1. Root Cause Analysis and Corrective Action Plans

2. Management Decision As of 05 September 2013 CARs identified on vessels will be handled by vessel officers It is expected that ship’s crew will be more effective than shore based personnel in resolving issues on their own vessel. Vessels are now responsible for conducting root cause and proposing corrective action for non-conformities.

3. Developing Corrective Action Plans Step 1: Root Cause Analysis (RCA) The first step in developing a corrective action plan is to determine the root cause of the problem. This can be done using either the “Why Tree” method or the “Fishbone” or “Cause and Effect” chart.

4. Developing Corrective Action Plans Step 2: Corrective Action Plan (CAP) Once you know the root of the problem, come up with a written plan of how to resolve the root problem so the event does not occur again. Submit your root cause analysis (RCA) and corrective action plan to the DPA for approval. You have 30 days from initial non-conformity to submit the corrective action plan to the DPA.

5. Implementing Corrective Action Plans Step 3: Implementation Once approved, office personnel will enter your CAP into NS5 and you will implement your plan. You have 90 days from initial non-conformity to implement your plan and verify its effectiveness.

6. Evaluating Corrective Action Plans Step 4: Review Effectiveness Determine a reasonable amount of time to evaluate the effectiveness of the plan. Is it working? Have any other incidents occurred?

7. Decision Point: Is the CAP effective? Yes- then management can verify effectiveness on next vessel visit and CAR may be closed. No- then the vessel must come up with a new CAP and submit it to the DPA.

8. How it’s tracked in NS5 Management will enter all non-conformances into NS5. Vessels will determine root cause and create corrective action plan- then submit all to DPA for approval. Once approved, the Corrective Action Plan will be entered into NS5 by management and implemented by the vessel.

9. How to conduct Root Cause Analysis Select investigation team Must have knowledge of the operation involved All information relative to the Non-conformance readily available and reviewed prior to beginning and during this process Define the “Failure” All personnel involved understand and agree what the problem is. (May require brainstorming)

10. How to conduct Root Cause Analysis Methods: “Why” Tree Develop a “WHY” Tree. Team asks the question “WHY” five times and answer each time to uncover the root cause of the problem. This is a systematic and disciplined approach to discover how and what went wrong. Document this phase. Goal is to improve from our mistakes and make the process or condition better.

11. “Why” Tree Example Problem: Lathe machine repeatedly stopping after blowing a fuse WHY 1: Why did the machine stop? Because the fuse blew due to overload WHY 2: Why was there an overload? Because the bearing lubrication was inadequate WHY 3: Why was lubrication inadequate? Because lubrication pump was not working properly

12. “Why” Tree Example Problem: Lathe machine repeatedly stopping after blowing a fuse WHY 4: Why was lube pump not working properly? Because the pump axle was worn out WHY 5: Why was pump axle worn out? Because sludge is getting in with the lubrication

13. “Why” Tree Example Corrective Action Plan: A strainer was attached to the lube pump to keep sludge out of bearings. Evaluation: Lathe machine was run for two full shifts with no further shutdowns or blown fuses. Therefore CAP was effective. No further action required.

14. Evaluate your answers Is the problem Physical, Human, or System related or a combination of all? This will help you identify: a) Probable Root Cause b) Contributing Factors c) Combination of all d) Could be many or only one

15. Look at the Human Factor Accident Causation: a) What were immediate cause on human side (unsafe acts or omissions)? b) Have there been any similar incidents onboard? c) Is there a pattern to these incidents? d) Are there any underlying causes?

16. Possible contributing factors 1) Standard operating procedure 2) Commercial pressure 3) “Git-R-Done” or “Superman” attitude 4) Workload 5) Fatigue 6) Communication 7) Training or lack of training 8) Housekeeping

17. Possible contributing factors 9) Organizational issues 10) Maintenance management 11) Hardware issues 12) Design problems 13) Incompatible goals 14) Error enforcing conditions

18. Error Type, Visibility & Tolerance Skill based routine error Rule, procedure, or lack of knowledge error Execution error Ergonomic design, layout of involved instrumentation, plant or machinery Was the error made highly visible and obvious to the participants?

19. Behavior & Safety Attitude Personnel involved in the incident: a) Had the required skills for the operation? b) Were aware of and following all required procedures or rules? c) Were experienced with the process? a) OR were Short Term Employees given an mentor? b) Was mentor training and monitoring SSE appropriately?

20. Management Style On Board Are all personnel working together as a team? What Management style resides on board? a) I am the BOSS b) We work as a team c) The Procedures are the law and vessel perceives they have to abide

21. Communication Was/Is communication on board effective? Is communication between vessel and Shoreside Management effective? Had a briefing (JSA) been conducted? Did all involved personnel involved participate? Was a check list required? If so was it used?

22. Situational Awareness Did all personnel involved in the operation ensure they were on the same page? Is there a reluctance to change? Was there an interruption or other disturbance that affected the process? Did all personnel involved have situational awareness?

23. Decision Making What type of decisions are made? Are they open or closed decisions? Do decisions look at both internal and external risks? Are decisions based upon procedures, habits pressure? Is risk analysis used for processes on board? (JSAs or hazard IDs)

24. Workload, Stress and Fatigue Was workload more or less than normal? Did the workload allow sufficient time to complete the process properly? Are workflow issues addressed as they occur? Was fatigue a prevailing factor? Did outside pressure encourage workers to cut corners to get the job done?

25. An Effective Corrective Action Plan Corrective Action Plan Should State: a) What is happening b) What should be happening c) How can it be fixed

26. An Effective Corrective Action Plan Create simple, measurable solutions that address the root cause: a) What are the regulatory requirements? b) What are the available resources to affect a solution? c) How can this reasonably accomplished?

27. An Effective Corrective Action Plan Personnel should be assigned and held accountable. What is a reasonable time frame to correct the problem? Actions need to be addressed promptly. Consider all recommendations to the issue or process. Corrective Action Plan needs to be monitored for its effectiveness.

28. Root Cause Example Problem Statement: After serving breakfast and all personnel had vacated the galley area, the Steward/Chief Cook decided to sweep and wash down the decks. He mixed soapy water in his pail and proceeded to mop the area. Upon finishing he stored his gear and retired to his cabin. He would return a few hours later to prepare the noon meal.

29. Continued: Not long after the cook retired, a crewman entered the galley area to get a bottle of water. Upon entering the galley area he slipped on the deck and fell. He put his hand out to break his fall and fractured his wrist when he came in contact with the deck. What was the root cause of this accident?

30. Why Tree: State the Problem/ Failure Slip and fall resulting in a fractured wrist Immediate cause – Wet deck surface PPE-He had proper non-skid shoes on Communication- He was unaware deck was wet Start asking questions WHY 1: Why did crewman fall? Floor was wet

31. Why Tree: WHY 2: Environment/ Housekeeping Why was floor wet? Cook mops floor daily at about the same time

32. Why Tree: WHY 3: Procedures Can you keep people from walking on wet floor? Yes, if you put cold drinks in a cooler on deck so crew would not have to walk in kitchen when floor was wet. No, it is part of main exit/ entrance to deck. But you could put wet floor sign up to warn people of slippery floor.

33. Why Tree: WHY 4: Communication Why wasn’t a sign put up in the first place? There is no policy or procedure for putting up wet floor signs after mopping. No signs on board.

34. Why Tree: WHY 5: Situational Awareness: Did cook think about displaying signage notifying personnel of wet decks in the galley area? No. This is part of his daily duties and nothing out of the ordinary.

35. Why Tree: WHY 6: Workload, Stress or Fatigue Was crewman over tired and perhaps not paying attention? No. Crewman had only been on shift 2 hrs- not overtired

36. Determine the Root Cause Rewrite your answers as statements. If you could fix one statement, which one would prevent the event from happening again? That statement probably contains the root cause.

37. Determine the Root Cause WHY 1- Floor was wet WHY 2- Cook has to mop floor daily WHY 3 – Can’t keep people from walking in that area – it’s part of main walkway WHY 4- No policy required a sign for wet floors WHY 5- Cook didn’t think he should advise crew of what his normal daily duties WHY 6 – Crew fatigue was not a factor

38. Determine the Root Cause WHY 1- Floor was wet WHY 2- Cook has to mop floor daily WHY 3 – Can’t keep people from walking in that area – it’s part of main walkway You can’t keep the floor from getting wet, the cook from mopping the floor or people from walking in the main area. What’s left?

39. Determine the Root Cause WHY 4- No policy required a sign for wet floors WHY 5- Cook didn’t think he should advise crew of what his normal daily duties WHY 6 – Crew fatigue was not a factor You could create a policy to put up wet floor signs after mopping

40. Determine the Root Cause WHY 4- No policy required a sign for wet floors WHY 5- Cook didn’t think he should advise crew of what his normal daily duties WHY 6 – Crew fatigue was not a factor You could have the cook tell the crew each time he mops (not practical). And WHY 6 was ruled out as a cause.

41. Determine the Root Cause WHY 4- No policy required a sign for wet floors So in this investigation, the most likely root cause was lack of policy requiring a wet floor sign. Corrective Action Plan- Make a new policy to post wet floor signs after mopping.

42. Corrective Action A procedure should be created that requires a “wet floor” sign to be posted after mopping until the floor is dry. After mopping any area signage should be displayed to notify personnel that deck may be wet and to be careful on entering.