Investigation Analysis

- Loss Causation Models & M-SCAT

The Sanko Steamship Co., Ltd./Sanko Shipmanagement Co., Ltd.

Colin Ip - DNV Maritime Solutions

27th September 2005
OBJECTIVES

„ To understand the Systematic of an Incident - Loss Causation Model

„ To use M-SCAT (Marine – Systematic Cause Analysis Techniques)

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WHAT IS A LOSS?

„ Types of loss are:

- Personnel Loss
Property Damage /
- Property Damage Financial Loss

- Financial
- Process and Productivity losses
- Product and Service Quality
- Pollution Personnel Loss (Injury,
- Poor Publicity Permanent Disability,
Fatality
- Administrative costs

Pollution Cost

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DNV LOSS CAUSATION MODEL

Lack of Basic Immediate

Incident Loss
Control Causes Causes

People
Substandard
Inadequate Personal Undesired
Act Property
System, Factors Event That
Standard, could lead
Substandard Environment
Compliance Job Factors to a loss
Conditions
Process

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M-SCAT STRUCTURE

Type of Contact

Immediate Causes

Substandard
Substandard Acts
Conditions

Basic Causes Basic Causes

Personal Factors Job Factors Personal Factors Job Factors

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IMMEDIATE CAUSES

„ Substandard / Practices
- Wearing unsafe clothing
- Wearing unsafe personal attire
such as slippery footwear, loose
long hair, etc.

- Failure to secure or warn

- Failure to lock, block or secure
machinery

- Improper use of tools and

equipment
- Use of materials, tools and
equipment in a manner for which
it is not intended.
- Overloading of cranes,
equipment, power lines, etc.

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IMMEDIATE CAUSES

„ Substandard Conditions
- Congestion or Restricted Action
- Poor design or placement of
valves

- Unsafe Guarding
- Unguarded mechanical or
physical hazards.
- Inadequate shoring or
supporting.
- Uncovered connections,
switches, fuse boxes.
- Unshielded against radiation,
heat, metal spray, UV rays.
- Inadequately shielded

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BASIC CAUSES

„ Human Factors „ Job Factors

- Mental or Physiological Stress - Inadequate Work standards
- Frustrations - Inadequate Maintenance
- Emotional overload - Inadequate Purchasing
- Improper Motivation - Abuse or Misuse
- Proper punishment is punished
- Lack of Knowledge
- Misunderstood Directions

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USE Of M-SCAT – ACTIVITY 1: Fatal Injury Analysis

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USE OF M-SCAT – ACTIVITY 2: ER Flooding Analysis

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