Marine Root Cause Analysis Map

 

Overall Incident Investigation Program Management System (Section 10)

Enter here with each intermediate cause from page 1 No

Company Standards, Policies, or 

Company Standards, Policies, or 

Administrative Controls (SPACs) Issue 2 5 2 • No SPACs/Issue Not Addressed 253 • Not Strict Enough 254 •Confusing, Contradictory, or  Incomplete 255 • Technical Error  256

Administrative Controls (SPACs) Not Used 25 7 • Tolerable Risk 258 •Unaware of  SPACs 259 • Recently Changed SPACs 260 • Enforcement Issue

261

Industry Standard Issue 262 • Situation Not Addressed by Standard 263 • Standard Confusin g, Contradictory (Internal or  External), or Incomplete 264 •Technical Concern with Standard 265 • Inappropriate Standard  Applied 266

Investigation needed? (Section8)

Yes Generatea CAR?

Yes  Analyzenow? Yes (Section8)

(Section 2)

Initiate investigation

Gatherdata (Section 3)

 Analyzedata (Section4)

(Section2)

Identifyroot causes

Develop recommendations

(Section 5)

(Section6)

No Noformal analysis

Trendincident characteristics (Section9)

No

STOP

Trendroot causes (Section9)

 Analyzedata tofindchronic incidents (Section8)

Completethe investigation (Section7)

Enterinto incident database (Section9)

Followupon investigationand resolve recommendations

(Section7)

*CARisanacronymforCorrectiveActionReques v eActionRequest

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Analyze Data ( Sectio Section n 4) • Use causal factor factor charts for tim me e relations relationships, hips, people issues • Use fault trees for multiple combinations combinations of events, machine-o machine-oriente riented d problems • Identify changes changes and relate them to the causal causal factor chart and/or and/or fault tree • Caus Causal al factor factor charts charts  – start with with the loss event and and work backwards backwards in small "baby" steps  – test for sufficienc sufficiency y by asking asking the three questions  – determine determine why each of the events events occurred  – develop develop questions questions and identify identify sources sources for for answering ng the questions questions  – use fault trees to fill fill in the gaps  – test for completeness completeness  – identify causal causal factors • Fault trees/wh trees/why y trees  – identify top events events carefully and specifically specifically  – develop develop successive successive levels levels with small increments increments ü think systems systems functions and take "baby steps"  – develop questions/tests questions/tests to eliminate eliminate branches branches as quickly as possible ü identify data sources to answer questions ü use answers to questions to eliminate branches  – use AND gates gates for co combinations mbinations (fault trees trees only)  – use OR gates gates for single events (fault trees trees only only)) Identify Root Causes (Section 5) Do NOT start root cause identification identification unt until il all causal f actors ar e

Initiate Investigation (Section (Section 2) 1.Check for legal issues 2.Determine the status status of the system. system. How did the s ystem get there? 3.Identify restart/voyage continuation issues – what are the short-term and long-term concerns? 4.What is different about this time? • Changes in operation, operation, c cargo, argo, systems, systems, personnel, maintenance maintenan ce practices, design, suppliers, etc. 5.Address logistical issues • Complete a safety briefing and obtain personal prote protectiv ctive equipment needed for access to incident scene • Identify location of tea team m room room  – secure, wit with h a wall for causal facto factorr chart and fault tree, flipchart paper, flipchart/easel, white board, access to phone/fax/ phone/fax/copier  copier  • Identify locations locations for interviews separate from th the e team room (at scene if possible) • Develop a list of team team members (w/ (w/titles titles and contact contact information). Fill required roles with team members • Obtain an overview overview of the system ope operati ration on • Briefly tour the incident scene • Identify any addittional ional expert experts s needed for the investigation investigat ion (e.g., metallurgis metallurgists, ts, combustion experts, vendor representatives, chemists) 6.Collect the required information (see Data to Gather and Gather Data sections)

Data to Gather (Section 3 3)) • Log s  – computer logs for tthe he last 24 hours (saved (saved so they can be printed later if needed)  – other logs • Personnel Personnel (to be made available for intervi ervie ews) ws)  – list of o other ther pers personnel onnel involved involved in in/related /related to the incident incident  – list of pe personnel rsonnel assigned assigned to the process/station/ equipment/vessel  – list of po potential tential witnesses  – list of emergency respons esponse e personnel personnel • System System inform informatio ation n  – process/ process/equipment equipment/structur /structural al diagra diagrams ms and pip piping ing and instrumentation diagrams  – schematic diagrams of of processes, processes, flows, connections  – log of operational operational and and safety s system ystem alarms  – flow, temperature, temperature, pre pressure, ssure, and o other ther parameter trend trends s  – startup and shutdown sequence documentation documentation  – navigatio navigational nal charts, charts, radar records, records, comm communications unications data • Main Maintena tenance nce status  – work permits permits and and their status  – inspection inspection reports reports and maintenance maintenance logs • Material Informatio on n (specifica (specifications, tions, welding procedures) • Pho Photogr tograph aphs s  – general photographs photographs of the the inciden incidentt scene  – failed/damaged/degraded failed/damaged/degraded parts parts from multipl tiple angles  – stains, residues, foreign foreign mate materials rials  – layout of equipment equipment/outfittin /outfitting/structures g/structures  – visibilit visibility y from duty stations

Gather Data (Section 3) Prioritize data gathering based on how fragile the data is • Int Interv erview iews s  – match interviewer interviewer to to intervie rviewee wee  – perform interviews one-on-one or two-on-o two-on-one. ne. IIff twotwoon-one, only one person asks questions  – interview interview guid guidelines elines übe nice übe quiet üno leading questions üno accusing questions ütell

me what you did, tell me what happened • Physical parts evaluation  – consider consider test plans plans for each item  – think before you you do; some some actions are irreversible • Paper/electronic Paper/electronic data analysis analysis  – identify and gather fragile computer computer data first  – use others others to assist st with paper paper data gathering gathering if  possible Use chain custody as required to keep track of your  data

identified • For each causal causal factor, factor, identify the  – problem em  – problem category category  – cause category category  – cause type  – intermediate intermediate cause cause  – root cause cause type  – root cause • Identify all roo roott causes that apply • Use the ABS the ABS Guidance Notes for the Investigation o off Marine Incid Incidents ents to achieve greater consistency • If you select Personnel Performance, Individual Issue, you have probably selected the WRONG root cause. Check other parts of the map Develop Recommendations (Section 6) • Develop four types of recommenda recommendations tions Level 1: address the causal factors (may be part of restart issues) Level 2: a ddress the causes of this particular incident at the root cause level Level 3: address other similar situations (at the root cause level) Level 4: correct the management system(s) that created the causal factors • Track recommendations recommendations to to completio on n • Ensure that that recommendations recommendations are assessed assessed using the management of change process Investigation Follow-up (Section 7) • Use the causal factor chart, chart, fault tree, and three-colum three-column n form to communicate communic ate the results of the analysis • Decide who should should know about about the results and determine determine what information they should know • Enter data data into the tracking system • Assess the investigation investigation process