Why the fix is not enough
A Port State Control inspector finds that the emergency fire pump does not deliver pressure. The crew clean the strainer, the pump works, the deficiency is closed. Six months later, on a sister ship, the same pump fails the same way.
The fix dealt with the pump. It did not deal with the reason the pump was allowed to fail. Section 9 of the ISM Code asks the company to investigate and analyse non-conformities, accidents and hazardous situations, and to take corrective action, including measures to prevent them from happening again. That is what a root cause analysis is for.
Correction, corrective action, preventive action
- Correction puts right what was found: the strainer is cleaned.
- Corrective action removes the cause, so it does not happen again on this ship: the job goes into the maintenance plan, the test routine gets a pass result.
- Preventive action stops the same problem elsewhere: the sister ships are checked and their routines changed.
A finding is only really closed when all three are done, and someone has checked later that they worked.
When to do one
- Deficiencies from Port State Control, flag and class.
- Findings from internal and external audits.
- Incidents and near misses.
- Defects that come back on the same equipment.
Match the effort to the risk. A missing signature needs a few lines. A detention, an injury or a repeated failure of critical equipment needs a proper analysis with the master, the chief engineer and the superintendent.
The steps
- Describe what happened. Facts only: what, where, when, which equipment, who found it. No blame at this stage.
- Keep the evidence. Photos, maintenance records, test records, log entries, short statements from the people involved.
- Find the causes. Ask "why" until the answer is something the company can change. Look at people, procedures, equipment, the working conditions and the organisation ashore.
- Check the root cause. If it had been removed, would the problem have been prevented? Is it something the company controls?
- Agree the actions. Each one specific, with a person responsible and a target date.
- Verify. After a set time, check that the actions were done and that they worked.
A worked example: five whys
The emergency fire pump fails to deliver pressure during a Port State Control inspection.
| No. | Question | Answer |
|---|---|---|
| 1 | Why did the pump not deliver pressure? | The suction strainer was blocked with marine growth. |
| 2 | Why was the strainer blocked? | It had not been cleaned for more than a year. |
| 3 | Why had it not been cleaned? | Cleaning the strainer was not a job in the maintenance plan. |
| 4 | Why did the weekly test not show the problem? | The test only checked that the pump starts, not the pressure it delivers. |
| 5 | Why did the test stop there? | The test routine had no pass result. It was written for the fleet and never checked against this ship. |
Root cause: a test routine without a pass result, and a job missing from the maintenance plan. Both are things the company can change. "The crew did not clean the strainer" is true, but it is not the root cause: nothing told them to.
| Action | Type | Responsible | Target |
|---|---|---|---|
| Clean the strainer, test the pump at the highest hydrant | Correction | Chief engineer | Before departure |
| Add strainer cleaning to the maintenance plan, with an interval | Corrective action | Superintendent | 14 days |
| Change the test routine: pressure at the highest hydrant, recorded | Corrective action | Technical manager | 30 days |
| Check the same pump and routine on the sister ships | Preventive action | Superintendent | 30 days |
| Review: three weekly test records with pressure | Verification | Superintendent | 3 months |
An example. Roles and target dates depend on the company's own procedures.
Common mistakes
- "Human error" as the root cause. It describes what happened, not why. Ask what made the error possible.
- "Retrain the crew" as the only action. Training helps, but if the procedure or the plan is wrong, the next crew will make the same mistake.
- Actions without an owner or a date. They stay open until the next audit finds them.
- Closing the finding on the day of the fix, before anyone has checked that the corrective action works.
- The analysis is written in the office without the people who were on board.
- Every finding on its own. Nobody looks across the fleet for the same cause behind different findings.
Checklist
- The facts are written down, with evidence.
- The people on board took part in the analysis.
- The root cause is something the company can change.
- There is a correction, a corrective action and, where it applies, a preventive action.
- Every action has a person responsible and a target date.
- The maintenance plan or the procedure is changed where needed.
- The sister ships are checked.
- The finding is closed only after the actions are verified.
Root cause analysis in SEA360
In SEA360 each finding gets a root cause analysis and a corrective action, and every corrective action has a responsible person and a target date. Overdue actions are highlighted. The analysis can start from an inspection finding or from a safety report, such as an incident or a near miss, and links back to its source.
The crew record inspections and findings on board, also without a connection. Photos and documents can be attached as evidence of the fix, and inspection reports can be exported to PDF.