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