Accidents dont happen. THey are the result of a chain of unsafe acts, near misses and incidents.

1. Maritime Accident and IncidentMaritime Accident and Incident
InvestigationInvestigation
(MAII)(MAII)
Ascent Marine InstituteAscent Marine Institute

2. INCIDENT INVESTIGATIONINCIDENT INVESTIGATION
Accidents happen due to a varietyAccidents happen due to a variety
of reasons.of reasons.
If unsafe acts are not rectifiedIf unsafe acts are not rectified
immediately the chances ofimmediately the chances of
accidents increase manifold.accidents increase manifold.
Thus unsafe acts and near missesThus unsafe acts and near misses
need to be carefully analyzed inneed to be carefully analyzed in
order to apply the lessons learntorder to apply the lessons learnt
and thereby prevent accidents.and thereby prevent accidents.

3. Once an accident occurs, the firstOnce an accident occurs, the first
action is to take corrective actionaction is to take corrective action
to reduce the adverse impacts.to reduce the adverse impacts.
The second action is to put intoThe second action is to put into
force procedures to prevent the re-force procedures to prevent the re-
occurrence of the same.occurrence of the same.
In order to take adequateIn order to take adequate
preventive actions it is necessarypreventive actions it is necessary
to find out the actual reasonsto find out the actual reasons
behind the accident.behind the accident.

4. Thus incident investigationThus incident investigation
assumes importance in every case.assumes importance in every case.
The objective of every incidentThe objective of every incident
investigation is to find out the rootinvestigation is to find out the root
cause behind the incident.cause behind the incident.
The root cause may be totallyThe root cause may be totally
different from the obvious ordifferent from the obvious or
apparent cause.apparent cause.
Incident : Inadequately controlledIncident : Inadequately controlled
event.event.

5. Incident InvestigationIncident Investigation
- A full and thorough investigationA full and thorough investigation
of accidents, near misses andof accidents, near misses and
non-conformities can ensure thatnon-conformities can ensure that
suitable controls are developedsuitable controls are developed
and recurrence is prevented.and recurrence is prevented.
- In simple terms, effectiveIn simple terms, effective
investigations are the results of ainvestigations are the results of a
well-managed investigationwell-managed investigation
process.process.

6. An effective investigate shouldAn effective investigate should
throw valuable light on thethrow valuable light on the
following:following:
Describe the incidentDescribe the incident
Determine the real causesDetermine the real causes
Evaluate the loss potentialEvaluate the loss potential
Develop controls to prevent repeatDevelop controls to prevent repeat
Demonstrate management'sDemonstrate management's
concern and commitment.concern and commitment.
Contribute to improved safetyContribute to improved safety
culture, not assign blame or guiltculture, not assign blame or guilt

7. SafetySafety: Freedom from: Freedom from
unacceptable risk. Thus if anunacceptable risk. Thus if an
organization or an individual wantsorganization or an individual wants
to be relieved of unacceptable risk,to be relieved of unacceptable risk,
safe operations is the only answer.safe operations is the only answer.
This is particularly so in the case ofThis is particularly so in the case of
ships, since a lack of safety willships, since a lack of safety will
directly lead to an increase in thedirectly lead to an increase in the
risk factor on board. On the otherrisk factor on board. On the other
hand controlling of the risk ishand controlling of the risk is
possible through safe practices.possible through safe practices.

8. LossLoss
The result of an accident isThe result of an accident is loss.loss.
As reflected in our accidentAs reflected in our accident
definition, the most obviousdefinition, the most obvious
losses are harm to people,losses are harm to people,
property, process or environment.property, process or environment.
Implied and important relatedImplied and important related
losses are performancelosses are performance
interruption and profit reduction.interruption and profit reduction.
So there are losses involvingSo there are losses involving
people, property, process andpeople, property, process and
ultimately the profit.ultimately the profit.

9. loss is generally measured inloss is generally measured in
terms of the following:terms of the following:
Costs of medical treatmentCosts of medical treatment
Crews' compensationCrews' compensation
Deviation costs, if anyDeviation costs, if any
Insurance claimsInsurance claims
Down timeDown time
Increase in insurance premiumsIncrease in insurance premiums
in case of claimsin case of claims
Man hours lost in documentationMan hours lost in documentation
and follow-upand follow-up

10. Loss Causation FactorsLoss Causation Factors
1. Lack of Control : Inadequate1. Lack of Control : Inadequate
system standards compliancesystem standards compliance
2. Immediate Causes : Substandard2. Immediate Causes : Substandard
Acts / Substandard ConditionsActs / Substandard Conditions
3. Root Causes : Personal Factors /3. Root Causes : Personal Factors /
Job FactorsJob Factors
4. Incident : Undesired event that4. Incident : Undesired event that
could lead to a losscould lead to a loss
5. Loss: Affects People / Property /5. Loss: Affects People / Property /
Environment / ProcessesEnvironment / Processes

11. ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS
Root Cause Analysis (RCA) is aRoot Cause Analysis (RCA) is a
structured process that uncoversstructured process that uncovers
the physical, human, and latentthe physical, human, and latent
causes of any undesirable event incauses of any undesirable event in
the workplace.the workplace.
Can be:Can be:
- Single or multidiscipline cases- Single or multidiscipline cases
- Small or large cases- Small or large cases

12. Some other definitionsSome other definitions
Failure CauseFailure Cause – The physical or– The physical or
chemical processes, designchemical processes, design
defects, quality defects, partdefects, quality defects, part
misapplication, or othermisapplication, or other
processes that are the basicprocesses that are the basic
reason for failure or that initiatereason for failure or that initiate
the physical process by whichthe physical process by which
deterioration proceeds to failure.deterioration proceeds to failure.

13. Failure EffectFailure Effect – The– The
consequence(s) a failure modeconsequence(s) a failure mode
has on the operation, function,has on the operation, function,
oror status of an item.status of an item.
FailureFailure – The termination of the– The termination of the
ability to perform a requiredability to perform a required
functionfunction
Failure ModeFailure Mode – The effect by– The effect by
which a failure is observed onwhich a failure is observed on
the failed itemthe failed item

14. Traditional maintenanceTraditional maintenance
strategies tend to neglectstrategies tend to neglect
something important:something important:
- Identification and correction of- Identification and correction of
the underlying problem.the underlying problem.

15. A Root Cause Analysis will disclose:A Root Cause Analysis will disclose:
Why the incident, failure or breakdownWhy the incident, failure or breakdown
occurredoccurred
How future failures can be eliminated:How future failures can be eliminated:
–– changes to procedures / operationchanges to procedures / operation
–– training of staff / design modificationstraining of staff / design modifications
–– verification that new or rebuiltverification that new or rebuilt
equipment is free of defects - repairequipment is free of defects - repair
and reinstallation is as per standardsand reinstallation is as per standards
- identification of any factors adversely- identification of any factors adversely
affecting service life andaffecting service life and

16. Improved availability “up-time”Improved availability “up-time”
and increased productionand increased production
ReactiveReactive
PeriodicPeriodic
Predictive maintenance/Predictive maintenance/
condition monitoringcondition monitoring
Proactive Maintenance StrategiesProactive Maintenance Strategies
Era of maintenance strategiesEra of maintenance strategies

17. Reactive maintenanceReactive maintenance
Run the equipment untilRun the equipment until
breakdownbreakdown
Overhaul and repairOverhaul and repair
Extensive unplanned downtimeExtensive unplanned downtime
and recurrent repairand recurrent repair

18. Periodic maintenancePeriodic maintenance
Scheduled calendar or interval-Scheduled calendar or interval-
based maintenancebased maintenance
Expensive components exchangedExpensive components exchanged
even without signs of wear oreven without signs of wear or
degradationdegradation
Unexpected failures with incorrectUnexpected failures with incorrect
schedules and componentschedules and component
change-outchange-out

19. Predictive maintenance byPredictive maintenance by
condition monitoringcondition monitoring
Apply technologies to measureApply technologies to measure
the condition of machinesthe condition of machines
Predict when corrective actionPredict when corrective action
should be performed beforeshould be performed before
extensive damage to theextensive damage to the
machinery occursmachinery occurs

20. Short and long-term benefits ofShort and long-term benefits of
Proactive Maintenance StrategiesProactive Maintenance Strategies
involving RCFAinvolving RCFA
Optimization of serviceOptimization of service
conditions:conditions:
Increased productionIncreased production
Reduced downtimeReduced downtime
Reduced cost of maintenanceReduced cost of maintenance
Increased safetyIncreased safety

21. Experience and statisticalExperience and statistical
datadata
Information on equipment design andInformation on equipment design and
service conditionsservice conditions
Failure statistics i.e. MTBFFailure statistics i.e. MTBF
Description of service failures,Description of service failures,
approach and methods for failureapproach and methods for failure
investigationinvestigation
Consequences of failure:Consequences of failure:
Downtime/pollution andDowntime/pollution and
spillage/secondary damagesspillage/secondary damages
Causes of failuresCauses of failures
Recommendations and remedial actionsRecommendations and remedial actions

22. Methods and analytical tools toMethods and analytical tools to
identify the causes of failure oridentify the causes of failure or
breakdownbreakdown
Review background dataReview background data
Loss Causation Model and RCALoss Causation Model and RCA
methods and workingprocessmethods and workingprocess
Detailed analyses of failedDetailed analyses of failed
parts/components:parts/components:
Analyse service conditionsAnalyse service conditions
Utilise experience data from dataUtilise experience data from data
bases or other sourcesbases or other sources
Laboratory investigationLaboratory investigation

23. Data CollectionData Collection
InterviewsInterviews
Documents (paper) evidenceDocuments (paper) evidence
Parts/component evidenceParts/component evidence

24. Interviewing ConsiderationsInterviewing Considerations
Where to interviewWhere to interview
Who to interviewWho to interview
Condition of people at the sceneCondition of people at the scene
How to handle multiple witnessesHow to handle multiple witnesses
How to handle after the incidentHow to handle after the incident
How to work with teamsHow to work with teams

25. Investigation techniquesInvestigation techniques
A number of named techniquesA number of named techniques
that are commonly used withinthat are commonly used within
RCA:RCA:
–– Step-method /Step-method /–– FMEAFMEA
–– Bow-tieBow-tie // – Event Tree– Event Tree
–– Failure TreeFailure Tree // –– InterviewInterview
–– Fish BoneFish Bone // – Why-Why– Why-Why
These techniques have theirThese techniques have their
own strength and weaknesses.own strength and weaknesses.

26. The main RCA reportThe main RCA report
1.1.Description of the IncidentDescription of the Incident
-- An incident is the event thatAn incident is the event that
precedes the loss or potentialprecedes the loss or potential
loss. This section should includeloss. This section should include
a description of what happened.a description of what happened.
Include all aspects related toInclude all aspects related to
the incidents, like outage time,the incidents, like outage time,
cost of repair, people involved,cost of repair, people involved,
tools in use, operational status,tools in use, operational status,
weather conditions etc.weather conditions etc.

27. 2 Immediate Cause(s)2 Immediate Cause(s)
The immediate causes of anThe immediate causes of an
incident are the circumstancesincident are the circumstances
that immediately preceded thethat immediately preceded the
contact and can usually be seencontact and can usually be seen
or sensed. For example if theor sensed. For example if the
incident is an oil spill, theincident is an oil spill, the
immediate cause could be aimmediate cause could be a
broken sealing. The Immediatebroken sealing. The Immediate
Causes often are the same asCauses often are the same as
the failure codesthe failure codes..

28. Substandard Conditions:Substandard Conditions:
- Defective Equipment and toolsDefective Equipment and tools
- Inferior working environmentInferior working environment
- Excessive noise levelExcessive noise level
- Too little space to do workToo little space to do work
- Fire and explosion risk in the areaFire and explosion risk in the area
- Bad housekeepingBad housekeeping
- Failure caused by bad WeatherFailure caused by bad Weather
conditionsconditions

29. - Failure of control / operationsFailure of control / operations
- Wrong set pointWrong set point
- Lack of instrumentationLack of instrumentation
- Lack of logic in the instrumentLack of logic in the instrument
- Defective controller devicesDefective controller devices
- Delay in equipment mobilizationDelay in equipment mobilization
- Effect of equipment modificationEffect of equipment modification
- Material deterioration / corrosionMaterial deterioration / corrosion

30. Substandard Acts:Substandard Acts:
- Irregular or insufficientIrregular or insufficient
maintenancemaintenance
- Operation of eq outside designOperation of eq outside design
- Rated capacityRated capacity
- Pressure limitsPressure limits
- Temperature LimitsTemperature Limits
- Wrong use of equipmenWrong use of equipmentt
- Purpose not designed forPurpose not designed for
- Overloaded during operationOverloaded during operation

31. - Violation of proceduresViolation of procedures
- Operational proceduresOperational procedures
- Safety proceduresSafety procedures
- Maintenance proceduresMaintenance procedures
- Defective process controlDefective process control
- Work permitsWork permits
- Defect in overall operationDefect in overall operation
controlcontrol
- Ineffective / InadequateIneffective / Inadequate
protectionprotection

32. 3. Basic Cause(s)3. Basic Cause(s)
Basic Causes are the real causesBasic Causes are the real causes
behind the immediate causes:behind the immediate causes:
reasons why substandard actsreasons why substandard acts
and conditions occurred.and conditions occurred.
In case of an oil spill caused by aIn case of an oil spill caused by a
broken sealing, the Basic Causesbroken sealing, the Basic Causes
could be that the sealing usedcould be that the sealing used
was of wrong type, it had awas of wrong type, it had a
design failure or it might bedesign failure or it might be
installed wronginstalled wrong

33. Personal FactorsPersonal Factors
- Inadequate knowledge of theInadequate knowledge of the
working processworking process
- Lack of experienceLack of experience
- Lack of informationLack of information
- Lack of trainingLack of training
- Inadequate competenceInadequate competence
- Lack of training instructionsLack of training instructions
- Long period between use ofLong period between use of
knowledgeknowledge
- Lack of instructionsLack of instructions

34. - Lack of motivationLack of motivation
- Lack of feedback for conductedLack of feedback for conducted
workwork
- Lack of follow-up during workLack of follow-up during work
executionexecution
- General frustration of workingGeneral frustration of working
conditionsconditions
- Lack of welfareLack of welfare

35. - Physical and psychological loadPhysical and psychological load
during workduring work
- Stress due to psychologicalStress due to psychological
pressurepressure
- High physical demandHigh physical demand

36. Causes related to the workCauses related to the work
- Inadequate management and controlInadequate management and control
- Unclear communication linesUnclear communication lines
- Unclear guidelines for responsibilityUnclear guidelines for responsibility
- Unclear goals for executed workUnclear goals for executed work
- Lack of instruction, procedures,Lack of instruction, procedures,
reference documentationreference documentation
- Lack of focus on possible loss /Lack of focus on possible loss /
damagesdamages
- Managers lack knowledge on workManagers lack knowledge on work
executionexecution
- Unqualified personnelUnqualified personnel

37. - Design failure (or lack of design)Design failure (or lack of design)
- Incomplete design requirementIncomplete design requirement
- Lack of operational responseLack of operational response
- Lack of start-up procedureLack of start-up procedure
- Inferior quality of PurchaseInferior quality of Purchase
- Inadequate specificationInadequate specification
- Inadequate handling, storageInadequate handling, storage
and transportand transport
- Inadequate quality control /Inadequate quality control /
testingtesting
- Lack of maintenance / AgeingLack of maintenance / Ageing

38. 4 Lack of Control4 Lack of Control
- means insufficient oversight of- means insufficient oversight of
the activities from design tothe activities from design to
planning and operation. Controlplanning and operation. Control
is achieved through standardsis achieved through standards
and procedures for operation,and procedures for operation,
maintenance and acquisition.maintenance and acquisition.
If an oil spill has occurredIf an oil spill has occurred
because of wrong installation ofbecause of wrong installation of
a sealing, the Lack of Controla sealing, the Lack of Control
could be related to inadequatecould be related to inadequate
procedures for checking.procedures for checking.

39. Reasons for Lack of ControlReasons for Lack of Control
- Inadequate management systemInadequate management system
- Inadequate system standardsInadequate system standards
- Inadequate compliance withInadequate compliance with
routinesroutines
- Inadequate maintenanceInadequate maintenance
procedureprocedure
- Inadequate operationalInadequate operational
proceduresprocedures
- Inadequate design procedureInadequate design procedure

40. Methods for RCAMethods for RCA
•• STEP; Sequential Time EventSTEP; Sequential Time Event
PlottingPlotting
•• FMEA; Failure Mode EffectFMEA; Failure Mode Effect
AnalysisAnalysis
•• FTA; Fault TreeFTA; Fault Tree
•• + common sense, engineering/+ common sense, engineering/
operational experienceoperational experience

41. STEP: Sequentially Time EventSTEP: Sequentially Time Event
PlottingPlotting
1. Identify actors1. Identify actors
2. Identify events2. Identify events
3. Link 1&23. Link 1&2
4. Mark Substandard4. Mark Substandard
acts/deviationacts/deviationss
Capturing of the sequentialCapturing of the sequential
events leading up to an accident.events leading up to an accident.
•• Can be a simple timelineCan be a simple timeline

42. Investigation of largerInvestigation of larger
incidents/accidents where theincidents/accidents where the
time sequence is importanttime sequence is important
•• Handles complex events with:Handles complex events with:
–– several actorsseveral actors
–– several events in parallelseveral events in parallel
–– a longer time horizona longer time horizon
•• Should include both equipment,Should include both equipment,
control and human actionscontrol and human actions

43. Example of a simple STEPExample of a simple STEP
diagramdiagram
Case: Manual valve oil leakageCase: Manual valve oil leakage
January: Missed annularJanuary: Missed annular
inspection of valve sealinginspection of valve sealing
Sealing becomes dry and brittleSealing becomes dry and brittle
Inadequate tighteningInadequate tightening
Manually Moving the valveManually Moving the valve
July: Oil leakageJuly: Oil leakage

44. Which one to use?Which one to use?
•• STEPSTEP::
–– For complex events with manyFor complex events with many
actorsactors
–– When time sequence is importantWhen time sequence is important
•• FMEAFMEA::
–– Getting overview of all potentialGetting overview of all potential
failurefailure
–– Easy to useEasy to use
•• FTA:FTA:
–– Identifies structure between manyIdentifies structure between many
different failure causesdifferent failure causes
–– Non-homogenous caseNon-homogenous case

45. The most common causes ofThe most common causes of
service failures or breakdown:service failures or breakdown:
Incorrect operationIncorrect operation
Poorly performed or inadequatePoorly performed or inadequate
maintenancemaintenance
Incorrect installation / badIncorrect installation / bad
workmanshipworkmanship
Incorrect repair introducing newIncorrect repair introducing new
defectsdefects
Poor quality manufacture leadingPoor quality manufacture leading
to substandard componentsto substandard components

46. Incident is followed by--Incident is followed by--
1. Immediate Correction1. Immediate Correction
2. Investigation2. Investigation
3.. Corrective Action3.. Corrective Action
4. Preventive action4. Preventive action
5. Risk Assessment & Risk5. Risk Assessment & Risk
ManagementManagement
6. Change in Process6. Change in Process
7.. Change Analysis7.. Change Analysis

47. Correction ,, Corrective ActionCorrection ,, Corrective Action
and Preventive Action andand Preventive Action and
Corrective agentsCorrective agents
•• Correction: To resume theCorrection: To resume the
normal and safe operation onnormal and safe operation on
board the vessel after detectionboard the vessel after detection
of direct cause.of direct cause.
•• Corrective Action: MeasureCorrective Action: Measure
taken to Control the causetaken to Control the cause
•• Preventive Measure: MeasurePreventive Measure: Measure
taken to Eliminate the causetaken to Eliminate the cause

48. ““Corrective Agents” are-Corrective Agents” are-
•• Ship StaffShip Staff
•• Company StaffCompany Staff
•• External Bodies (PortExternal Bodies (Port
Authorities, MRCC, Class, Flag,Authorities, MRCC, Class, Flag,
PortPort agents, Suppliers, coastagents, Suppliers, coast
Guards etc)Guards etc)

49. Example --Example --
•• Incident: Fire during use ofIncident: Fire during use of
cutting torch due to flash back.cutting torch due to flash back.
•• Correction:Correction:
- Extinguish the fire.- Extinguish the fire.
•• Corrective Action:Corrective Action:
- Install the Flash back arrestor- Install the Flash back arrestor
in Cutting torch.in Cutting torch.

50. •• Preventive Measure:Preventive Measure:
- Circulation of Safety Alertt in- Circulation of Safety Alertt in
company and all fleet vessels.company and all fleet vessels.
- Change in the procedure of- Change in the procedure of
checking the Cutting Torch &checking the Cutting Torch &
Nozzle.Nozzle.
Use of Flash back arrestor inUse of Flash back arrestor in
cutting torch on all ships.cutting torch on all ships.
Incident InvestigationIncident Investigation

51. By study the case to investigateBy study the case to investigate
the Root cause of the Incident.the Root cause of the Incident.
•• Inspection – Safety & QualityInspection – Safety & Quality
Auditor, Suptd.Auditor, Suptd.
•• Assessment – Equipment/Assessment – Equipment/
Material/ Personnel/ Design/Material/ Personnel/ Design/
Training Deficiency/Training Deficiency/
Management ProblemManagement Problem

52. Analysis of Records - Logs,Analysis of Records - Logs,
Maintenance schedule etcMaintenance schedule etc
•• Collection of Evidences –Collection of Evidences –
Photographs,,Photographs,,
Interview,, Statements etc.Interview,, Statements etc.
•• Report of findingsReport of findings
•• Over all Analysis and ResultOver all Analysis and Result

53. Cases/ExamplesCases/Examples

54. Offshore Gas production:Offshore Gas production:
Statistics from 320 incidents/Statistics from 320 incidents/
“RCA” cases“RCA” cases
Personal related: 26 %Personal related: 26 %
Lack of management of work: 15Lack of management of work: 15
%%
Design Failure: 33 %Design Failure: 33 %
Preventive Maintenance: 8 %Preventive Maintenance: 8 %
Other: 18 %Other: 18 %