root cause analysis for shipping internal auditors

8/12/2019 ROOT CAUSE ANALYSIS for Shipping Internal Auditors

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Delivering Maritime Solutions

ROOT CAUSE ANALYSIS

The Core of Problem

Solving and Corrective

Action

GUIDELINES FOR INTERNAL AUDITORS


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Why Do Root Cause Analysis?

Just fix it, there is too much to do.

We dont have time to think, we need results

now.

Usual Approach - fix symptoms without regard

to actual causes

Root Cause Analysis - structured and thorough

review of problem designed to identify andcorrect what is causing the symptoms


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BASIS OF RCA


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DEFINITION


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Definitions Cause (causal factor): a condition or event that

results in an effect

Direct Cause: cause that directly resulted in the

occurrence

Contributing Cause: a cause that contributed tothe occurrence, but by itself would not have

caused the occurrence

Root Cause: a cause that, if corrected, would

prevent recurrence of this and similaroccurrences


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ROOT CAUSES ARE:

1. Specific underlying causes

2. Those can reasonably be identified

3. Those management (ship or shore)

has control to fix.

4. Those for which effective

recommendations for preventingrecurrencescan be generated.


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Root cause analysis is a problem solving process for

conducting an investigation into an identified non-

conformity or observation. Root cause analysis is acompletely separate process to incident management

and immediate corrective action, although they are

often completed in close proximity.

Root cause analysis (RCA) requires the auditor to lookbeyond the solution to the immediate problem and

understand the fundamental or underlying cause(s) of the

situation and put them right, thereby preventing re-

occurrence of the same issue. This may involve the

identification and management of processes, procedures,activities, inactivity, behaviours or conditions.

What is Root Cause Analysis (RCA)?


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Identification of

preventive measures

Prevention of recurring

failures

Introduction of a logical

problem solving

process applicable to

non- conformities and

observations

BENEFITS OF RCA


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Steps to Root Cause Analysis


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It should be noted that this is a simplified

process flow, which is typical of themajority of situations. However, for a

complex non-conformity, such as a major

fire, root cause analysis will become

proportionally more detailed, require extraactivities and can require considerable

time.

For example, some or all of the followingsteps may be required:

NOTE


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Establish a root cause team to investigate the issue

Compilation of a summary of the event or non-conformity (ie a

summary of what was wrong)

Confirmation of the sequence of events

List of dates/times (for example when the non-conformity was

discovered and when the last acceptable monitoring result was

obtained)A list of implicated materials or processes

Any other relevant data or information (for example records, test

results, information from staff in the relevant area or complaints)

Investigation of possible scenarios & collation of information (forexample this may include material or environmental testing or

liaison with technical experts and regulatory authorities).

FURTHER POSSIBLE STEPS


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DEFINITION


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An important part of any non-conformity management is the

identification of the root cause and the implementation of suitable

action. There are a number of requirements as under:

Senior managementto ensure the root cause of audit non-

conformities have been effectively addressed to prevent

recurrence.

Identification of the root cause of non-conformities and

implementation of any necessary corrective action.

Following an audit, the root cause of non-conformities shall be

identified and an action plan to correct this, including timescales,

must be provided.

Review of risk assessment and evaluation of incidentsCorrective actions and prevention of re-occurrence

Where is RCA Required?


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There is no single prescribed method of conducting root cause

analysis and any structured approach to identifying the factors

that resulted in the non-conformity can be used, many tools andmethods have therefore been published (two popular methods are

highlighted below). The choice of root cause methodology may be

dependent on the type of issue/non-conformity being investigated.

Whichever method of root cause analysis is used it is usually

necessary to commence with, and record the knownfacts. Depending on the situation these may include:

What the non-conformity is

Implicated equipments/processes

Any immediate corrective action completed

How to Complete Root Cause Analysis?


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Throughout the process it should beremembered that the key question that

root cause analysis is seeking to answer

is:

What system or process

failed so that this problem

could occur?

KEY QUESTION


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Why did this occur?

The documented policy didnt include

the requirement or

The procedure wasnt trained to staff

In these situations the subsequent steps

of the investigation and action can be

planned immediately.

WHY


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On other occasions the cause is not

immediately clear and investigative steps willbe required, for example:

Does the operator understand the procedure?

Does the method laid out in the policy work iffollowed precisely?

Does the specified time/procedure achieve the

expected outcome?

In these situations it is necessary to gather

and collate evidence

WHY


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AND THEN Once the underlying cause has been established, the

next stage of the process is to establish a proposed

preventive action plan, indicating the action that will betaken to prevent the nonconformity recurring. The

preventive action plan should include a defined

timescale in which the action will be completed and

define who is responsible for completion. An important final step of an effective root cause

analysis is to consider monitoring or verification activity.

This is necessary to ensure that the changes to (or new)

activity or procedures is fully operational, that it iseffective in managing the root cause and that it does not

inadvertently introduce any additional problems.


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VERIFICATION

Verificationwould be done to checkthat the preventive action is fully

embedded and effective.

Later,review of effectiveness ofpreventive action would be done to

confirm that the preventive actions

are effective.


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Methods of Root Cause Analysis

The 5 Whys is the simplest method forstructured root cause analysis.

It is a question asking method used to

explore the cause/effect relationshipsunderlying the problem.

The investigator keeps asking the

question Why?until meaningful

conclusions are reached


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The 5 Whys


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APPLICATION OF 5 WHYS


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In this example it would be easy for the investigator to

stop the analysis part way through thinking that all the

conclusions had been reached (ie that this was purely a

training issue), however, the further questions revealuseful information about the nature of the cause and

therefore the appropriate action.

The issue actually had a number of causes that

contributedto the incident:

Incomplete or ineffectivetraining procedure

Inadequate checks and balances by the

supervising staff

Lack of knowledge of the Safety Procedures


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Proposed action can now be planned, for

example:

Update training procedure to ensure sign off(& possibly a supervision step)

Post Notices in control locations to serve as

reminders Ensure an individual is responsiblefor

completing the procedure.

Ensure all staff fully understand and aretrained in the awarenessof the risks.


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Fishbone method


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FISHBONE METHOD


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FISHBONE METHOD This type of RCA is a causal process, it seeks to understand the

possible causes by asking what actually happened?, When?,

Where? Why?, How? and So what?in other words a possible

cause is identified and the consequences and significance isinvestigated for each of the group categories.For example:

What happened? - Procedure was not followed correctly

Why? - Staff member was untrained in the procedure

When? - Monday morning

Where?Engine room

How? - Lack of time

So what? (i.e. is this important)

CAUTION


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CAUTION The root cause shou ld be someth ing that can be

managed or changed,wh ich means that i t normal ly

relates to a sys tem or p rocess and occasionally analterable behavio ur. For examp le, it is of ten

tempting to reach a conclusion such as they

forgot, not enough time, not enough money, not

enough staff, staff sickness or made a mistake,these answers may be true, bu t in mos t cases they

are ou t of our co ntro l , whereas root cause analysis

sho uld lead to contro l lable, manageable or

adjustable pro cesses.Danger:The FISHBONE Diagram is a list of potent ia lroot causes. This includes bothprobable causes, real causes and guesses.


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Inclusion of Root Cause Analysis in the

Audit Report

The NC/Observation Note of the internal auditreport, complete with root cause analysis and

proposed action(corrective & preventive) plan

is to be reported (in the relevant sections)

The root cause and the proposed preventive

action must be determined by the auditee. The

auditor should only guide the auditee based on

his experience in determining the root causeand the proposed preventive action .


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Any Questions ?

Thank You

root cause analysis for shipping internal auditors

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