root cause analysis and corrective action plans. management decision as of 05 september 2013 cars...
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Root Cause Analysis and Corrective Action Plans
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.
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.
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.
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.
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?
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.
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.
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)
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.
“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
“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
“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.
Evaluate your answers
Is the problem Physical, Human, or System related or a combination of all?
This will help you identify:
a) Probable Root Causeb) Contributing Factorsc) Combination of alld) Could be many or only one
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?
Possible contributing factors
1) Standard operating procedure2) Commercial pressure3) “Git-R-Done” or “Superman” attitude4) Workload5) Fatigue6) Communication7) Training or lack of training8) Housekeeping
Possible contributing factors
9) Organizational issues
10) Maintenance management
11) Hardware issues
12) Design problems
13) Incompatible goals
14) Error enforcing conditions
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?
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?
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
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?
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?
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)
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?
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
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?
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.
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.
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?
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
Why Tree:
WHY 2: Environment/ Housekeeping Why was floor wet?
Cook mops floor daily at about the same time
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.
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.
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.
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
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.
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
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?
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
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.
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.
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.