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LOSSPREVENTIONBRIEFINGFORNORTHMEMBERSSHIPS/JULY2015NorthofEnglandP&IAssociationTheQuayside,NewcastleuponTyne,NE13DU,UKTelephone:+441912325221Facsimile:+441912610540Email:loss.prevention@nepia.comwww.nepia.comCopyright©NorthofEnglandP&IAssociationLimited20151RootCauseAnalysisContentsRootCauseAnalysis-Whatisit?...................................1LegalDisclosure.............................................................2RCA–Methodology........................................................2RCAofanIncident..........................................................6WhyRCAsareSoOftenFlawed.....................................6RCAs–EnsuringEffectiveness.......................................7RCABenefits:.................................................................8Appendix–RCAofanIncident.......................................9DisclaimerThepurposeofthispublicationistoprovideasourceofinformationwhichisadditionaltothatavailabletothemaritimeindustryfromregulatory,advisory,andconsultativeorganisations.Whilstcareistakentoensuretheaccuracyofanyinformationmadeavailablenowarrantyofaccuracyisgivenandusersofthatinformationaretoberesponsibleforsatisfyingthemselvesthattheinformationisrelevantandsuitableforthepurposestowhichitisapplied.InnocircumstanceswhatsoevershallNorthbeliabletoanypersonwhatsoeverforanylossordamagewhensoeverorhowsoeverarisingoutoforinconnectionwiththesupply(includingnegligentsupply)oruseofinformation.Unlessthecontraryisindicated,allarticlesarewrittenwithreferencetoEnglishLaw.Howeveritshouldbenotedthatthecontentofthispublicationdoesnotconstitutelegaladviceandshouldnotbeconstruedassuch.MembersshouldcontactNorthforspecificadviceonparticularmattersRootCauseAnalysis-Whatisit?RootCauseAnalysis(RCA)isamethodofproblemsolvingthattriestoidentifytherootcausesoffaultsorproblems.Arootcausecanbesaidtobeafactorthatinitiatesasequenceofeventsleadingtoanoutcome.Oncearootcauseisremovedfromasequenceofeventsthatcauseaproblem,thentheproblemcannotrecurasthatsequencecannolongeroccur.Acausalfactor,ontheotherhand,isafactorthataffectstheoutcomeofanevent,butisnotarootcause.Removingacausalfactorfromasequenceoffaultsthatleadtoaproblemmaybenefittheoutcome,butdoesnotguaranteethepreventionofrecurrenceoftheproblem.Asystemfrequentlyemployedistofirstuseanapplicabletooltounearththecausalfactorsofanincidentandthenuseanothertooltoprobedeeperintothosecausalfactorstounearththerootcause(orrootcauses).Intheshippingindustry,RCAisemployedtotrytoidentifythecausesofaccidentsandincidents,soastoimplementcorrectiveandpreventativeactionsthataredesignedtoensuretheincidentdoesnotrecur.Aprudentshipoperatorwillensurethatallincidentsthatresultininjuryordamagetopeopleand/orproperty,ornearmissesthatcouldleadtosuchincidents,arethoroughlyinvestigated.Incidentinvestigation(includingtheinvestigationof‘near-misses’),cantellanoperatormuchaboutoperationalpracticesandsafetycultureonboard.Wellconductedanddocumentedincidentinvestigationscan:•Uncoverpreviouslyunidentifiedbreachesinregulatoryrequirements.•Assistwithclaimsorlegalproceedings.•Provideatruesnapshotofwhatreallyhappenedandhowworkisreallydoneonboard.•Actasalearningtoolfleet-wide.•Improveriskmanagementinthefuture.RootCauseAnalysisNorthofEnglandP&IAssociationTheQuayside,NewcastleuponTyne,NE13DU,UKTelephone:+441912325221Facsimile:+441912610540Email:loss.prevention...