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I N C I D E N T I N V E S T I G AT I O N

Root Cause Analysis


Why Investigate Incidents? public domain and by proving, and regulatory exposure, complexity,
continually improving, the overall etc. Help can be found in the ABS
Maritime industries experience approach through its application Guidance Notes for the Investigation
incidents that range from major throughout many incident of Marine Incidents. Classifying is
accidents to near misses (or more investigations. The associated ABS important for many reasons,
appropriately, near hits). Why Incident Investigation – Root including the need to match the
should these incidents be Cause Analysis (II-RCA) software skill level of the investigator(s) and
investigated? International provides a suite of tools to help the investigation resources with the
agreements mandate it (such as conduct incident investigations and incident to be investigated. Since
the IMO “International Safety to document those investigations good preparation can make a
Management Code”), many flag by storing the information collected difference to the investigation’s
administrations require it, and within an integrated database. The outcome, the lead investigator
industry initiatives (such as the II-RCA software is fully reflective (and team members) can use the
Oil Companies International Marine of the methods and techniques guidance, forms and checklists
Forum’s Tanker Management Self discussed in the associated ABS provided in the Guidance Notes
Assessment scheme) encourage it. Guidance Notes for the Investigation to determine the approach for
Investigating incidents is also of Marine Incidents. conducting the investigation.
good business: if one can prevent
recurrence and reduce the Why Use the ABS Incident Data gathering. The quality of
likelihood of other incidents with Investigation – Root Cause the answers about what happened
the same root causes, costs Analysis Methodology? will rely on the data collected.
(human, environmental and Interviewing skills are essential
property) associated with incidents This proven technique guides and for gathering key data from people.
can be eliminated. standardizes the investigation Critical evidence can also be
process found by examining equipment
and the components, computer files,
generation chemicals/residues and written
of incident logs/documents. Gathering data
reports, and is not a single, discrete step in an
meets the investigation. In fact, the more
accident and efficient investigations overlap
near miss data gathering with data analysis,
analysis and allowing the data-gathering effort
reporting to be driven by the analysis
requirements of significant possibilities.
of the ISM Unfortunately, investigators
Code and typically find more evidence than
OCIMF’s they need for some facts, but rarely
TMSA. It was find all the supporting evidence
expressly necessary to unequivocally state
developed the chain-of-events and conditions
for the leading to the incident. Sound data
maritime industry and reflects collection techniques (such as
What Can Be Used to those elements of maritime those outlined in the Guidance
Investigate Incidents? operations and accident causation Note) address this problem.
particular to our industry.
The techniques provided in the ABS Data analysis. When the right
Guidance Notes for the Investigation How Does the ABS Incident data has been collected (by
of Marine Incidents offer an effective Investigation – Root Cause interviewing witnesses, reviewing
approach for investigating marine Analysis Methodology Work? paper and computer records,
incidents of any magnitude. ABS examining/ analyzing physical
has developed the methodology by Initiating an investigation. Once evidence, etc.), the next step in an
customizing and combining the an incident is reported, the incident investigation is analyzing the data.
better techniques available in the is classified according to its impact, The ABS Guidance Notes for the
Investigation of Marine Incidents The third step in data analysis is to must be feasible and must address
outline a three-step process for data determine why the contributing all levels of the analysis. II-RCA
analysis. conditions existed and why certain uses the following four levels of
negative actions occurred. The recommendations:
The first step in any analysis, even negative conditions and events are
simple investigations, is to convert typically called causal factors, • Address the causal factor
the data into statements of either however, the investigation process • Address the causes of this
fact or supposition, and then does not stop there. Root causes particular event at the root
to describe these facts and must be determined. Using the ABS cause level
suppositions as events and Root Cause Analysis Map, root • Address other similar, existing
conditions. causes can be systematically situations at the root cause level
determined by using a structured • Address the management system
The second step is to collect the approach and uniform reasoning that created the causal factors
data, or develop informed process. It also imposes a consis- (the root causes)
assumptions to bridge gaps in the tent framework and maritime
events and conditions. For simple nomenclature of accident caus- By addressing each of the levels,
incidents, this step may not be ation, allowing for codification in the organization gets the greatest
necessary. For more complex electronic databases. This facilitates return for the investment made in
incidents (and for many incidents analysis of causal trends over the the investigation.
that look straightforward), one years and it ensures consistency
would determine how the event across all investigations. Generating a Report. The
could have occurred. Once these Guidance Notes suggest a concise
possible scenarios are developed, Developing Recommendations. report that summarizes the results
these scenarios are compared to After having determined the what, and findings of an investigation.
the available data to determine the how, and why of an incident, the The report should include key
scenario that best fits, or at least important task of developing data (such as when the incident
to eliminate scenarios that don’t recommendations to prevent a occurred, when the investigation
appear to fit. After completing recurrence is undertaken. The began, what happened, and how
Steps 1 and 2, an investigation recommendations must be based on and why the conditions leading to
team will understand what conclusions founded on the facts the incident came to be). A sample
happened and how it most likely established during data analysis. To report form is provided in the
happened. be most effective, recommendations toolkit within the Guidance Notes.

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