
Incident – Indirect Costs
 Investigation costs
 Fines
 Hiring or training replacement staff
 Loss of experience and expertise
 Lowering of morale
 Loss of goodwill
 Loss of image
 Business interruptions
 Product liability
 Production delays
 Increased insurance premiums
Page 22
COSTS OF INCIDENTS & LIFE
 Costs of personnel accidents run between US$ 12,000 & US$ 34,000 per
incident
 Oil escaping into the environment can cost up to US$ 80,000 per barrel to
clean (depending where)
 A delay of 8 hours can cost about US$ 14,000 but a minor or soft
grounding can cost US$ 20,000 plus
 US$ 1.54 million - value of human life based on road accidents in US (as
per University of Chicago study)
 Implied Cost of Averting a Fatality (lCAF) - oil companies in UK around $3

million, in shipping vary between $50-300000, nuclear industry - S500
million.
Page 23
THE ROLE OF FLEET MANAGEMENT IN
ACCIDENT PREVENTION
 Continual Quality & Safety Improvement
 Eliminating Waste & Reducing Costs
 Promoting Teamwork & Training
 Responsibility & Accountability
 Long-service Benefits
 Behavior & Motivation
 Collecting Data for data's sake! (Analysis)
Page 24
SMS FUNDAMENTALS
 All accidents and unsafe conditions are preventable through proper

planning
 Safety performance can be improved
 All accidents and unsafe conditions that do occur must be identified and
reported
 Why?
Page 25
IMPROVEMENT OPPORTUNITY
 Incidents should be viewed as opportunities to improve

management systems rather than as opportunities to assign blame.
 Incident investigation, analysis & follow-up constitute an essential

feature of any SMS.
Page 26
Why Investigate Incidents?
The objective of incident investigation is to prevent recurrence.
This is accomplished by establishing a management system that:
 Identifies & evaluates root and other causes
 Identifies & evaluates recommended preventive measures that act to reduce

the probability and/or consequence
 Ensures effective follow-up action to complete and/or review all

recommendations.
 Ensures that appropriate controls are put in place to prevent further

occurrences
Page 27
Incident Reporting
 Incident reporting within each organization will vary.
 Workers must report all incidents to their supervision/employer as soon as

possible after they happen.
 Supervisors & employers have responsibility to investigate incidents and

take appropriate actions.
 Procedures must be in place for above.
Page 28
3 Approaches to Incident Investigation
 Type 1: Traditional, informal investigation carried out by immediate supervisor.
 Type 2: Committee-based investigation using expert judgment to find a credible

solution of cause and remedy.
 Type 3: Multiple-cause, systems oriented investigation that focuses on root cause

determination, integrated with an overall safety management program.
Page 29
Incident Prevention
The basic premise of an incident prevention program is that all

incidents caused by people can be prevented by people.
Page 30
The goal of incident investigation
process
The overall goal of the incident investigation process is to ensure that

the proper safeguards are in place and functioning to prevent and mitigate
loss events. If adequate safeguard are provided, any losses that do occur
will be acceptable losses.
Page 31
Individuals in the organization may have
specific investigation objectives, such as
the following;
 Protect the safety and health of workers and the public
 Preserve the organization‟s human and capital resources
 Improve quality, reliability and productivity
 Ensure continued service to clients and customers
 Comply with regulatory and insurance requirements\
 Comply with organizational and industry policies
 Respond to legal, regulatory, organization, community and/or employee concern
 Educate management staff and employees
 Demonstrate management concern and promote employee involvement
 Advised others of an unrecognized risk and/or more effective risk management strategies
Page 32
Incident Causation Model
INCIDENT
CONTACT (CAUSAL FACTORS)
IMMEDIATE CAUSES
ROOT CAUSES (SYSTEM)
SAFETY MANAGEMENT SYSTEM DEFECTS
Page 33
Progression To Disaster
Serious
Incident
Minor Injuries
(any injury reported)
Property Damage Incidents
(Incident with no visible injury/damage)
At-Risk behaviors and unsafe conditions
Page 34
Incident Types & Causes
Can be divided into 3 groups:

 Serious or fatality
 Minor
 Near Miss
Causes from contributing factors can be divided into 3 levels:

 Direct causes
 Indirect causes
 Root causes
Page 35
Factors That Contribute to Incidents May
Include:
 People
 Environment
 Management System
 Work Process Task
 Material
Page 36
Active and Latent Errors
 Active errors can be seen to be the actions leading up to and at the time of the
incident
 Latent errors may have their origins many years before
For instance:
 During the building of a ship – design, installation, etc,
 Some high level management decision
 Some lower level line management decision
Page 37
Latent Errors
 Operators may inherit systems defects and their part is usually that
of adding the final garnish to a lethal brew whose ingredients have
already been cooking.
Page 38
SMS Essential Components
 Safety Policy  Safety Inspection

 Safe Work Practices  Maintenance Regime
 Safety Training  Hazard Analysis
 Safety Meetings  Control of Movement and use of
 Incident Investigation and Analysis Hazardous Chemicals
 In-house Safety Rules & Regulations  Occupational Health Program
 Safety Promotion  Emergency Preparedness
 Contractors Evaluation Selection & Control  Documentation Control and Records
Page 39
Systems Thinking
 People‟s behavior is strongly influenced by the system they operate in
 The organization controls the system through the Management Systems

they set up
 By changing management systems, the organization can change people‟s

behavior
Page 40
General Principles For Operational
Excellence
 Integrated Management Systems are the foundation of Loss Control
 Risk Analysis to identify potential problems – proactive approach
 Solution to problems through Root Cause Analysis
Page 41
Selecting an incident to investigate
 Root cause analysis should not be used in all situation.
 Rather than investigate every incident, when should investigation be undertaken?
There are three types of incident that should be analyze in depth:
Page 42
First Type: Large Consequences
Incident
 The actual consequences are large enough that a single is intolerable to the
organization.
Example of this type of incident would be:
grounding, allisions, collisions, fatalities, Lost time accidents and environmental

spills
Page 43
2nd Type: Near miss (or near hit)
incidents
 The actual consequences of the actual experienced incident are small, but there
is a reasonable potential for large consequence.
Examples of these types of incidents;
near miss allision, near miss grounding, medical treatment incidents and small
spills with a potential for a much larger spill.
Page 44
3rd type: Set of incidents
 There are number of small incidents that collectively add up to something big
Page 45
Incident investigation approach
to the analysis
 When Performing an incident investigation, the investigator must question

many of the “givens” of a situation. In a pro-active analysis, such as a
process hazard analysis or reliability analysis, many assumption are
made to expedite the analysis. However, assumptions should be
questioned when performing incident.
Page 46
Common question that must be asked when
performing an incident investigation to prevent
making assumption about the organization:
 Are personnel well trained?
It is assumed that personnel are well trained to perform majority of the task they
encounter. However, changes in normal situation and practices are often not
address in the training or procedures provided to personnel
 Are written procedures accurate and clear?
Procedures are clear to those who wrote the procedures. However, they are often
vague and unclear to those who use them. As the result, users are forced to
interpret the procedures for situation not explicitly covered by the procedures.
Page 47
Are policies enforced?
Many policies are written but are not enforced by the organization. As a
result, there are often many deviations from this written and unwritten
policies
No possibilities within the scope of the investigation should be prematurely

excluded. Often the root cause incidents are deficiencies in the
management systems that are design to ensure that these assumption will
be valid. The investigation process is designed to ensure that assumptions
are questioned and confirmed by the investigator
Page 48
Difference between Traditional problem
solving and structured RCA
Traditional
 Blame the individual (The human)
 Fix it and forget it
Structured RCA approach

 All relevant events and conditions identified
 All causal factors identified
 Deep underlying causes of all causal factors identified
 No stray recommendation
 Management system approach
 Focus on effective, long term solution
Page 49
 In the past, accident investigations have generally aimed to find fault or blame.
 Disciplinary action, well publicized, was expected to deter people from
causing a recurrence.
 This approach rarely discovers the real cause of an incident, therefore it
cannot prevent a similar incident from happening again.
 The result is always superficial, and often leads to important facts being
hidden by people anxious to avoid blame.
Page 50
The Modern Method of Incident Investigation gives emphasis to:
 Ensure that all causes are identified.
 Remove reluctance to reveal all facts, by eliminating the “blame culture”.
 Identify problem areas early enough to allow preventive action.
Page 51
 2nd Day
Page 52
4. Basic of Incidents and
Investigation
Page 53
ABS Incident investigation model
• Section 2, Basics of Incident Investigation presents a basic overview of the

MaRCAT (e.g., Marine Root Causes Analysis Technique) investigation process. It
describes the reasons why an organization should perform investigations.
• Section 3, Initiating Investigations describes the steps the organization must

perform before the actual investigation is begun, such as setting up processes for
incident classification and team selection.
• Section 4, Gathering and Preserving Data provides guidance for gathering and
preserving the different types of data that are usually collected as part of an
investigation.
• Section 5, Analyzing Data discusses three different methods (fault tree analysis, 5-
Whys analysis and causal factor charting) for analyzing the data that have been
collected.
• Section 6, Identifying Root Causes describes the use of ABS's Marine Root Cause
Analysis Map to assist in the identification of the underlying causes of incidents.
Page 54
Contents of the Guidance notes
• Section 7, Developing Recommendations explains the different types of

recommendations that should be developed to ensure that the highest return is
obtained from the analysis.
• Section 8, Completing the Investigation describes the activities that should be

performed to complete an investigation.
• Section 9, Selecting Incidents for Analysis provides guidance on selecting

appropriate incidents for analysis
• Section 10, Results Trending, explains the factors that should be considered when
setting up an incident investigation trending program. Trending will allow an
organization to look across all the investigations that have been performed and
see if common factors are related to different incidents.
• Section 11, Developing Incident Investigation Programs describes the process of

setting up the overall investigation program.
Page 55
MOI 4.4.4 Investigation
 The Company will provide investigation and root cause analysis training for all Senior Officers and the
Safety Officer.
 Masters are required to be familiar with the incident investigation processes used within Veritas and are
responsible for investigating all incidents taking place onboard their vessel.
 The purpose of investigation is to identify the root cause of the incident and to use conclusions to
improve the Company‟s Management System in order to prevent the recurrence of similar incidents.
 The Master is responsible to facilitate and assist the investigation of all incidents taking place onboard
the vessel and must define the root cause of the accident in order to minimize the possibility of
recurrence.
 The DPA will analyze all incident reports received, inform appropriate personnel of the reported incident
and determine whether or not further investigation is required. The DPA shall assess the necessity to
notify the Flag State authorities and other third parties.
 The depth of the investigation shall be determined by the criticality and severity of the incident. The
investigation report shall include reference to possible breaches of Company and legislative
requirements when determining root cause.
 Depending upon the severity or complexity of the circumstances leading to an incident, the DPA may
delegate the conduct of an investigation to third parties. This may be an external party or the Company‟s
Operational Integrity Department.
 In all cases the DPA shall ensure that the person who is leading the investigation has undertaken an
“Incident Investigation Course” and has sufficient practical experience to carry out the specific
investigation.
Page 56
 Company‟s personnel that have obtained the theoretical knowledge on Incident Investigation and have
learn the tools and techniques that are part of seeking the Underlying Root Causes of Events
methodology, should participate in investigations (and practice the relevant skills) before being expected
to lead an investigation.
 The Investigation leader is responsible to ensure that effective interviewing skills along with methods for
collecting and analyze data using causal factor charting (event and condition charting), timelines and
cause and effect tree analysis have been implemented in the investigation.
 It is also the Investigation‟s leader responsibility to verify that root cause determination techniques,
include the 5-Whys technique and ABS Root Cause Map, were thoroughly illustrated and explained to the
trainee investigator along with all key points of the investigation allow him/her to practice his/her new
skills.
 All findings by either the Operations Integrity Department or by third party inspectors/surveyors shall be
forwarded directly to the Managing Office DPA.
 The DPA shall ensure that all lessons learned have been communicated and shared with oil-major vetting
departments, as appropriate.
 Prior to any release of the final incident investigation report to any external parties, each Managing Office
DPA shall forward the report to the Office‟s Managing Director and the Head of SQE for final review and
approval.
 If changes to the Management System are required, the DPA is responsible to ensure that these are
brought to the attention of the Managing Office‟s senior management and the Quality Manager for
implementation.
 Following an investigation, the Master is responsible to ensure that any recommendations that are
designed to prevent recurrence are implemented onboard the vessel.
Page 57
Phases of an Investigation
 Preparation
 Implementation
 Research
 Analysis
 Correction
Page 58
Steps in Investigation
Company Standards
National & Insurance &

International Stakeholder
Legislation
Requirements
Incident Reporting
Dissemination of Findings Corrective

Action
Implement
Recommendations / Follow-up
Evaluate
Effectiveness
Trend Analysis
Page 59
INCIDENT INVESTIGATION FLOW CHART
Preparation Phrase Pre-Planning
 Set objectives Critique Process for

 Develop procedures Team Selection Continuous Improvement
 Select & train investigation

 Prepare investigator‟s kit
INCIDENT
Implementation Phrase Secure Evidence
Receive Alert Notification

 Executive modifications
 Preserve evidence at scene
Activate Team
 Interview witnesses
 Follow 4Ps technique
 Initiate data mapping Develop Team Plan
Collect Evidence
Reserve Phrase
 Review documentation  Search QSB for past incidents
Research Additional Evidence
 Conduct test or re-creations
 Perform calculation
Analyze and Interpret

Analysis Phrase
 Complete critical factors chart
 Identify SMS elements deficiencies
 Identify immediate causes Identify immediate & System Cause (s)
 Identify system cause
Develop Proposals for Corrective Actions
Corrective Phrase
 Write report Prepare Report
 Develop proposals for corrective action

 Share information and learning Share Key Learning
Implement Corrective Actions & Follow-up

Page 60
Root Cause Analysis
It is simply a tool designed to help investigators
 Describe WHAT happened

 Determine HOW it happened
 Understand WHY it happened
Page 61
Features of Root Cause Analysis
 Understand how a loss event occurred
 Discover the underlying root causes (management system weakness) of key

contributors
 Develop / implement practical and effective recommendations for preventing

future losses
Page 62
PITFALLS IN ROOT CAUSE ANALYSIS
Pitfalls in Finding Root Causes during Incident Investigation:
AVOID Focus on
Personal factors alone System Causes
Fault, blame, discipline Objective to prevent

reoccurrence
People’s needs Incident problems
Page 63
Poor Investigations
 Focus only on personnel
 Are directed away from systems
 Create a lack of co-operation
 Foster distortion of facts
 Reinforce cover-up
 Tend to make employee protect themselves
 Do not present all facts
 Concentrate on immediate causes only
 Do not eliminate system causes
Page 64
Benefits from Incident Investigation
 An effective incident reporting and investigation program:
 Assures that all incidents reported and investigated
 Identifies basic causes of incidents
 Reduces recurrences of similar incidents
 Identifies program needs
 Makes information available in case of litigation
 Minimizes compensation claims
 Increases production time and reduces operating costs by control of accidental

losses
Page 65
Who Should Conduct The Investigation?
 The employer is responsible for conducting the investigation.
 Investigations may be led by supervisors, managers, health and safety professionals, etc.
 Whoever investigates the incident should be trained in how to conduct and investigation.
 Workers should be also be involved in the investigation whenever possible. Worker

involvement:
 Provides additional expertise and insight.
 Lends credibility to the results.
 Educates workers on potential hazards.
 Increase workers awareness & commitment to health safety.
Page 66
Causal Factor
 Equipment failures and human errors that caused an incident, allowed an

incident to occur, or allowed the consequences of the incident to be worse
than they might have been.
 For a typical event there are multiple causal factors.
 {A gap between the ideal and actual performance of front-line people or

equipment.}
Page 67
INTERMEDIATE CAUSE
An underlying reason why a causal factor

occurred, but it is not deep enough to be a
root cause.
Page 68
Item of Note
A system deficiency that is not directly related to the

incident sequence that is discovered during the
course of the investigation.
Page 69
Root Cause
 The absence, neglect, or deficiencies of management systems that allow the

causal factors to occur or exist
 For a typical causal factor there are one to four root causes.
Page 70
Management System
A System put in place by management to encourage desirable behaviors

and discourage undesirable behaviors.
It is what you do to get people to behave the way you want them to behave.
Page 71
Two general levels of analysis
Apparent cause analysis

 Less structured, less rigorous
 Usually identifies most causal factors
 May identify some root causes
 Limited scope (fewer levels) of recommendations
 Level of effort may be determined by time available
Page 72
Root cause analysis
 Structured, rigorous
 Identifies all causal factors and root causes
 Broad scope (multiple levels) of recommendations
 Level of effort required determined by analysis goals
Page 73
MOI 4.4.5 Root Cause Analysis
 An investigation into any raised incident or defect must include a root cause
analysis.
 The purpose of root cause analysis is to identify how the incident or defect
occurred and define controls in an effort to prevent recurrence in the future.
 The method to be used for the determining of shipboard root cause analysis
is the ABS Marine root cause analysis map.
 Upon opening the root cause tab in the SDR, there is a preloaded copy of
the ABS Marine root cause analysis map. Starting with the cause factor, the
relevant problems then should be selected and the map navigated
accordingly until the cause is determined.
Page 74
Correlation
 When there is a strong correlation between two events, they tend to occur
together.
 However, one does not cause the other.
Page 75
Correlation Example
 Recent studies have proven that watching too much violence on television leads
to people being violent in real life.
 Fewer incidents happen on Saturday and Sunday than during the rest of the
week. Therefore, the weekend staff must have a better safety attitude than those
that work during the week.
 We always have more incidents in February than any other month. Therefore, the
cold weather must be the cause of the incidents.
 California has more national parks than any other state. Therefore, states that
begin with letter C will have many national parks.
Page 76
Causation
 When there is a causation connection between events or conditions, the events and
conditions can be grouped into causes and effects.
 Causes ALWAYS occur before effects
 Examples:
 when the fire got out of control, I called 911
 when the pressure got high enough, the relief valve opened
 the wind blew the sign over
 the vibration of the cabinet caused the insulation to wear off the wiring
 when it rains, I use an umbrella
 Note that one cause may not be sufficient to cause the effect
Example: The wind didn’t blow ALL the signs over, just the ones that were not
sufficiently anchored.
Page 77
Sequence Relationship
 When there is no causation link, there may be only be a timing relationship

with a correlation or causation relationship.
 Example:
 When I walked outside, it started to rain
 Just as I looked up, the tank exploded
 Right after I called the control room, I heard the evacuation alarm go off
 Just when I started eating a doughnut, the fire started.
Page 78
Correlation, Cause, Or Sequence
Relationship?
 When the temperature rose to the high setpoint, the cooler started
 Answer: Cause
Page 79
Relationship?
 There are more people in college with first names that start with A-M than N-Z.
Therefore, you are more likely to get into college if your name is Adam, than if
your name is Steve.
 Answer: Correlation
Page 80
Relationship?
 The A line has twice as many incident report as the B line. The B line workers are
safer that the A line workers.
 Answer: Correlation
Page 81
Relationship?
 Jim called the control room operator and told him there was oil dripping on the
floor near the pump. Just then, the pump seized.
 Answer: Sequence
Page 82
Root Cause Analysis Puzzle
 Collecting and Preserving Data
 Causal Factor Charting
 Judging relevance of facts
 Analysis
 Determining Root Causes
 Developing Recommendations
Page 83
Breakdown of Investigation Tasks By
Time
Task: Collecting and preserving data Task: Judging relevance of facts
Apparent % of Time: 25% Apparent % of Time: 10%
Actual % of Time: 80% Actual % of Time: 3%
Task: Fault tree analysis/causal factor Task: Filling gaps in chart

charting
Apparent % of Time: 5%
Actual % of Time: 4%
Page 84
Breakdown of Investigation Tasks By
Time
Task: Determining root causes
Task: Generating recommendations
Page 85
Common Weaknesses
Some areas of incident investigation where weaknesses are common;
 It is difficult to get personnel to report near misses, especially those involving their
own errors
 Inadequate reporting generally happens if personnel are reprimanded for their

errors
 Analysis for root cause is the exception rather than the rule
 Recommendations tend to address symptoms rather than underlying causes
 Status of recommended actions are not tracked
Page 86
However…..Remember…..
 Reactive analysis provided valuable feedback on the performance of our

management systems
 Management systems control the performance of people and equipment
 Our goal is to ensure proper safeguards are in place
 We need to achieve this goal in the most efficient manner using a structured
analysis method
 Please always keep in mind the definitions of

 Causal factor
 Root Cause
Page 87
Workshop no. 2
 Identifying Causal Factors and Root Causes
 20 mins. To execute
 20 mins for all groups feed back
Page 88
Phases of an Investigation
 Preparation
 Implementation
 Research
 Analysis
 Correction
Page 89
Preparation Phase
 Set objectives on investigation

 Commitment
 Plan actions
 Co-ordination
 Develop procedures
 Incident investigation procedures
 Emergency procedures
 Emergency shutdown procedures
 Select and train investigators
 Prepare investigator’s kit
Page 90
Team Activation
Who appoints the Team?
 Company policy
 Site manager
 Regulators
Big Incident: Other concurrent investigations
Company – Police – Gov’t. - Insurance
Page 91
Team Activation
Investigation Team composition
 Team Leader
 Team Members
 Other participants
Page 92
Team Activation
Team leader responsibilities:
 Directs and manage overall investigation
 Establishes administrative protocols
 Ensures safe work practices used at the scene
 Team spokesperson and point of contact
 Obtain necessary resources-tools, PPE, background info., etc.
 Arrange and facilitates team meetings
 Organize teamwork for investigation activities
 Protects proprietary and other sensitive info.
Typical Team Leader: Senior Manager (independent)
Page 93
Team Activation
Team Members Responsibilities

 Gathers data
 Analyses data
 Recommends remedies
 Draft report
Typical Team Members

 Department representatives
 Specialist on related work affected
 Operations/Maintenance representatives
 HSE Department (Safety Officer)
 Safety committee member
 Contractor representative
 Root cause specialist
Page 94
Team Activation
 Root Cause Specialist Responsibilities
 Assist and advice to the Team leader

 Part of Investigation Team
 Materials/equipment available at site
 Provide training in techniques of RCA
 Assure quality control of investigation

 Understand what occurred
 Verify proper interview techniques are used
 Push team to root cause level of investigation
Page 95
Site Investigator Kit
Personal Equipment
Evidence Logbook Graph paper
Magnifying glass Plastic baggies
Measuring tape Evidence tags
Camera Scotch tape
Investigation forms Toothbrush
Ruler & 100’ measure tape Flashlight
Clipboard, paper & pencil Permanent markers
Audio and video recorders Colored Post-It Notes
Protective Gear
Hard Hat Respiratory Protection
Goggles Ear Protection
Gloves
Safety Boots
Page 96
Implementation Phase
Normally after an Incident….
Notification
Secondary Incident Prevention
Preserve evidence at scene
Follow 4 P‟s technique (People, Parts, Positions, and Papers)
Interview witnesses
Initiate data mapping
Page 97
Notification
As soon as the incident is discovered it must be reported to all concerned

parties:
 Raise the alarm (as applicable)
 Notify the Managers & Supervisors
 Notify the others in the facility
 Notify top management
 Notify outside agencies to assist
 Notify authorities
Page 98
Potential Hazard at Scene
Consider the following areas before assessing the scene:

 Is there any danger of further injuries or damages?
 Have personnel moved away from scene
 Turnoff power sources, lockout possible
 Ventilate the workplace
 Shutdown equipment
 Confine the leak, spill or dangerous material
 Initiate clean-up or other appropriate actions
 Perform emergency medical first aid
Page 99
Initial Site Activities
Not to be delayed:
 Emergency response phase
 Secure the scene
 Employee assistance
 Preserve fragile evidence
 Photography, videotaping, sketching
 Saving instrument or computer data (VDR)
 Gathering documents, permits…
 Identify witnesses
 Regulatory requirements
Page 100
Emergency Response Activities:

 Protect people, environment, property from further damages
 Determine if emergency response is warranted
 Do not allow investigation objectives to interfere with the emergency
response
Page 101
Investigate the Incident
 Secure the scene
 Collect the facts
 Physical evidence
 Eyewitness accounts
Page 102
Secure the Site
 Protect investigators (site safety)
 Isolate area if possible
 Often energy hazards are still present after the incident is “over”
 Beware of sources of pressure, temperature and electricity, hazardous

materials, unstable structures
 Use appropriate PPE
Page 103
Secure the Site
 Preserve data
 Control access to incident site
 Determine data useful to investigation
 Identify transient conditions subject to change
 Identify and list witnesses to the incident
 Take preliminary photographs, video or initial sketches
 Step-by-step walk-through
Page 104
 Mentally survey the scene and form a rough outline of what happened
 Who is injured?
 What happened?
 What steps lead to incident?
 What property damaged?
 What actions contributed to the incident?
 When did the actions take place?
 Where did the actions take place?
 How did the undesired contact occur?
Page 105
Collect the Facts
When collecting the facts, remember:
 Keep an open mind. If you think you already know what happened and why, you
might overlook something really important in your investigation.
 Facts should be separated from “opinions”. Record what people actually saw or
experienced, not what someone “thinks” happened, or what someone else “said”
happened.
 Consider all possible causes. Making notes of ideas as they occur is a good
practice, but do not draw conclusions until all the information is gathered.
 The purpose of the investigation is to find the facts, identify the causes of the
incident, and identify how to prevent similar incidents from happening in the
future.
Page 106
Physical Evidence
Physical evidence is subject to rapid change and should be the first to be

recorded. Check things like:
 Position of injured worker
 Equipment being used
 Materials being used
 Safety devices in use
 Presence or absence of appropriate guards
Page 107
Study the Scene
 Record exact location of the incident
 Take note of any broken equipment, debris or samples of materials. Look at the
pattern of debris and location of each piece. This may be further analyzed.
 Gather any product information including names and MSDS of any substance
involved
 Make sketches of the scene-including measurements. Make notes for each

illustration.
 Take photographs of anything before it is moved-both of general area and specific

items.
Page 108
Benefits of Photographs
 Record what the eye misses
 Record vast details
 Allows you to look back at the „original‟ condition of the equipment or site after
incident
 Pre-incident condition photos make job easier
 Save time and work
Page 109
Study the Scene
 Find out who was involved and who can provide expert advice on technical
issues. Prepare a list of witness and experts to interview.
 Note lighting, visibility, time of day and weather conditions.
 Find out if any changes in design products or work procedures were introduced
before the incident.
 Compare what happened with accepted standards or procedures to identify any

gaps
Page 110
Eyewitness Accounts
 Interview witnesses. Witnesses may be your primary source of information.

Witnesses include injured or ill workers, nearby workers, pre-shift workers or
supervisors, and any workers in the area at the time.
 Interview witnesses as soon as possible after the incident. If witnesses discuss

the event with each other, their own perceptions can get mixed up with people‟s.
 Witnesses should be interviewed alone, rather than in a group. You may decide to
interview witnesses at the scene where it is easier to find out where each person
was during the incident and get a description of the events.
 Alternatively, you may want to do it in a quiet office where there will be fewer
distractions. Which option you choose will depend on the nature of the incident
and the mental state of the witnesses.
Page 111
Formal Investigation Team Activities
 Initial:
 Preliminary data review
 Statements from witnesses
 Ongoing:
 Detailed interviews
 Testing of parts or other evidence
 Elimination of data or evidence
 Statements regarding cause
Page 112
Data Gathering
Types of Data
People
Paper Type of Data Position
Parts
Page 113
Data From People
 People with information
 How people acquire information
 Assessing data from people
 Interviewing
 Initial interviews
 Following-up interviews
Page 114
Data From People
 Direct Witnesses
 Injured / co-workers
 Emergency responders
 Others in area
 Indirect Witnesses
 Contractors
 Others in adjacent areas
Page 115
Data From People
People with information:
 Participants who contributed to the incident
 People who are injured
 People who influenced the behavior of participants or victims
 Anyone who has valid, constructive knowledge or information that contributes to

determine what happens
Page 116
Data From People
How people Acquire Information:
1. Primary focus of interviews
 Direct Sensory observation
 I saw
 I smell
 Memory of their own actions
 People may not recall frequently performed task
Page 117
Data From People
How people Acquire Information:
2. Secondary focus of interviews
Conclusions or reasoned decisions
 Filling in the gaps in the story
Personal opinions, feeling, and beliefs
Page 118
Data From People
Assessing Witness Statements:
What witnesses say may differ significantly
 Witness position issues
 Sensory illusion issues
 Other witness reliability and credibility issues
Page 119
Witness Reliability & Credibility
Issues
 Intelligence
 Knowledge/Familiarity with the process
 Emotions (personal loss)
 Position / Job Threat
 Exaggeration
 External Influences
 Tendency to underestimate long distances or periods of time, while

overestimating shorter ones
 Non-verbal signals (bored, scared, interested, stalling, etc.)
Page 120
Data From People
Data from witnesses:
 Written statement
 Verbal during interview
 Other documentation
 Video and audio tapes
 Instruments charts
 Operating logs
 {Is not confined to statements from interview}
Page 121
Interview Guidelines
Plan
Establish Rapport
Uninterrupted Narrative
Interactive Dialogue
Conclusion
2nd Interview
Update team
If needed
Page 122
Plan Interview:
 Identify all the witnesses
 Select their interviewers
 Location of interviews
 Sequence of witnesses
 Interview schedule
 Core topics / questions
 Document the interview
 Reference information
Page 123
Select an Interviewer
The interviewer should be someone with whom the interviewee will be

comfortable with:
 Similar in the organization – not too high or too low
 Familiar with system & technology
 Good interviewing skills
Page 124
Establish Rapport:
 Make introductions if necessary
 Explain investigation purpose & objectives
 Warm up with non-business issues
 Begin with non-threatening questions
 Highlight witness importance contributions
 Be respectful and friendly
 Do not judge, refute, anger, or suggest
 Do not rush
Page 125
Uninterruptive Narrative:
 Allow uninterrupted account of the incident
 Avoid urge to interrupt with questions
 Jot down question and asked later
 Use open ended and neutral questions
 Avoid closed-ended and leading questions
Page 126
Questioning
Avoid these questions…….
Accusatory
“This is not the way you’re supposed to do it, is it?”
“Why didn’t you stop him when you saw him start the wrong pump?”
Closed ended
“Do you use a procedure to start the system?”
“Were you using the right procedure?”
Leading
“You open valve 2 before valve 3, right?”
“It sure looks like the procedure is wrong, isn’t it?”
Page 127
Questioning
Use these questions……
Open ended:
“How do you start up this system?”
“What caused the pressure to increase?”
“Which hazards are associated with lifting?”
“Can you explain the events prior to the incident?”
Neutral:
“Is that action consistent with the procedure?”
“In what order do you open the valves?”
Page 128
Interactive Dialogue
 After the uninterrupted narrative, if there are specific issues not resolved this is
the time to ask.
 Time for clarifications and more detailed questions & answers
 Use plans, P &IDs, and other aids to extract info
 Explore incident causes
Page 129
During interactive dialog, area of interest……….
 Timing of events
 Positions of participants and victims
 Environmental and weather conditions
 Anything moved/repositioned
 Emergency response activities
 Actions of other people
 Training and preparation
 Histories of similar incidents
 Inconsistencies in data
 Management involvement
 Beliefs, opinions and judgments
Page 130
Look out for Errors during interviews……..
 Error of omission
 Failure to do something
 Error of commission
 An act committed incorrectly
 Sequence error
 Performs an operation out of sequence
 Timing error
 Performs an operation not within allotted time
Page 131
10 Commandments of Interviewing
 1. Stop talking
You cannot listen if you are talking.
 2. Put the witness at ease
Help witness feel that he/she is free to talk.
 3. Show that you want to listen
Look and act interested. Listen to understand what is being said rather than
concentrating on your next question. This is difficult as the next question may
desert you, but it may return and,by a full story, may be answered anyway.
 4. Remove distractions
Don't doodle, or give the impression you are not listening or that you would rather
be elsewhere.
Page 132
 5. Empathise
Try to put yourself in the other person's place.
 6. Be patient
Allow plenty of time, do not interrupt.
 7. Hold your temper
Any impatience or anger can pass the initiative to the interviewee.
Page 133
 8. Avoid argument and criticism
Causes the witness to become defensive and possibly qualify answers or "clam up".
 9. Try and make your question flow responsive to his/her priorities
Shows you are listening and that you understand. Try not to break continuity, you
can always return to other issues later.
 1O. STOP TALKING
This is the first and last command.
Page 134
Concluding Interview
 Summarize witness story to confirm facts recorded accurately.
 Ask witness, “Is there anything else you want to add regardless of how important
it may be?”
 Ask who else may be able to contribute valuable information.
 Invite additional input if new info remembered.
 Express appreciation for the witness‟s time, information and co-operation.
 Indicate possibility of follow up for clarification.
Page 135
Follow-up Interviews
 Focus on gaps in information and apparent inconsistencies.
 Use straight-to-the-point interview style (closed ended questions)
 Ensure witnesses do not misunderstand that the follow-up interview indicates

doubts in their credibility.
Page 136
Parts Data
Are there any pieces of equipment which have failed or are thought to have
contributed to the cause of the incident? (serve as Physical Evidence)
 Failed equipment parts
 Failed computer parts
 Personal protective equipment
 Liquid/solid samples – test before & after incident
Page 137
Parts Data
Identification of Physical Data of Interest
 Fractures, distortions, surface defects/marks
 Suspected internal failure or yield
 Seized parts
 Misaligned/misassembled parts
 Control/indicating devices in wrong position
 Incorrect components
 Foreign objects
 Products – raw, complete
Page 138
Parts Data
Perform detail testing for more information
 Macro visual examination
 Micro visual examination
 Non-destructive testing
 Chemical analysis
 Mechanical testing
Seek legal advice before testing!
Page 139
Position Data
It refers to locations of PARTS after incident. It may also refer to PEOPLE

before and after the incident.
 The rest position of equipment & other items – what is on top of what
 Evidence of movement
 Skid marks, distance of gaskets blown off,
 Location of personal protective equipment
 Char and burn patterns
 Incident location
Page 140
Paper Data
Importance of paper data
- Lead to root causes
- Show factors that:
 Mold the environment
 Influence attitudes
- Generally provide objective data
- Least fragile of the four data types.
Page 141
Paper Data
Types of paper data:
 Information records
 Physical environment records
 Logs and maintenance records
 Procedures
 memo / correspondence
 Program manuals
 Policy statements
Page 142
Organization of Evidence
 All photographs identified and documented
 Sample analysis completed
 Complete witness interviews
 Log evidence in a formal logbook
Page 143
Incident Investigation Processing
 By now we have the evidence, we must now process it
Page 144
WORKSHOP no. 3
Investigation data need
 20 mins. To execute
 20 mins. For all groups to feedback
Page 145
 3rd Day
Page 146
Causal Factors Charting
 Data mapping
 Chronological graphical format
 Events leading to the unwanted incident
 Conditions surrounding these events
 Covers negative and non hazardous events and relevant conditions
Page 147
Data Mapping
 Data Mapping includes
 Performance errors Oversights
 Changes Omissions
 Critical failure
 Start early in data gathering process
 Use charting format that can be easily updated
 Search and fill as many gaps
 Resolve any contradictions
Page 148
Identify What is Missing
Make a conscious effort to determine what is absent that

should be expected to be present.
Page 149
Facts vs Suppositions
 Events based on facts or suppositions
 Uncertainty in the data collected
 Mind set of witness
 Motive of witness
 Deterioration of data source
 Uncomfortable calling fact since judgments are subjective.
 Most cases differentiation minor importance
 Very important when it is a critical factor or used in court or dealing with regulator.
Page 150
Facts…….
A simple rule of thumb:
 Direct witness observations
 Data recorded by process instrument
 Strong conclusions reached by those who analyze physical evidence
 Paper evidence (policies, procedures, records, field readings, etc.)
 EG: “Leaking forklift brake seal causing an oil spill.”
 “Pre-use forklift inspection record completed by the operator showing that the forklift
was not safe for operation.”
Page 151
Suppositions…..
A simple rule of thumb:
 Second-hand testimony or hearsay
 Conclusions by witness or others
Recorded as supposition until proven to be fact
 EG: “I heard the contractor saying the fire started from the drum.”
Page 152
Causal Factors Help
Point us to the areas that need to be examined for what caused that factor to exist.
 Negative events or undesirable conditions
 Major contributions to the incident
 Events or conditions, which if eliminated, would have either prevented the occurrence or
reduced its severity
 Itemized through the Building Block process
Page 153
Layout Timeline
 Use a flip chart
 Apply appropriate, tentative timeline to bottom of chart
 Capture general sequence of events and conditions
 Apply “Building Blocks” (BB) in chronological order
Page 154
Layout Timeline Chart
 Hints for building the timeline chart:
 Identify the loss event first, then work backwards from this point
 Test the sufficiency of each event
 Generate questions to bridge gaps
 Test for necessity, eliminate event/conditions not related to „loss event‟ cause
 Keep level of detail to manageable level
 Update sequences as new info is gathered
 Use chart extensively to guide to guide investigation and as a communication tool during
investigation.
Page 155
Timeline Advantages
 Provides organization of evidence
 Advantage of collating individual teams knowledge
 Guides the investigation
 Forces investigators to think about critical factors one at a time
 Allows validation of incident sequence
 Allows identification of Critical Factors
 Simplifies organization of event report
 Easier than narrative representation
Page 156
Immediate Causes
Substandard actions
 Not following procedures
 Not using correct tools & equipment
 Not using safeguards and protective methods
 Inattention/lack of awareness
Substandard conditions
 Inadequate protective systems
 Defective tools & vehicles
 Exposure to unsafe conditions
 Work place hazards
Page 157
System (Root) Causes
Personal Factors
 Physical capabilities/ conditions
 Mental state/ stress
 Behavior
 Skill level
Page 158
System (Root) Causes
Job Factors
 Training/ knowledge transfer
 Management/ supervision/ leadership
 Contractor selection & oversight
 Engineering/ design
 Work planning
 Purchasing, material handling & control
 Tools and equipments
 Work rules/ Policies/ Standards/ Procedures
 Communication
Page 159
Comprehensive List of Causes
System (root) causes failure
 Inadequate program
 Inadequate standards
 Inadequate compliance
Page 160
Comprehensive List of Causes
CLC advantages
 Systematic method of analyzing incident causes
 Consistent, organized reasoning
 Graphically reinforces principle of multiple causes
 Provides reference for evaluating investigation quality
 Consistent trending analysis
 Common tool for incident investigation
Page 161
The Analysis Phase
The Analysis Phase
Page 162
Root & System Causes
A reminder:
The most basic causes that can reasonably be identified, that management has
control to fix, and for which effective corrective actions are needed for preventing
recurrence.
Page 163
Root cause map
 A structured process
 List of causes - map out
 A pick list-type technique
 System causes
 Suitable for multiple causation
 Relates to the management system
 Organizes consistency
Page 164
What is a Root Cause?
 For virtually every incident, some improvements in safety managements in

systems could have prevented most (or all) of the contributing events from
occurring
 The absence, neglect or deficiencies of management system features are

fundamentally the root causes of incidents
Page 165
Traits of a Root Cause
 Indicates a safety management system weakness
 Addresses something over which management has to control
 Represents an “elemental” level for which further resolution would be

unproductive
 Rarely travels alone
 Influences other possible incident scenarios
Page 166
Common Root Cause Analysis Traps
Examples:
 Equipment failures
 “ It just wore out; nothing lasts forever”
 “ It was just a bad part”
Page 167
Common Root Cause Analysis Traps
 Human errors
 “Nobody else would have made that mistake; he has never been one of our best operators”
 “The procedures are right and she received our standard training; she just goofed up”
 External Events
 “It was a natural phenomena event beyond our control”
Page 168
Importance of Addressing Root
Causes
 Prevents recurrence of the same or similar incidents
 Promotes more cost-effective solutions to problems because the proper solutions are
implemented
 Prevents recurrence of seemingly unrelated incidents involving the same root causes
Page 169
Importance of Addressing Root
Causes
 Supports trending analysis to identify issues symptomatic of larger problems
 Improves compliance with regulations, industry standards, and company requirements
Page 170
Procedure for Determining Root
Causes
Jumping to root cause identification before the incident is understood and causal factors are
identified may result in:
 Developing the wrong recommendations
 Developing the ineffective recommendations
 Recurrence of the event
Page 171
Techniques For Root Cause
Identification
 Engineering / expert judgment
 The 5-Whys Technique
 Root Cause Map
Page 172
Engineering / Expert Judgment
 Most common approach in use today
 Dependent on analyst‟s/team‟s experience, background, and understanding of root causes
 Not auditable for thoroughness
 Not inherently consistent or reproducible
Page 173
The 5 Whys Technique
 The „5 Whys‟ technique is a brainstorming type technique for identifying the root cause of an
incident.
 Through questioning why the incident happened and why the unfavorable conditions
existed?
Page 174
Using the 5 Whys
 Select one causal factor associated with an incident
 Ask why this event occurred (i.e., the most direct cause of the causal factor)
 Solicit answers to this question (the answer may identify more than one sub event or
condition as the cause)
 For each of these sub events or causes, ask why it occurred.
Page 175
Using the 5 Whys
 Solicit answers to these why questions and repeat the process through at least three more
iterations of why questions
 Repeat the process for the other causal factors associated with the incident
 Can also be used as a data analysis technique
Page 176
5 Whys Technique
Advantages:
 Minimal training necessary
 Judgment/experience key factors
 Resulting sub-events should be root causes or near root causes
Page 177
5 Whys Technique
Disadvantages:
 Can be time consuming with no formal guidelines
 Results not reproducible/consistent
 System causes may not be identified
 Not appropriate for every complicated incident
Page 178
Conclusions About 5 Whys
 Resulting sub events/conditions should be at or near the root causes of the event
 More or less detailed evaluation may be necessary for some cases to reach management
system root causes
 Judgment and experience are key factors in selecting the right level of evaluation and
completeness of results
Page 179
Conclusions About 5 Whys
 This technique takes more time than other techniques that do not require brainstorming
 Although the application is auditable, the results are not reproducible/consistent
Page 180
Exercise
 Develop a 5 why techniques on the following incidents:
 1. Fire in the waste bin
 2. Ruptured cargo line during discharging
 3. Bunker tank overflow while bunkering
 4. Parted mooring lines while at berth
 Group participants into four
Page 181
ABS Root Cause Analysis Map
 Originally derived from management oversight and risk tree (MORT) for DOE‟s Savannah
River Laboratory
 Structures the reasoning process for identifying root causes
 Identifies detailed root causes for each major root cause category
 Facilitates consistency across all investigations
 Supports trending of “root causes” and “categories”
 Faster to use – no brainstorming required
Page 182
ABS Marine Root Cause Analysis Map
Page 183
Using the Root Cause Map
 Select a causal factor from the causal factor chart or fault tree
 Think about the underlying causes
 Work through the map for each causal factor
 Step down paths, noting:
 Primary difficulty source (equipment, personnel, other)
 Problem category
 Major root cause category
 Near root cause
 Root cause
Page 184
 Record results on forms, at each step
 Perform 5 Whys if root causes are not deep enough
 Use root causes (and perhaps categories) for:
 Generating recommendations
 Trending
Page 185
Multiple Coding
 Most causal factors have more than one associated root cause
 Example:
 Operator fails to follow procedure
 Operators are taught to always follow procedures
 Policy is to always follow procedure
 Dual root cause code:
 Procedures not used
 Standards, policies, or administrative controls are not enforced (S.P.A.CS)
Page 186
Using the Root Cause Analysis
Handbook
 Root Cause Map usually enough to get to root causes
 Using the Root Cause Map increases consistency across investigations
 Greatest consistency achieved by customizing the map and handbook to your organization
Page 187
Typical Problems Encountered When
 Policies versus Procedures – policies higher
 Human Factors versus Design – interface
 Communications – address only verbal aspect
 Personal Performance – rare, limited to 1
Page 188
Key Points To Remember
 The primary reason for identifying the underlying causes of each causal factor is to help
identify leveraged solutions (i.e., solving many actual and potential problems at one time).
 Root cause identification cannot begin until the causal factors are identified.
 The Root Cause Map should be used as a guide to help you brainstorm underlying causes.
You still have to think!
 Using the Root Cause Map and the RCA Handbook facilitates consistency in root cause
coding. This increases the validity of your trending.
Page 189
Root Cause Identification –
Evaluation Criteria
 Root causes should identify:
 Something over which management can control (so a recommendation can be written
to address the cause)
 A basic, underlying cause
 Each root cause should be associated with a causal factor or observation
 Most root causes should be associated with management system issues
 Multiple root causes should be identified
 {Note: Some methods do not specifically identify root causes. They are just deeper causes
in a continuum of causes}
Page 190
 Exercise
Page 191
The Corrective Phase
Corrective Action
We now enter the "Corrective Phase" of the investigation.

Here we develop proposals for corrective action, and assemble the evidence,
analysis, system causes and proposals into a final report.
Page 192
Corrective Action
 Important products of analyses and based on conclusion of data analysis result.
Attributes…
 Addresses root and system causes
 Addresses incident events
 Fixes the system
 Clearly states intended action(s)
Page 193
 Are practical, feasible and achievable within organization capacity
 Eliminates or decrease risk
 Does not pose undesirable or unacceptable risk
 Aligns with company objectives
 State as task request – What to be done
 Responsibility for corrective action identified
 List priorities of action
Page 194
 States outcome to be achieved
 If reprinted in news
 responsive
 responsible
Writing the actions
 - Task to be done
 Define clear objective (s) for each corrective action so it can be

 observed
 measured
 solved
Page 195
Corrective Action
Is recommendation Yes Can Implementation

No Assign Responsibility Track
practical and reasonable
cause more and schedule for
Implementation
Is it technically correct / problems than implementation
feasible? Status and
It fixes
Is it justified by low / no Document resolution
cost alone?
It is requirement?
Does it have an
attractive
Benefit-to-cost ration?
No
Flowchart
Consider ways to improve
the recommendation of
Guidelines
Chose not to implement
Yes For Investigating
Incidents
Page 196
Checklist for developing and implementing
corrective actions (CA)
 Is there one corrective action associated with each root or system cause?
 Does the CA specifically address the root cause?
 Will the CA cause detrimental effects?
 What are the consequences of implementing the CA ?
 What is the cost of implementing the CA ?
 Will training be required as part of implementing the CA ?
Page 197
 In what time frame can the CA be reasonably be implemented?
 What resources are required for successful development of CA?
 What resources are required for successful implementation and continue

effectiveness of the CA ?
 What impact will the CA have on other work groups?
 Is implementation of the CA measurable?
Page 198
Final Team Actions
 Propose corrective action for each root or system cause failure.
 Prepare forlllal written report
 Present to Management for approval
Page 199
KEY RECOMMENDATION CONCEPTS
 Recommendations are the most important products of analyses
 Recommendations should address system improvements aimed at a problem's root cause

(s)
 Recommendations should inhibit the flow of events .
Page 200
Successful Recommendation
 Address options for reducing frequency and/or reducing the consequences of one or more
root causes
 Clearly state the action
 Are practical, feasible and achievable
 Do not pose other undesirable and/or unforeseen risk
 Are base on conclusion from data analysis result
Page 201
Successful Recommendation
 Have assigned responsibility and a date for completion
 Are compatible with other objectives of the system facility
 Improve safeguard or inherent protection

 Reduction of Inventories
 Substitution
 Elimination of Hazards
 Increase the number of events necessary to generate a loss event
Page 202
Four Levels of Recommendation
 Address the causal factor
 Address the specific problem
 Fix similar problems
 Correct the process that creates these problems
Page 203
Example - A Seal on a Pump Fails
 Replace the pump seal and fix the pump
 Modify maintenance or operational practices to prevent failure of this pump
 Ensure pump seals are matched to their operating environment on other

equipment
 Correct the maintenance scheduling system to ensure maintenance is

performed on time
Page 204
Suggested Format for Recommendations
 Provide a general objective to be accomplished, followed by a specific example of

how it could be accomplished
Example:
 Provide a means for operators to detect slow changes in tank levels. For example,
provide a strip chart recorder that shows trends over 8 hours.
Page 205
Recommendation Hierarchy
 Eliminate the hazard
 Make the system inherently safer/more reliable
 Prevent the occurrence of the event
 Detect and mitigate the loss
 Contain the damage
 Perform emergency response
Page 206
Special Recommendation Areas
 Restart/resumption criteria may be important recommendations for controlling

risks
 Disciplinary actions or commendations should generally be avoided unless

specifically included within the scope
 "No action” may be an appropriate recommendation for certain instances in which

the risk of recurrence is very low or the cause is beyond the control/influence of
the organization
Page 207
Management Responsibilities
 Review recommendations
 Establish schedules
 Assign individuals
 Evaluate recommendations
 Allocate resources
 Inform affected employees
 Document resolutions
 Track status of recommendations
 Reduce risks in other systems
Page 208
Management Responsibilities
 Document resolutions: (special note)

 accept the recommendation
 accept a modification or similar alternative recommendation
 Defer the implementation until after further evaluation
 Reject the recommendation for cause
Page 209
Reasons for Rejecting/Modifying
Recommendations
 Recommendation not a good idea
 Problem not as severe as thought
 No longer valid
 No longer required
 A better way exists
Page 210
Recommendation Resolution flowchart
Is recommendation Yes Can Implementation

No Assign Responsibility Track
practical and reasonable
cause more and schedule for
Implementation
Is it technically correct / problems than implementation
feasible? Status and
It fixes?
Is it justified by low / no Document resolution
cost alone?
It is requirement?
Does it have an
attractive benefit-to-cost
ratio?
No
Flowchart
Consider ways to improve
the recommendation of
Guidelines
Chose not to implement
Yes For Investigating
Incidents
Page 211
 An investigation into any raised incident or defect must include a root cause
analysis.
 The purpose of root cause analysis is to identify how the incident or defect
occurred and define controls in an effort to prevent recurrence in the future.
 The method to be used for the determining of shipboard root cause analysis is the
ABS Marine root cause analysis map.
Page 212
Root Cause Analysis
Root Cause Analysis (cont.)
 Upon opening the root cause tab in the SDR, there is a preloaded copy of the
ABS Marine root cause analysis map. Starting with the cause factor, the relevant
problems then should be selected and the map navigated accordingly until the
cause is determined.
Page 213
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Page 218
Veritas Policy on Incident Reporting
 The following slides shows the step by step procedure on how to record
incident on the NS5.
Page 219
1. Open the NS5 Program
Page 220
2. Click on Quality & Compliance
Page 221
3. Click on INC (Incident)
Page 222
4. Populate
 You need to populate the following:

 Incident Type
Page 223
4. Populate
Page 224
4. Populate
 On the Incident Type List, the “Accident” option no longer exist. You can
only choose from either “Incident” or “Near Miss”.
 Then you press “Select”.
Page 225
4. Populate
Fill-up the following:
 Date: Time: Reported: Reported By: Title (code of ship / year / sequence
number / brief description): Place: City, Country:
The following will be automatically populated:
 Ship:
 Voyage Number :
 Incident Number:
Page 226
4. Populate (Category)
Incident Category List
Page 227
4. Populate
Description and Remarks
Page 228
Participants
Page 229
Participants
Page 230
Statements
Page 231
Conduct incident investigations with accident

prevention in mind – investigations are NOT to place
blame.
Page 232

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Incident

 Initiate an investigation and gather evidence;

The marine industry experiences incidents that range

 To introduce you to the philosophy, processes, and procedures required to

 The Code seeks to introduce to the international shipping community

 The international aviation industry has subscribed to such a code (Annex 13

 The IMO Code is aimed at a safety outcome to identify the circumstances

 The course is designed to introduce the investigators with an introduction

 Marine accidents as seen by public and media

 Shipping accidents bring into question the safety of the industry

 News media are quick to focus public attention on shipping accidents

 Ship safety issues

 Triangle or iceberg of accident.

The Modern Method of Incident Investigation gives emphasis to:

 Ensure that all causes are identified.

 Remove reluctance to reveal all facts, by eliminating the “blame culture”.

 Identify problem areas early enough to allow preventive action.

 Protection of seafarers and the environment – IMO, ILO and UNCLOS

 ILO Maritime convention

 IMO Resolutions and Circular

 Resolution A 849 (20) – the code

 Article 27 – Criminal jurisdiction is severely limited unless crime committed in coastal

 ILO Convention 134:

 deals with the prevention of occupational accidents to seafarers:

 - requiring accidents to be investigated - statistics to be kept

 - research undertaken into general trends - action taken to prevent accidents.

 • laws covering safety standards • exercise of jurisdiction

 Recommendation 142 of 1970

 SOLAS Chapter 1, Part C, Regulation 21

 International Convention on Loadlines, 1966 Article 23

 IMO Resolutions and circulars

 IMO Conventions have been supported and amplified by Resolutions and

 The flag State should provide qualified investigators, to carry out

 IMO Requirements, Reports to IMO and Data Base on Casualties, MSCICirc.B27-MEPCICirc.433

 As described earlier, investigation by Administrations of casualties to any of their ships are to be

 Resolution A 884 (21)

 The purpose of the guidelines is to provide practical guidelines for systematic

 The contents of the guidelines are:

 2. Investigation procedures and techniques

 4. Qualifications and training of casualty investigators

The Human Element

 Is a complex multi-dimensional issue that affects maritime safety &

 Involves the entire spectrum of activities performed by ship's crew, shore

 In considering human contribution to disasters, we must distinguish

Culture Ability/Situation Awareness

Unlicensed Crew Error

 Structural & equipment failure cause about 20% of incidents

 Major claims tend to have the same causes as minor claims

 1.4% of the claims account for 71.8% of the costs

 10-14 yr old ships have highest Incidence of human error

 Major injury claims tend to peak in ships 5 to 9 years old

 Hospital, etc treatment

 Damage to buildings, vehicles, machinery, etc.

 Product loses and or damage

 Material loses and or damage

 Hiring or training replacement staff

 Loss of experience and expertise

 Increased insurance premiums

 Implied Cost of Averting a Fatality (lCAF) - oil companies in UK around $3

 Continual Quality & Safety Improvement

 Eliminating Waste & Reducing Costs

 Promoting Teamwork & Training

 Responsibility & Accountability