Start here with each causal factor 1

After identifying an intermediate

Machinery/ External Factors cause , proceed to page 2
Structural Outfitting Human
2 Equipment 3 4 5 6 to identify root causes.

Newly Assigned/
Reliability Installation/ Permanent/ Other Uncharted/
Misuse/Overload Contract/ Company Sea/Weather Sabotage/
Design Problem Program
Problem
Fabrication Returning Temporary Employee
(Third-party Unknown Hazard
Condition Terrorism/War Suicide/Homicide External Events Other
Problem Problem Officers/ Crew Employee) to Navigation
7 8 9 10 11 Officers/Crew 12 13 14 15 16 17 18 19 20

Design Maintenance Maintenance Training/

Design Program Equipment Management Responsibility/ Operations/Job Personnel
Review/ Program Procedures Human Factors Personnel Communications
Input/Output Design Implementation Records Systems Qualifications 174 Authority Supervision Performance
21 Verification 32 35 41 69 73 115 139 196 202 216 241

Design Input No Independent No Program 36 Planned Maintenance Corrective Equipment No Training 175 Responsibility/ 197 Preparation 203 Company Issue 242
Issue 22 Review/ Issue 42 Maintenance Issue 57 Design Records 70
Authority Not Defined
Verification 33 Program • Decision Not to Train 176 • Planning, Scheduling, or • Inadequate Problem
• Design Scope Inadequacy 37 • Scheduling Issue 43 • Troubleshooting/ Manufacturer's Responsibility/
Review/ Manuals 71 • MS Familiarization Not Tracking of Work Activities Detection/Situational
Unclear 23 • Scope Issue 44 Corrective Action Authority Unclear 198
Verification • Critical Provided 177 Issue 204 Awareness243
• Design Input Equipment/ Issue 58 Equipment • Ambiguous 199
Issue 34 • Implementation
Operating/ • Training Requirements Not • No Preparation 205 • Rewards/Incentives
Obsolete 24 System Not Issue 45 • Repair Implementation • Conflicting/
Maintenance Fulfilled 178 Overlapping 200 • Unclear Instructions to Issue 244
• Design Input Identified 38 Condition Monitoring Issue 59
Incorrect 25 History 72 • Training Need Not Personnel 206
• Inappropriate Maintenance Issue 46 Failure Finding • Not Documented 201 Individual Issue 245
• Necessary Design Identified 179 • Ineffective Walkthrough 207
Maintenance • Scheduling Issue 47 Maintenance Issue 60
Input Not Available 26 Type Applied 39 Training Records • Scheduling/Rotation Issue 208 • Inadequate Sensory/
• Detection Issue 48 • Scheduling Issue 61 Perceptual Abilities* 246
Design Output • Acceptance System Issue 180 • Personnel Selection/
• Monitoring Issue 49 • Scope Issue 62 • Poor Reasoning* 247
Issue 27 Criteria • Training Records Incorrect 181 Assignment Issue 209
• Troubleshooting/ • Troubleshooting/ Human Resource • Inadequate Motor/
• Design Output Inadequate 40 Corrective Action Issue 63 • Training Certificate/ Supervision During Work 210
Unclear 28 Corrective Action Issue 74 Physical Capabilities* 248
Issue 50 • Implementation • Employee Endorsement Expired/ • Insufficient Supervision 211
• Design Output Issue 64 Invalid 182 • Improper Performance Not • Disregard for
Incorrect 29 • Implementation Screening/Hiring Company
Issue 51 Servicing and Routine Issue 75 Training Issue 183 Corrected 212
• Design Output Inspection Issue 65 • Crew Coordination Issue Procedures/Policies* 249
Shore-base d • Resource/Staffing • Training Program Design/ 213
Inconsistent 30 • Inadequate Rest/
Maintenance Issue 52 • Scheduling/Frequency Issue 76 Objectives Issue 184 • Fatigue Management Issue 214
• Design Input Not Issue 66 Sleep (Fatigue)* 250
Addressed in • Event Specification • Content Issue 185 • Ineffective Teamwork 215
Issue 53 • Scope Issue 67 • On-the-job Training Issue 186 • Personal Medication
Design Output 31
• Scheduling Issue 54 • Implementation • Qualification Testing Issue 187 Use/Abuse* 251
Issue 68 • Continuing Training Issue 188
• Scope Issue 55
• Implementation • Emergency Preparedness
Issue 56 Training Issue 189
• Special Operations
Safety/Hazard/Risk/ Probl e m Change Control Document Vessel Spares/ Purchasing Charter/Contract Training Issue 190 No Communications or Communication Bridge Team Duty/Watch
Security Review Identification/ Issue 88 (Drawing) Control Stores Issue 99 Issue 107 Fulfillment Issue 112 Untimely 217 Misunderstood/ Management 231 Handover Issue 237
Issue 77 Control Issue 82 Issue 94 Qualifications Issue 191
• Change Not • Handling Issue 100 • Purchasing • Charter Requirements • Method Unavailable or Incorrect 224
• Unclear 232 • Communication
• No License/Certificate 192
• Review Skipped or • Problem Reporting Identified 90 • Documentation • Storage Issue 101 Specifications Not Documented/ Inadequate 218 • Standard Communications Within Watch
• Expired License/Certificate 193
Incomplete 78 Issue 83 • Change Review Content Inaccurate or • Packaging/ Issue 108 Communicated 113 • Communication Between Terminology Not • Information Not Issue 238
• Forged Document 194
• Recommendations 79 • Problem Analysis Issue 91 Incomplete 95 Transport Issue 103 • Changes to • Vessel Not Suitable Work Parties Issue 219 Used 225 Communicated 233 • Communication at
• Unclear License/
Not Yet Implemented Issue 84 • Change 92 • Required Documents • Substitution Issue 104 Purchasing for Charter • Communication Between • Language/ • Information Watch Handover
Certificate/Endorsement
• Risk Acceptance • Audit Issue 85 Verification Issue Not Available or • Inventory Issue 105 Specifications 109 Requirements 114 Vessel and Owner Issue 220 Translation Issue 226 Ignored 234 Issue 239
Requirement 195
Criteria Issue 80 • Change Not Missing 96 • Inspection Issue 106 • Supplier/Contractor • Communication with • Verification or • Ambiguous • Personnel
• Ineffective Review 81 • Corrective Actions • Obsolete Documents
Documented 93 Selection Issue 110 Other Vessels 221 Repeat-back Not Information 235 Change/Relief
Ineffective 86 Being Used 97 • Inspection on • Communication with Used 227 • Communication Procedure Issue 240
• Corrective Actions • Change Review or Receipt Issue 111 Charterer Issue 222 • Long Message 228 with Pilot 236
Not Implemented 87 Approval Not • Communication with • Garbled Message 229
Performed 98 • Wrong Instructions 230
Parties Ashore Issue 223

Marine Root Cause Analysis Map™

Notes
Shape Description Not Used 116 Misleading/Confusing 120 Wrong/Incomplete 131 Workload 140 Situational Awareness 146 Work Environment 154 Workplace Layout 161 Intolerant System 171
Numbers here correspond to the • No Procedure for • Format Confusing/Complex/ • Typographical Error 132 • Sustained High • Information Incomplete/ • Ambient Conditions • Individual Control/Display/ • Errors Not Detectable 172
Problem
Map Item number in Appendix A of Task/Operation 117 Difficult to Use 121 • Wrong Action Sequence 133 Workload/Fatigue 141 Unuseable 147 Issue 155 Alarm Issue 162 • Errors Cannot Be
the ABS Guidance Notes for the • Procedure Not • Multiple Actions per Step 123 • Facts Wrong/ • Excessive Action • Information Inaccurate 148 • Protective Clothing/ • Control/Display/Alarm Corrected/Mitigated 173
Problem Category Readily Available or • No Checkoff Space Provided Requirements Incorrect 134 Requirements 142 • Information Inaccessible 149 Equipment Issue 156 Integration/Arrangement
Investigation of Marine Incidents
Inconvenient to but Should Be 124 • Obsolete Version Used 135 • Unrealistic Monitoring • Information Unverified 150 • Slippery/Unsteady Issue 163
Cause Category * These items are for descriptive Obtain 118 • Content Issue 125 • Inconsistency Between Requirements 143 • Alarm/Signal Issue 151 Work Surfaces 157 • Awkward/Inconvenient/
purposes only. Code only to • Language Difficulty 119 • Graphics/Drawing Issue 126 Requirements 136 • Insufficient Time to • Excessive/Complex • Housekeeping Issue 158 Inaccessible Location of
Personnel Performance - Individual • Ambiguous/Confusing • Incomplete/Situation Not Respond 144 Calculations Required 152 • Tool Issue 159 Control/Display/Alarm 164
Cause Type
Issue. Language/Wording Issue 127 Covered 137 • High Transient • Knowledge-based • Other Excessive • Inconsistent/Mirrored
• Insufficient or Excessive • Overlap or Gaps Workload 145 Decision Required 153 Workplace Stresses 160 Layout 165
Intermediate Cause Copyright 2005, Rev. 1M (03/05) References 128 Between Procedures 138 • Awkward/Inconvenient/
• Too Much/Little Detail 129 Inaccessible Equipment
Root Cause Type • Procedure Difficult to Location 166
Identify 130 • Poor/Illegible Labeling of
FOUNDED 1862 Equipment or Space 167
Root Cause
www.eagle.org • Labeling Language Issue 168
marcat@eagle.org Page 1 of 2 • Poor Accessibility 169
(281) 877-6000 • Inadequate Visibility/
Line of Sight 170
 Analyze Data (Section 4)
• Use causal factor charts for time relationships, people issues
• Use fault trees for multiple combinations of events, machine-oriented
problems
• Identify changes and relate them to the causal factor chart and/or fault
Overall Incident Investigation Program Management System (Section 10)
Enter here with tree
each intermediate
cause from Investigation
• Causal factor charts
page 1 needed?
(Section 8)
– start with the loss event and work backwards in small "baby" steps
No
– test for sufficiency by asking the three questions
Company Company Industry Standard Yes – determine why each of the events occurred
Standards, Standards, Issue 262
Policies, or Policies, or Generate a Yes Analyze now? Yes Initiate
Gather data Analyze data
Identify root Develop – develop questions and identify sources for answering the questions
• Situation Not Addressed CAR? investigation causes recommendations
Administrative Administrative
by Standard 263
(Section 2)
(Section 8)
(Section 2)
(Section 3) (Section 4)
(Section 5) (Section 6) – use fault trees to fill in the gaps
Controls Controls (SPACs)
(SPACs) Issue 252 Not Used 257 • Standard Confusing, No – test for completeness
• No SPACs/Issue • Tolerable Risk 258 Contradictory (Internal or
No formal No
Trend incident
characteristics
Trend root
causes
– identify causal factors
Not Addressed 253 • Unaware of External), or Incomplete 264 analysis (Section 9) (Section 9) • Fault trees/why trees
• Not Strict Enough 254 SPACs 259 • Technical Concern with Analyze data
Complete the
Standard 265 STOP
to find chronic
incidents
investigation – identify top events carefully and specifically
• Confusing, • Recently Changed
• Inappropriate Standard (Section 8)
(Section 7)
– develop successive levels with small increments
Contradictory, or SPACs 260
Incomplete 255 • Enforcement Issue 261 Applied 266 Enter into Follow up on
ü think systems functions and take "baby steps"
• Technical Error 256
incident
database
investigation and
resolve – develop questions/tests to eliminate branches as quickly as possible
recommendations
(Section 9)
(Section 7) ü identify data sources to answer questions
*CAR is an acronym for Corrective Action Request
ü use answers to questions to eliminate branches
– use AND gates for combinations (fault trees only)
Page 2 of 2 – use OR gates for single events (fault trees only)

Identify Root Causes (Section 5)

Do NOT start root cause identification until all causal factors are
identified
• For each causal factor, identify the
– problem
– problem category
– cause category
Initiate Investigation (Section 2) Data to Gather (Section 3) Gather Data (Section 3) – cause type
1.Check for legal issues • Logs Prioritize data gathering based on how fragile the data is – intermediate cause
2.Determine the status of the system. How did the system – computer logs for the last 24 hours (saved so they can – root cause type
get there? be printed later if needed) • Interviews – root cause
3.Identify restart/voyage continuation issues – what are the – other logs – match interviewer to interviewee • Identify all root causes that apply
short-term and long-term concerns? • Personnel (to be made available for interviews) – perform interviews one-on-one or two-on-one. If two- • Use the ABS Guidance Notes for the Investigation of Marine Incidents
4.What is different about this time? – list of other personnel involved in/related to the incident on-one, only one person asks questions to achieve greater consistency
• Changes in operation, cargo, systems, personnel, – list of personnel assigned to the process/station/ – interview guidelines • If you select Personnel Performance, Individual Issue, you have
maintenance practices, design, suppliers, etc. equipment/vessel übe nice probably selected the WRONG root cause. Check other parts of the
5.Address logistical issues – list of potential witnesses übe quiet map
• Complete a safety briefing and obtain personal protective – list of emergency response personnel üno leading questions
equipment needed for access to incident scene • System information üno accusing questions Develop Recommendations (Section 6)
• Identify location of team room – process/equipment/structural diagrams and piping and ütell me what you did, tell me what happened • Develop four types of recommendations
– secure, with a wall for causal factor chart and fault instrumentation diagrams • Physical parts evaluation Level 1: address the causal factors (may be part of restart issues)
tree, flipchart paper, flipchart/easel, white board, – schematic diagrams of processes, flows, connections – consider test plans for each item Level 2: address the causes of this particular incident at the root
access to phone/fax/copier – log of operational and safety system alarms – think before you do; some actions are irreversible cause level
• Identify locations for interviews separate from the team – flow, temperature, pressure, and other parameter trends • Paper/electronic data analysis Level 3: address other similar situations (at the root cause level)
room (at scene if possible) – startup and shutdown sequence documentation – identify and gather fragile computer data first Level 4: correct the management system(s) that created the
• Develop a list of team members (w/titles and contact – navigational charts, radar records, communications – use others to assist with paper data gathering if causal factors
information). Fill required roles with team members data possible • Track recommendations to completion
• Obtain an overview of the system operation • Maintenance status • Ensure that recommendations are assessed using the
• Briefly tour the incident scene – work permits and their status Use chain custody as required to keep track of your management of change process
• Identify any additional experts needed for the – inspection reports and maintenance logs data
investigation (e.g., metallurgists, combustion experts, • Material Information (specifications, welding procedures) Investigation Follow-up (Section 7)
vendor representatives, chemists) • Photographs • Use the causal factor chart, fault tree, and three-column form to
6.Collect the required information (see Data to Gather and – general photographs of the incident scene communicate the results of the analysis
Gather Data sections) – failed/damaged/degraded parts from multiple angles • Decide who should know about the results and determine what
– stains, residues, foreign materials information they should know
– layout of equipment/outfitting/structures • Enter data into the tracking system
– visibility from duty stations • Assess the investigation process