M-SCAT ®

Marine Systematic Cause Analysis Technique

PY
O
C
ED
LL
O
TR
N
O
C
N
U
 Introduction

Effective accident/incident Six major phases of effective

investigation and follow up investigation
Accident/Incident investigation should be part Following are six major phases of effective inves-
of every loss control system. Effective investiga- tigation, with key point guidelines for each:
tions can
1. Describe what happened 1. Respond to the emergency promptly and
positively

PY
2. Determine the real causes
3. Decide the risks a. Take control at the scene.
4. Develop controls b. Ensure first aid and call for emergency.

O
5. Define trends c. Control potential secondary accidents.

C
6. Demonstrate management’s concern. d. Identify sources of evidence at the scene.
e. Preserve evidence from alteration or
ED
Officers and line management should conduct removal.
most investigations. f. Investigate to determine loss potential.
g. Decide who should be notified.
LL

1. They have a personal interest in the people

and workplace involved.
O

2. They know the people and conditions. 2. Collect pertinent information

3. They know how best to get the information a. Get “the big picture” first.
TR

needed.
4. They are the ones who implement most b. People evidence – Interviewing
1) Interview witnesses separately.
N

remedial actions.
5. They are held accountable for what happens 2) Interview on-site whenever feasible.
O

in their areas. Staff personnel and higher 3) Put the person at ease.
C

level managers take part in major loss cases 4) Get the individual’s version.
5) Ask questions at the right time.
N

and those where specialized knowledge is

needed. 6) Give the witness feedback of your
U

understanding.
7) Record (in writing) critical information
Reasons why people may not report quickly.
accidents
8) Use visual aids.
1. Fear of consequences 9) Use re-enactment sparingly and
2. Concern about the safety record carefully
3. Lack of understanding of the importance of 10) End on a positive note.
complete reporting. 11) Keep the communication line open.

Basic ways to get better reporting
1. Communicate
2. Educate
3. Train employees on the need for reporting
and why it is so critical
4. React in a positive way to timely reporting.
c. Don’t re-enact an accident unless absolutely
necessary and under strictly-controlled condi-
tions.
d. For capturing Position evidence, use sketch-
es, maps and photography to show relative
positions and before-and-after details.

2 M-SCAT® – Marine Systematic Cause Analysis Technique

e. Collect and safeguard important Parts such
as equipment, tools, damaged areas and fluid
samples.
f. Examine Records to identify basic causes
such as training, maintenance or scheduling
problems.
Accidents are costly in both human and econom-
ic terms. When they occur, people and organiza-
tions pay a steep price. Effective investigation is
the only known way to get something for the
price you have paid – better safety from this day
forward.

PY
3. Analyze and evaluate all significant
causes
Want to learn more?

a. Use the cause and effect (domino) sequence.
b. Make a causal factor outline.
c. Cover immediate causes or symptoms (sub-
standard acts/practices and conditions).
ED
d. Cover basic or underlying causes (personal
factors and job/system factors).
LL
O
DNV stations world wide offer a range of train-
ing courses and advisory assistance in managing
C
accident/incident investigations. Please contact
your local DNV office for more information.
Note to the user

e. Determine the critical few specific causes. The M-SCAT is developed to aid you in the
f. Cover deficiencies in the management system analysis of accidents and near misses. The
O

(inadequate system, inadequate standards, M-SCAT is best used as an “aide de memoir”

inadequate compliance with standards).
TR

to guide the investigator, rather than a compul-

sory check list where all points rigorously have
4. Develop and take corrective actions to be checked off.
N

a. Consider alternative controls.

O

b. Lower the likelihood of occurrence.

C

c. Reduce the potential severity of loss.

d. Take temporary actions immediately.
N

e. Take permanent actions as soon as possible.

U

f. Document with written report.

5. Review findings and recommendations

a. Have every report reviewed by the next high-
er level manager.
b. Measure the quality of the reports and coach
for improvement.

6. Follow through
a. Conduct investigation review meetings.
b. Monitor timely implementation of remedi-
al/preventive actions.
c. Analyze data for trends.
d. Profit from prompt and positive changes
based on reviews, analysis and experience.

M-SCAT® – Marine Systematic Cause Analysis Technique 3

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Description of accident or incident

" People

" Process/operation

" Property

PY
O
" Environmental

C
ED
LL
O
TR
N
O
C
N
U

4 M-SCAT® – Marine Systematic Cause Analysis Technique

Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Evaluation of loss potential if not controlled

Loss severity potential Probability of recurrence

(A) Major – loss of life; (A) High – probability of

permanent disability, loss of recurrence of loss.
process; major cost, oil spill
> 10 barrels. (B) Moderate – probability of

PY
recurrence of loss.
(B) Serious – lost time injury,

O
no disability; disruption to (C) Low – probability of
process; significant cost,
oil spill < 10 barrels. C
recurrence of loss.
ED

(C) Minor – minor injury with

LL

no lost time; partial disruption

O

to process; minor cost.

TR
N
O
C
N
U

M-SCAT® – Marine Systematic Cause Analysis Technique 5

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Type of contact

Personal injury/illness

1. Falls from elevation

(ICs 1, 2, 3, 4, 5, 8, 9, 10, 11, 13,
14, 15, 16, 18, 19, 20, 21, 22, 23,
24, 25, 27, 35)

PY
2. Falls on same level (slips, trips)

O
ICs 1, 2, 4, 5, 8, 11, 12, 13, 14, 15,
18, 21, 22, 23, 24, 25, 26, 27, 35)
3. Struck against/by C
ED
(ICs 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12,
13, 14, 15, 16, 18, 19, 20, 22, 24,
LL

25, 26, 27, 35, 36)

O

4. Caught in/on/between
TR

(ICs 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12,

13, 14, 15, 16, 18, 19, 20, 22, 24,
N

25, 26, 27, 35, 36)

O

5. Contact with heat, cold, electricity,

C

radiation, noise, toxics, biological

N

(ICs 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12,

U

13, 14, 15, 16, 18, 19, 20, 22, 23,

28, 29, 30, 31, 32, 34, 36)
6. Overstress by overexertion,
overload, overexposure,
ergonomic factors
(ICs 1, 2, 4, 5, 6, 8, 10, 11, 12, 13,
14, 18, 19, 20, 26, 27, 32)

6 M-SCAT® – Marine Systematic Cause Analysis Technique

Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Property/process/environmental
damage
7. Collision 13. Cargo damage and/or loss
(ICs 1, 4, 5, 6, 7, 8, 10, 13, 14, 15, (ICs 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13,
20, 22, 23, 24, 33, 34, 35) 14, 15, 18, 20, 21, 22, 23, 24, 25,
28, 29, 31, 33, 34, 35, 36)

PY
8. Grounding
(ICs 1, 4, 5, 6, 7, 8, 9, 13, 14, 15, 14. Pollution/environmental

O
18, 20, 22, 23, 24, 33, 34, 35) (ICs 1, 3, 4, 5, 6 7, 8, 9, 10, 13, 14,
15, 18, 20, 21, 22, 23, 24, 25, 28,
9. Contact damage (docks, locks,
buoys, etc.) C
31, 32, 33, 34, 35, 36)
ED
(ICs 1, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15. Loss of stability
15, 18, 20, 22, 23, 24, 33, 34, 35) (ICs 1, 3, 4, 5, 6, 7, 8, 9, 10, 14, 15,
LL

18, 20, 21, 22, 23, 24, 34, 36)

10. Fire and explosion
O

(ICs 1, 3, 4, 5, 6, 8, 9, 10, 13, 14, 16. Other contact(s)

TR

15, 18, 20, 22, 23, 24, 25, 28, 29, (ICs 1 through 37)
30, 31, 32, 26)
N

11. Hull and watertight integrity

O

failure
C

(ICs 1,3, 4, 5, 6, 7, 9, 10, 14, 15,

N

18, 20, 21, 22, 24, 35, 36)

U

12. Machinery and equipment

breakdown
(ICs 1, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14,
15, 18, 20, 22, 23, 24, 25, 28, 31,
32, 34, 36)

M-SCAT® – Marine Systematic Cause Analysis Technique 7

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Immediate/direct causes (IC)

Substandard acts/practices
1. Failure to follow rules and
regulations
(BCs 2, 3, 4, 5, 6, 7, 8, 10, 13, 15)
2. Failure to use ppe properly
10. Making safety devices inoperative
(BCs 2, 3, 4, 5, 6, 7, 8, 12, 13, 15)
11. Improper position for task
(BCs 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13,

PY
(BCs 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 15)
15)
12. Improper lifting, handling or

O
3. Operating equipment or storage
machinery without authority
(BCs 2, 3, 4, 5, 7, 8, 12, 13, 15) C
(BCs 1, 2, 3, 4, 5, 6, 7, 8, 9)
ED
13. Horseplay/inappropriate
4. Incorrect use of equipment or behaviour
LL

machinery (BCs 2,3, 4, 5, 7, 8, 13, 15)

(BCs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12,
14. Under the influence of alcohol
O

13, 15)
and/or other drugs
TR

5. Using defective equipment or (BCs 2, 3, 4, 5, 7, 8, 13, 15)

machinery
N

15. Sabotage, wilful damage

(BCs 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
O

(BCs 2, 4, 7)
12, 13, 14, 15)
C

16. Suicide/homicide
6. Failure to follow repair/
N

(BCs 2, 3, 4, 7)
maintenance instructions
U

(BCs 2, 3, 4, 5, 6, 7, 8, 10, 13, 15) 17. Other substandard act(s)

(BCs 1 through 15)
7. Incorrect navigation or ship
handling
(BCs 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13,
15)
8. Failure to warn
(BCs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12,
13, 15)
9. Failure to secure
(BCs 2, 3, 4, 5, 6, 7, 8, 9, 12, 13,
15)

8 M-SCAT® – Marine Systematic Cause Analysis Technique

Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Substandard conditions
18. Inadequate guards or barriers
(BCs 5, 7, 8, 9, 10, 11, 12, 13, 15)
19. Inadequate or defective ppe
(BCs 5, 7, 8, 9, 10, 12, 13)
30. Radiation exposure
(BCs 5, 6, 7, 8, 9, 10, 11, 12, 13,
14)
31. Inadequate ventilation

PY
(BCs 8, 9, 10, 11, 12, 13)
20. Defective equipment, machinery
or tools 32. Environmental conditions

O
(BCs 8, 9, 10, 11, 12, 13, 14, 15) (BCs 8, 9, 10, 11)
21. Hull or structural condition
C
33. Outdated charts, publications and
ED
(BCs 8, 9, 10, 11, 12, 13, 14) other documentation
(BCs 5, 6, 7, 8, 10, 13, 15)
22. Inadequate warning system
LL

(BCs 8, 9, 10, 11, 12, 13, 14, 15) 34. Bunkers and/or lubricating oils
(BCs 5, 6, 7, 8, 9, 10, 11, 13, 15)
O

23. Adverse weather conditions

TR

(BCs 5, 6, 7, 8, 9, 13) 35. Port and berthing facilities

(BCs 5, 6, 7, 8, 13, 15)
24. Adverse sea conditions
N

(BCs 5, 6, 7, 8, 9, 13) 36. Cargo

O

(BCs 5, 6, 7, 8, 13, 15)

25. Poor housekeeping
C

(BCs 5, 6, 7, 8, 9, 10, 11, 12) 37. Other substandard condition(s)

N

(BCs 1 through 15)

U

26. Congestion or restricted action

(BCs 8, 9, 13)
27. Inadequate or excess illumination
(BCs 8, 9, 10, 11, 12, 13)
28. Fire and explosion hazards
(BCs 5, 6, 7, 8, 9, 10, 11, 12, 13,
15)
29. Noise or temperature
(BCs 1, 2, 3, 5, 6, 7, 8, 9, 10, 11,
12, 13, 15)

M-SCAT® – Marine Systematic Cause Analysis Technique 9

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Basic/underlying causes (BC)

Personal factors

1. Inadequate physical/physiological 4. Mental or psychological stress

capability (see CAN: 1, 4, 5, 6, 10, 11, 12, 15, 16, 18, 20)
(see CAN: 6, 9, 12, 15, 18) 4.1 Emotional overload
1.1 Inappropriate height, weight, size, strength, 4.2 Fatigue due to mental task load or speed
reach, etc. 4.3 Extreme judgment/decision demands
1.2 Restricted range of body movement 4.4 Routine, monotony, demand for uneventful

PY
1.3 Substance sensitivities or allergies vigilance
1.4 Sensitivities to sensory extremes 4.5 Extreme concentration/perception demands
(temperature, sound, etc.) 4.6 “Meaningless” or “degrading” activities

O
1.5 Vision deficiency 4.7 Confusing/conflicting directions/demands
1.6 Hearing deficiency 4.8 Preoccupation with problems
1.7 Other sensory deficiency (touch, taste, smell,
balance) C
4.9
4.10
Frustration
Mental illness
ED
1.8 Respiratory incapacity
1.9 Other temporary or permanent disabilities 5. Lack of knowledge
(see CAN: 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15,
LL

2. Inadequate mental/psychological 16, 18, 20)

capability 5.1 Lack of experience
O

(see CAN: 6, 9, 10, 15, 18) 5.2 Inadequate orientation

2.1 Fears and phobias 5.3 Inadequate initial training
TR

2.2 Mental illness/emotional disturbance 5.4 Inadequate update training

2.3 Intelligence level 5.5 Misunderstood directions
2.4 Inability to comprehend
N

2.5 Poor judgment 6. Lack of skill

O

2.6 Poor coordination (see CAN: 2, 4, 5, 6, 7, 9, 10, 13, 15, 16)

2.7 Slow reaction time 6.1 Inadequate initial instruction
C

2.8 Low mechanical aptitude 6.2 Inadequate practice

2.9 Low learning aptitude 6.3 Infrequent performance
N

2.10 Memory failure 6.4 Lack of coaching

U

6.5 Inadequate review instruction

3. Physical or physiological stress
(see CAN: 4, 6, 9, 11, 12, 13, 15, 18, 20) 7. Improper motivation
3.1 Injury or illness (see CAN: 1, 2, 4, 5, 6, 8, 10, 11, 13, 14, 17, 18)
3.2 Fatigue due to task load or duration 7.1 Improper performance is rewarded
3.3 Fatigue due to lack of rest (tolerated)
3.4 Fatigue due to sensory overload 7.2 Proper performance is punished
3.5 Exposure to health hazards 7.3 Lack of incentives
3.6 Exposure to temperature extremes 7.4 Excessive frustration
3.7 Oxygen deficiency 7.5 Inappropriate aggression
3.8 Atmospheric pressure variation 7.6 Improper attempt to save time or effort
3.9 Constrained movement 7.7 Improper attempt to avoid discomfort
3.10 Blood sugar insufficiency 7.8 Improper attempt to gain attention
3.11 Drugs and/or alcohol 7.9 Inadequate discipline
7.10 Inappropriate peer pressure
7.11 Improper supervisory example
7.12 Inadequate performance feedback
7.13 Inadequate reinforcement of proper
behaviour
7.14 Improper production incentives

10 M-SCAT® – Marine Systematic Cause Analysis Technique

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Job factors

8. Inadequate leadership and/or supervision 10. Inadequate purchasing

(see CAN: 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, (see CAN: 1, 3, 4, 6, 9, 12, 13, 14, 15, 19)
14, 15, 16, 17, 18) 10.1 Inadequate specifications on requisitions
8.1 Unclear or conflicting reporting relationships 10.2 Inadequate research on materials/equipment
8.2 Unclear or conflicting assignment or 10.3 Inadequate specifications to suppliers
responsibility 10.4 Inadequate mode or route of shipment

PY
8.3 Improper or insufficient delegation 10.5 Inadequate receiving inspection and
8.4 Giving inadequate policy, procedure, acceptance
practices or guidelines 10.6 Inadequate communication of safety and

O
8.5 Giving objectives, goals or standards that health data
conflict 10.7 Improper handling of materials
8.6
8.7
Inadequate work planning or programming
Inadequate instructions, orientation and/or
10.8
10.9 CImproper storage of materials
Improper transporting of materials
ED
training 10.10 Inadequate identification of hazardous
8.8 Providing inadequate reference documents, materials
directives and guidance publications 10.11 Improper salvage and/or waste disposal
LL

8.9 Inadequate identification and evaluation of 10.12 Inadequate contractor selection

loss exposures
O

8.10 Lack of supervisory/management job 11. Inadequate maintenance

knowledge (see CAN: 1, 3, 4, 6, 9, 10, 13, 15, 19)
TR

8.11 Inadequate matching of individual 11.1 Inadequate preventive

qualifications and job/task requirements 11.1.1 Assessment of needs
8.12 Inadequate performance measurement and 11.1.2 Lubrication and maintenance
N

evaluation 11.1.3 Adjustment/assembly

O

8.13 Inadequate or incorrect performance 11.1.4 Cleaning or resurfacing

feedback 11.2 Inadequate reparative
C

11.2.1 Communication of needs

9. Inadequate engineering 11.2.2 Scheduling of work
N

(see CAN: 1, 3, 4, 9, 12, 14) 11.2.3 Examination of units

U

9.1 Inadequate assessment of loss exposures 11.2.4 Part substitution

9.2 Inadequate consideration of human factors/
ergonomics 12. Inadequate tools and equipment
9.3 Inadequate standards, specifications and/or (see CAN: 1, 3, 4, 6, 7, 9, 11, 12, 14, 15, 19)
design criteria 12.1 Inadequate assessment of needs and risks
9.4 Inadequate verification of design 12.2 Inadequate human factors/ergonomics
9.5 Inadequate validation of design considerations
9.6 Inadequate monitoring of construction 12.3 Inadequate standards or specifications
9.7 Inadequate assessment of operational 12.4 Inadequate availability
readiness 12.5 Inadequate adjustment/repair/maintenance
9.8 Inadequate or improper controls 12.6 Inadequate salvage and reclamation
9.9 Inadequate monitoring or initial operation 12.7 Inadequate removal and replacement of
9.10 Inadequate evaluation of changes unsuitable items

M-SCAT® – Marine Systematic Cause Analysis Technique 11

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

13. Inadequate work standards

(see CAN: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13,
14, 15, 16, 19)
13.1 Inadequate development of standards for:
13.1.1 Inventory and evaluation of
exposures and needs

PY
13.1.2 Coordination with process design
13.1.3 Personnel involvement
13.1.4 Procedures/practices/rules

O
13.2 Inadequate communication of standards for:
13.2.1 Publication
13.2.2
13.2.3
Distribution
Translation of appropriate C
ED
languages
13.2.4 Training
13.2.5 Reinforcing with signs, colour codes
LL

and job aids

13.3 Inadequate maintenance of standards for:
O

13.3.1 Tracking of work flow

13.3.2 Updating
TR

13.3.3 Monitoring use of procedures/

practices/rules
13.4 Inadequate monitoring of compliance
N

14. Excessive wear and tear

O

(see CAN: 3, 4, 6, 9, 10, 13, 14, 15)

C

14.1 Inadequate planning of use

14.2 Improper extension of service life
N

14.3 Inadequate inspection and/or monitoring

U

14.4 Improper loading or rate of use

14.5 Inadequate maintenance
14.6 Use by unqualified or untrained people
14.7 Use for wrong purpose

15. Abuse or misuse

(see CAN: 1, 3, 4, 6, 8, 9, 10, 11, 13, 14, 15,
16, 17, 19)
15.1 Improper conduct that is condoned
15.1.1 Intentional
15.1.2 Unintentional
15.2 Improper conduct that is not condoned
15.1.1 Intentional
15.1.2 Unintentional

12 M-SCAT® – Marine Systematic Cause Analysis Technique

Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

Control Action Needs (CAN)

P S C P S C

1. Leadership and administration 3. Planned inspections and

1.1 General policy and long-range plan maintenance
1.2 Designated loss control coordinators 3.1 Planned general loss control
1.3 Management participation and inspections
verification 3.2 Critical systems, equipment,
1.4 Established loss control performance components and parts/items

PY
standards 3.3 Planned inspection and maintenance
1.5 Participation in loss control activities system
1.6 Management meetings 3.4 Emergency and safety systems

O
1.7 Loss control reference manual 3.5 Special stand-by, inactive and pre-use
1.8 Internal audits conducted equipment testing and maintenance
1.9 Individual responsibility for loss
control
3.6
C
Alternate substandard condition
reporting system
ED
1.10 Establishment of annual loss control 3.7 Compliance requirements
objectives 3.8 Planned inspection and maintenance
1.11 Shipboard safety and environmental follow-up system
LL

protection committees 3.9 Planned inspection and maintenance

1.12 Refusal to work due to loss control report analysis
O

hazards
1.13 Reference library 4. Critical operations and task analysis
TR

1.14 Document control and record-keeping 4.1 Administration

1.15 Regulations, codes and standards 4.2 Critical operations and critical task
1.16 External communications inventory
N

4.3 Objectives for critical task analysis and

2. Leadership training
O

procedures
2.1 Training needs analysis 4.4 Analysis and procedures for critical
C

2.2 Loss control leadership operations and critical tasks

orientation/induction 4.5 Identification and control of potential
N

2.3 Formal initial training of shore-based losses

U

management and professionals

2.4 Formal review/update/advanced 5. Accident/incident investigation
training of shore-based management 5.1 Accident/incident investigation system
and professionals 5.2 Operating management participation
2.5 Formal initial shipboard loss control 5.3 Major and high-potential
leadership training accidents/incidents
2.6 Formal review/update/advanced loss 5.4 Corrective action and follow-up
control leadership training on board 5.5 Incident (near-miss) reporting and
2.7 Formal training of shore-based loss investigation
control coordinator(s) 5.6 Accident/incident reporting
2.8 Training records maintenance

Legend: P – program activity S – performance standards are established C – full compliance to standards achieved

M-SCAT® – Marine Systematic Cause Analysis Technique 13

 Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

P S C P S C

6. Observation of work performance 10. Knowledge and skill training

6.1 Administration 10.1 Administration
6.2 Work performance observations 10.2 Training needs analysis
6.3 Critical work performance observations 10.3 Instructor qualifications
6.4 Follow-up system 10.4 Training systems
6.5 Work performance observation report 10.5 Training system evaluation and follow-

PY
analysis up

7. Emergency preparedness 11. Personal protective equipment

O
7.1 Administration 11.1 Identification of personal protective
7.2 Emergency response analysis equipment needs
7.3
7.4
Emergency plan
Spill response and clean-up
11.2
CPersonal protective equipment record-
keeping
ED
7.5 Sources of energy controls 11.3 Enforcement of standards
7.6 Safety and rescue systems
7.7 Emergency teams 12. Occupational health and hygiene
LL

7.8 Lessons learned system control

7.9 First aid 12.1 Administration
O

7.10 Organized outside help and mutual aid 12.2 Health hazard identification and
7.11 Post-event planning evaluation
TR

7.12 Emergency communication 12.3 Health hazard control

7.13 Communications with the community 12.4 Occupational health and industrial
hygiene monitoring
N

8. Company safety rules and work 12.5 Information and training

permits
O

12.6 Health care system

8.1 General loss control rules 12.7 Professional assistance
C

8.2 Specialized work rules 12.8 Communications

8.3 Work permit systems 12.9 Records
N

8.4 Statutory and classification certificates

13. System review and evaluation
U

8.5 Rule education and review

8.6 Rule compliance and recognition 13.1 Evaluation of long-range plan
8.7 Use of educational signs and colour 13.2 Regular system monitoring
codes 13.3 Master’s and management review
13.4 Perception survey
9. Accident/incident analysis 13.5 Record-keeping
9.1 Consequence measurements
9.2 Cause and control analysis
9.3 Property damage/process loss
identification and analysis
9.4 Incident (near-miss) analysis
9.5 Problem-solving project teams

Legend: P – program activity S – performance standards are established C – full compliance to standards achieved

14 M-SCAT® – Marine Systematic Cause Analysis Technique

Description Evaluation Type of Immediate/ Basic/ Control
of Accident of Loss Contact Direct Underlying Action
or Incident Potential Causes (IC) Causes (BC) Needs (CAN)

P S C P S C

14. Engineering and change 19. Purchasing and contract

management management
14.1 Administration 19.1 Procurement
14.2 Hazard identification and risk 19.2 Subcontractor selection
assessment 19.3 Management of subcontractors
14.3 Ship design review and change 19.4 Ship management and charter

PY
management contracts
14.4 Operational and work process controls
14.5 Acquisition (second hand tonnage) 20. Off-the-job safety

O
20.1 Problem identification and analysis
15. Personal communications 20.2 Off-the-job safety education
15.1
15.2
Personal communication systems
Job orientation/induction C
ED
15.3 Task instruction
15.4 Planned personal contacts
LL

16. Group communications

16.1 Group loss control meetings
O

16.2 Record-keeping
16.3 Management involvement
TR

17. General promotion

17.1 Loss control bulletin boards
N

17.2 Use of accident/incident statistics

O

17.3 Critical topic promotion

17.4 Individual awards and recognition
C

17.5 Loss control information publications

17.6 Ship performance awards and
N

recognition
U

17.7 Shipboard housekeeping promotion

system
17.8 Records of promotion activities

18. Personnel recruitment and

orientation
18.1 Capability requirements
18.2 Medical examination
18.3 General orientation/induction
18.4 Personnel selection and recruitment

Legend: P – program activity S – performance standards are established C – full compliance to standards achieved

M-SCAT® – Marine Systematic Cause Analysis Technique 15

 U
N

www.dnv.com
C
O
N
TR
O
LL
ED
C
O
Det Norske Veritas, NO-1322 Høvik, Norway, tel +47 67 57 99 00

PY

x,000/ 12-2003 Layout: DNVE Graphic Communications Print: xxxx