M-SCAT® Marine Systematic Cause Analysis Technique MANAGING RISK EEIntroduction Accidents are costly in both human and economic terms. When they occur, people and organizations pay a steep price. Eflective investigation is the only known way to get something lor the price you have paid ~ better safety from this day forward. Effective accident/incident investigation and follow up Accident/Incident investigation should be part of every loss control system. Effective investiga- tions can 1, Describe what happened 2, Determine the real causes 3. Decide the risks 4, Develop controls 5. Define wends 6. Demonstrate management's concern. Officers and line management should conduct most investigations. 1. They have a personal interest in the people and workplace involved. 2. They know the people and conditions. 3. They know how best to get the information needed 4. They are the ones who implemi remedial actions. nL most ‘They are held accountable for what happens in their areas, Staff personnel and higher level managers take part in major loss eases and those where specialized knowledge is needed. Reasons why people may not report accidents 1. Fear of consequences 2 Concern about the safety record 3. Lack of understanding of the importance of complete reporting. Basic ways to get better reporting 1. 2. 3, 4 Communicate Educate ‘Train employees on the need for reporting and why itis so critical React in a positive way to timely reporting, Six major phases of effective investigation Following are six major phases of effective investigation, with key point guidelines for each: Respond to the emergency promptly and positively a, Take control at the scene. b. Ensure first aid and call for emergency atrol potential secondary accidents Identity sources of evidence at the scene. e. Preserve evi removal £ Investigate 10 determine loss potential Decide who should be notified. lence from alteration or a M-SCAT® ~ Marine Systematic Cause Analysis Technique 25 Collect pertinent information Get “the big picture” first People evidence ~ Interviewing 1) Interview witnesses separately 2) Interview onsite whenever feasible. 8) Put the person at ease 4) Get the individual's version, 5) Ask questions at the right time, 6) Give the wines feedback of your understanding. 7) Record (in writing) critical information quickly8) 9%» Use visual aids, Use re-enactment sparingly and carefully. End on a positive note. Keep the communication line open. 10) 1) Don’t re-enact an accicient unless absolutely necessary and under strietly.controlled condi- tions. For capturing Position evidence, use sketch- ¢s, maps and photography to show relative positions and before-and-after details. Collect and safeguard important Parts such as equipment, tools, damaged areas and fluid samples. Examine Records to identify basic causes such as training, maintenance or scheduling problems, Analyze and evaluate all significant causes Use the cause and effect (domino) sequence. Make a causal factor outline Cover immediate causes or symptoms (sub- standard acts/practices and conditions). Cover basic or underlying causes (personal factors and job /system factors). Note to the user The M-SCAT is developed to aid you in the analysis of, accidents and near misses. The M-SCAT is best used as an “aide de memoir” to guide the investigator, rather than a compulsory check list where all points rigorously have to be checked off. MSCAT aoge Determine the critical few specific causes. Cover deficiencies in the management system (inadequate system, inadequate stan- dards, inadequate compliance with stan- dards). Develop and take corrective actions Consider alternative controls. Lower the likelihood of occurrence. Reduce the potential severity of loss. Take temporary actions immediately ‘Take permanent actions as soon as possible. Document with written report. 5. Review findings and recommendations Have every report reviewed by the next higher level manager. Measure the quality of the reports and coach. for improvement. Follow through Conduct investigation review meetings. Monitor timely implementation of remedial/ preventive actions. Analyze data for trends. Profit from prompt and positive changes based on reviews, analysis and experience Marine Systematic Cause Analysis TechniqueEvaluation >| of Loss: Potential Type of Immediate Basic/ Control >| Contact >| Direct >| Underlying [>| Action Causes (IC) Causes (BC) Needs (CAN) Description of accident or incident Q People Q Process/operation Q Property Q Environmental M-SCAT @ Systematic Cause Analysis TechniqueY Description Type of Immediate? Basic] Control of Accident |» | Contact > | Direct Underlying =| Action or Incident Causes (IC) Causes (BC) Needs (CAN) Evaluation of loss potential if not controlled Loss severity potential Probability of recurrence (A) Major — loss of life; (A) High - probability of permanent disability, loss of recurrence of loss. process; major cost, oil spill > 10 barrels. (B) Moderate — probability of recurrence of loss. (B) Serious — lost time injury, no disability; disruption to (C) Low ~ probability of process; significant cost, recurrence of loss. oil spill < 10 barrels. (C) Minor = minor injury with no lost time; partial disruption to process; minor cost. M-SCAN atic Cause Analysis Technique¥ Description | [Evaluation immediate”) [Basic/ Control of Accident |»|of Loss > | Direct Underlying >| Action orincident | | Potential Causes (1€)_} [Causes (8C)_ | | Needs (CAN) Type of contact Personal injury/illness 1, Falls from elevation s 1, 2,3, 4,5, 8,9, 10, 11, 13, 16, 18, 19, 20, 21, 22, 28, 35) 2. Falls on same level (slips, trips) (ICs 1, 2, 4, 5, 8, 11, 12, 18, 14, 15, 18, 21, 22, 23, 24, 25, 26, 27, 35) 3. Struck against/by (ICs 1, 2.3, 4,5, 6, 8,9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 22, 24, 25, 26, 27, 35, 36) 4. Caught in/on/between (ICs 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 22, 24, 25, 26, 27, 35, 36) Contact with heat, cold, electricity, radiation, noise, toxics, biological (ICs 1, 2,8, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 22, 23, 28, 29, 30, 31, 32, 34, 36) 6. Overstress by overexertion, overload, overexposure, ergonomic factors (ICs 1, 2, 4, 5, 6, 8, 10, 11, 12, 13, 14, 18, 19, 20, 26, 27, 32) o M-SCAT® ~ Marine Systematic Cause Analysis TechniqueDescription | [Evaluation Immediate? | [Basic/ Control of Accident |»| of Loss > Direct >| Underlying || Action or Incident Potential Causes (IC) Causes (BC) | [Needs (CAN) Property/process/environmental damage 7. Collision 13. Cargo damage and/or loss 10. (ICs 1, 4, 5, 6, 7, 8, 10, 13, 14, 15, 20, 22, 23, 24, 33, 34, 35) Grounding (ICs 1, 4, 5, 6, 7, 8, 9, 13, 14, 15, 18, 20, 22, 28, 24, 33, 34, 35) Contact damage (docks, locks, buoys, etc.) (ICs 1, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 18, 20, 22, 23, 24, 33, 34, 35) Fire and explosion (ICs 1, 3, 4, 5, 6, 8, 9, 10, 13, 14, 15, 18, 20, 22, 23, 24, 25, 28, 29, 30, 31, 32, 26) Hull and watertight integrity failure 4,5, 6, 7,9, 10, 14, 15, 1, 22, 24, 35, 36) |. Machinery and equipment breakdown (ICs 1, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 18, 20, 22, 23, 24, 25, 28, 31, 32, 34, 36) 14. 15. 16, M-SCAT (ICs 1, 8, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 18, 20, 21, 22, 28, 24, 25, 28, 29, 31, 33, 34, 35, 36) Pollution/environmental (ICs 1, 3, 4, 5, 6 7, 8, 9, 10, 13, 14, 15, 18, 20, 21, 22, 23, 24, 25, 28, 31, 32, 33, 34, 35, 36) Loss of stability (IGs 1, 3, 4, 5, 6, 7, 8, 9, 10, 14, 15, 18, 20, 21, 22, 23, 24, 34, 36) Other contact(s) (ICs 1 through 37) Marine Systematic Cause Analysis TechniqueDescription Evaluation Type of of Accident |»| of Loss >>| Contact or Incident Potential Immediate/direct causes (IC) ee Control Action Needs (CAN) Basic/ Underlying [> Causes (BC) Substandard acts/practices 1. Failure to follow rules and regulations (BCs 2, 3, 4, 5, 6, 7, 8, 10, 13, 15) 2. Failure to use ppe properly (BCs 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 15) 3. Operating equipment or machinery without authority (BCs 2, 3, 4, 5, 7. 8, 12, 13, 15) 4, Incorrect use of equipment or i: 486, 7, 8.9, 10, 12; Using defective equipment or machiner (BCs 2, 3, 4,5, 6, 7,8,9, 10, 11, 12, 13, 14, 15) 6. Failure to follow repair/ maintenance instructions (BCs 2, 3, 4, 5, 6, 7, 8, 10, 13, 15) Incorrect navigation or ship handling (BCs 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) x 8. Failure to warn (BCs 1, 2, 3, 4,5, 6, 7,8,9, 10, 12, 13, 15) 9. Failure to secure (BCs 2, 3, 4, 5, 6, 7, 8, 9, 12, 13, 15) 10, IL. 14. M-SCAT* ~ Marine Systematic Cause Analysis Technique Making safety devices inoperative (BCs 2, 3, 4, 3, 6, 7, 8, 12, 13, 15) Improper position for task (BCs 1, 2, 3, 4,5, 6, 7,8, 9, 12, 13, 15) . Improper lifting, handling or storage (BCs 1, 2, 3, 4, 5, 6, 7, 8, 9) . Horseplay/inappropriate behaviour (BCs 2,3, 4, 5, 7, 8, 13, 15) Under the influence of alcohol and/or other drugs (BCs 2, 3, 4, 5, 7, 8, 13, 15) . Sabotage, wilful damage (BCs 2, 4, 7) . Suicide/homicide (BCs 2, 3, 4, 7) . Other substandard act(s) (BGs I through 15)Description Evaluation Type of of Accident |»| of Loss > | Contact or Incident Potential Basic/ Underlying |» Causes (BC) Control Action Needs (CAN) y Substandard conditions 18. 19. 20. 29. Inadequate guards or barriers (BCs 5, 7, 8, 9, 10, 11, 12, 18, 15) Inadequate or defective ppe (BCs 5, 7, 8, 9, 10, 12, 13) Defective equipment, machinery or tools (BCs 8, 9, 10, 11, 12, 13, 14, 15) . Hull or structural condition (BCs 8, 9, 10, 11, 12, 13, 14) . Inadequate warning system (BCs 8, 9, 10, 11, 12, 13, 14, 15) ‘se weather conditions , 6, 7, 8, 9, 13) se sea conditions , 6, 7, 8, 9, 13) . Poor housekeeping (BCs 5, 6, 7, 8, 9, 10, 11, 12) . Congestion or restricted action (BCs 8, 9, 13) . Inadequate or excess illumination (BCs 8, 9, 10, 11, 12, 13) . Fire and explosion hazards (BCs 5, 6, 7, 8, 9, 10, 11, 12, 13, 15) Noise or temperature (BCs 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15) 30. 31, M-SCAT Radiation exposure (BCs 5, 6, 7,8, 9, 10, 11, 12, 13, 14) Inadequate ventilation (BCs 8, 9, 10, 11, 12, 13) . Environmental conditions (BCs 8, 9, 10, 11) . Outdated charts, publications and other documentation (BCs 5, 6, 7, 8, 10, 13, 15) . Bunkers and/or lubricating oils (BCs 5 . 6, 7,89, 10, 11, 13, 15) . Port and berthing facilities (BCs 5, 6, 7, 8, 13, 15) . Cargo (BGs 5, 6, 7, 8, 13, 15) '. Other substandard condition(s) (BCs 1 through 15) = Marine Systematic Cause Analysis TechnDescription Evaluation | [Type of of Accident | | of Loss |Contact fm Potential or Incident immediate/ Control Direct > >| Action Causes (IC) Needs (CAN) Basic/underlying causes (BC) Personal factors Md 34 32 33 34 35 35 37 38 3.10 31 Inadequate physical/physiological capability (see CAN: 6, 9, 19, 15, 18) Inappropriate height, weight, size, strength, reach, ete Restricted range of body movement Substance sensitivities or allergies Sensitivities ta sensory extremes (cemperanuse, sound, etc.) Vision deficiency Hearing deficiency Other sensory deficieney (touch, taste, smell, valance) Respiratory ineapacity Other temporary or permanent disabilities Inadequate mental/psychological capability (see CAN: 6,9, 10, 15, 18) Fears and phobias Mental illaess/emotional disturbance Intelligence level Inability to comprehend Poor judgment Poor coordination Slow reaction time Low mechanical aptitude Low learning aptitude Memiiy failnen Physical or physiological stress (see CAN: 4, 6,9, 11, 12, 18,15, 18, 20) Injury or illness Fatigue due to task load or duration Fatigue duc to lack of rest Fatigue due to sensory overload Exposure ta health hazards Exposure to temperature extremes Oxygen deficiency Atmospheric pressure variation Constrained movement Blood sugar insufficiency Drugs and/or alcohol 10 M-SCAT* ~ Marine Systematic Cause Analysis Technique 6. ‘Mental or psychological stress (sce CAN: 1, 4, 5, 6, 10, 11, 12, 15, 16, 18, 20) Emotional overload Fatigue due to mental task load or speed Extreme judgment/decision demands Routine, monotony, demand for vneventfal vigilance Extreme concentration ‘perception demands “Meaningless” or “dlograding” activities Confusing/conflieting divections demands Preoecupation with problems Frustration, Mental illness Lack of knowledge (see CAN: 2, 4, 5,6, 7.8.9, 10, 11, 12, 13, 1, 16, 18, 20) Lack of experience Inadequate orientation Inadequate inital raining Inadequate upelate training Misunderstood directions Lack of skill (see CAN: 2, 4,5, 6,7, 9, 10,13, 15, 16 Inadequate initial instruction Inadequate practice Infrequent performance Lack of caching Inadequate review instruction Improper motivation (sce CAN: 1,2, 4,5,66,8, 10, 11, 18, 14,17, 18) Improper perlormance is rewarded (olerated) Proper performance is punished Lack of incentives Excessive frustration Inappropriate aggression Improper attempt to save time or effort Improper attempt ro avoid discomfort Improper artempt to gain attention Inadequate discipline Inappropriate peer pressure Improper supervisory example Inadequate performance feedback Inadequate reintorcement of proper behaviour Improper production incentivesDescription | [Evaluation | [Type of Immediate/ Control of Accident || of Loss >|contact |» | Direct > >| Action or Incident Potential Causes (IC) Needs (CAN) Job factors 8. Inadequate leadership and/or supervision 10. inadequate purchasing: ce CAN: 1,2, 3, 4,5, 6,89, 10, 11, 12, 18, {see CAN: 1, 3, 4 6, 9, 12,18, 14,15, 19) 14,15, 16,17, 18) 10.1 Inadequate specifications on requisitions 81 Undear or conflicting reporting relationships 10.2 Inadequate research on matetals/equipment S2 Unclear or conflicting assignment or 103 Inadequate specifications to suppliers responsiility 104 Inadequate mode or route of shipment 83 Improper or insufficient delegation 10.5 Inadequate receiving inspection ancl B4 Giving inadequate policy procedure, acceptance practices oF guidelines 106 Inadequate communication of safety and. 8.5 Giving objectives, goals or standards that health data contliet 10.7 Improper handling of materials 8.6 Inadequate work planning or programming 108 Improper storage of materials 87 Inadequate instructions, orientation and/or 10.9 Improper transporting of materials waining 10.10 Inadequate identification of hazardous S8 Providing inadequate reference documents, materials directives and guidance publications 10.11 Improper sahage and/or waste disposal 89 Inadequate identification and evaluation of 10.12. Inadequate contractor selection Joss exposures 8.10 Lack of supervsory/management job 11. Inadequate maintenance knowledge (see CAN: 1, 3,4, 6,9, 10,18, 15,19) 8.1 Inadequite matching of individual 111 Inadequate preventive qualifications and job ‘task requirements 11441 Assesment of needs 12 Inadequate performance measurement and 1112 Lubrication and maintenance valuation 111.3 Adjustment/assembly 8.13 Inadequate or incorrect performance U4 Cleaning or resurfacing feedback 112 Inadequate reparative 112.1. Communication of needs 9. Inadequate engineering 1122 Scheduling of work Gee CAN: 1,9, 4,9, 19, 14) 1193 amination af nin Inadequate assessment of loss exposures 1.24 Partsubstitution Inadequate consideration of human factors/ ‘exquasmice 12. Inadequate tools and equipment 93 Tnadequate standards, specifications and/or (sce CAN: 1, 3, 4,6, 7,9, 11, 12, 14, 15, 19) design criteria 12.1 Inadequate assessment of needs and risks Qed Inadequate verification of design 122 Inadequate human factors/ergonomies 95 Inadequate validation of design considerations 9.6 Inadequate monitoring of construction 123 Inadequate standards or specifications 9.7 Inadequate asessment of operational 124 Inadequate availability readiness 12.5 Inadequate adjustment/sepair/maintenance Inadequate or improper controls 12.6 Inadequate salvage and reclamation Inadequate monitoring or inital operation 12.7 Inadequate removal and replacement of Inadequate evaluation of changes ‘unsuitable items M-SCAT® ~ Marine Systematic Cause Analysis Technique 11Evaluation Type of Immediate? Control of Accident >| of Loss |Contact | >| Direct Action or Incident Potential Causes (10) Needs (CAN) 13. Inadequate work standards (see CAN: 1,2, 4,5, 6,7,8,9, 10, 11,13, 14,15, 16, 19) 13.1 Inadequate development of standards for 13.1.1 Inventory and evaluation of exposures and needs 13.12 Coordination with process design 13.13 Personnel involvement 13.14 Provedures/practices/rules 182 Inadequate communication of standards for: 132.1 Publication 1322 Diswibution 182.3 Translation of appropriate Tanguages 1324 Traming 152.5 Reinforcing with signs, colour codes and job aids 138 Inadequate maintenanee of standards for: 193.1 Tracking of work flow 1932 — Updating 183.3 Monitoring use of procedures/ practices/rules 13,4 Inadequate monitoring of compliance 14, Excessive wear and tear (see CAN: $, 4.6.9, 10, 18, M4, 15) 141 Inadequate planning of use 142 Improper extension of service life 143 Inadequate inspection and/or monitoring 144 Tinproper loading or rate of use 145 Inadequate maintenance 146 Use by unqualified or untrained people 17 Use for wrong purpose 15. Abuse or misuse (see GAN: 1, 3, 4,6,8, 9,10, 1, 13, 14, 16,17, 19) 15.1 Improper conduet that is condoned 15.1.1 Imentional 2 Unintentional 15.2 Improper conduct that is not condoned 152.1 Incentional 1522 Unintentional 2 M-SCAT® ~ Marine Systematic Cause Analysis TechniqueDescription Evaluation Type of Immediate/ Basic/ of Accident [>Joftoss pe) contact Direct >| Underiying fm» or Incident Potential Causes (IC) Causes (BC) Control Action Needs (CAN) ? 1 Leadership and administration 3 Planned inspections and 1.1 General policy and long-range plan maintenance 112 Designated loss contol cooreinators Planned general loss contol 3. Management paretpaion and inspections verison 82 Ceti! gatems,equipmen 14 Fotabishen tok control porfotmnice coumpousbir ad para ict canard 23 Planned inspection and maintenance 1G Management meetings Henge anti epecon 13 Toweontol reference manual Special stand, inacve and prease 1S Inter audig conducted clapment testy and tintenanee 19 Individual responsibly forse 26. Alematc substandard condition ‘contol paring pao 1.10. Faulasamentof annual ts contol 2:7 Compliance requirements objectives, 88 Mantel apecion and malnithonce! 111 Shipboard safery and ensironmental follweup oiten provetion eommitecs 39 Planned inpecuon and maintenance 11g Reta wo work duet lass contol repertanaheis havards Li eee they 4. Critical operations and task analysis LM Document cond and record beering 41 Adninistraton 113 — Regulations, codes and standards 42 Geideal operations and extial sk 43° Oyctnes fre 2. Leadership training procedures 21 Training needs anals 44 Rnatss and procedures fr eral 22 Loss como! leadership opernions and ecal wala ncn ton induction 43. MentiReation and contol of potential 23° Formal inital taining of shore-based pa management and profesional 24 Formal review uplatevadanced 5. Actidentincident investigation 26 Formal review/upsdate /advanced loss control leadership training on board 2.7 Formal taining of shore-based loss control coordinators) 28 Training records Legend: P- program activity taining of shore-based management and professionals Formal initial shipboard loss control leadership taining ‘S~ performance standards are established Accident/incident investigation system Operating management participation Major and high-potential sccidlents/incidemts Correetive action and followup Incident (nearamiss) reporting and Accident incident repor M-SCAT* ~ Marine Systematic Cause Analysis Technique C~ full compliance to standards achieved14 Description Evaluation Type of Immediate! Basic/ of Accident || of Loss >| Contact Direct >| Underlying [> or incident | [Potential Causes (ic) | | Couses (80) ? 6. Observation of work performance 10. Knowledge and skill raining 6.1 Administration 10.1 Administration 62 Work performance observations 102 Training needs analysis 63 Grtcal work performance observations 103. nstrucior qualifications 64 Follows sister 104 Training systems Work performance observation report 105 Training sytem evaluation and follow analysis wp Emergency preparedness 41. Personal protective equipment Administration IAL Identification of personal protective Emergency response analysis equipment nceds Emergency plan 112 Personal protective equipment record- Spill response and clean-up keeping Sources of energy controls 113. Enforcement of standards Safety and rescue systems : ‘Emergency teams 12. Occupational health and hygiene Lesions learned system control Fist aid 121 Administration Organized ontside help and mutual aid 122 Health harard identification and Postevent planning evaluation Emergency commnication 123° Health harard control (Communications with the community 124 Occupational health and industrial hygiene monitoring 8. Company safety rules and work 125. Information and training permits 126 Health care system 8.1 General loss control rules 12:7 Professional assistance 82 Specialized work rules 128 Communications 83. Work permit ystems 129 Records 814 Starmory and clanification cerientes 85 Ruleedncmtion and review 43, System review and evaluation 85 Rule compliance and recognition 181 Eraluation of longrange plan BY toe otaticrtonl ae et oe oy een ome codes 183. Masters and management review 184 Perception survey ‘Accidentlincident anal iss mone Legend: M-SCAT®— Mi Consequence measurements Case and control analysis Property damage/ process loss identification and analysis Incident (near-miss) analysis Problemsolving project teams P= program activity larine Systematic Cause Analysis Technique S= performance standards are established C - full compliance to standards achievedDescription Evaluation Type of Immediate? ] [Bas of Accident [>| of Loss b= | contact >| Direct >|Underlying [> or Incident Potential Causes (1) Causes (BC) P PIS|C 14, Engineering and change 19, Purchasing and contract management management 14.1 Administration 19.1 Procurement 142 Hazard identification and risk 192 Subcontractor selection assessment 193 Management of subcontractors 143 Ship design review and change 19.4 Ship management and charter veg RAEI ; contracts perational and work process controls 145 Acquisition (second hand tonnage) es | Site ante. 181 182 183 Isa Legend: Personal communications Personal communication systems Job oriemtation/induction Task instruction Planned personal contacts Group communications Group loss control meetings Recordkeeping Management involvement General promotion Loss control bulletin boards Vee of accident incident statistics Gritical topic promotion Individual awards and recognition Loss control information publications Ship performance awards and recognition Shipboard housckeeping promotion system Records of promotion activities Personnel recruitment and orientation Capability requirements Medical examination General orientation /induetion Personael selection and recruitment 20.1 Probl 20. P~ program activity performance standard: are established M-SCAT* ~ Mai Off:hejob safery education m identification and analysis C- full compliance to standards achieved \e Systematic Cause Analysis Technique 15Det Norske Veritas, NO-1322 Hovik, Norway, tel +47 67 57 99 00 www.dnv.com Want to learn more? DNV stations world wide offer a range of training courses and advisory assistance in managing accident/incident investigations. Please contact your local DNV office for more information. © am DEL NOnSKE YREITAS "O25 ip Ine examen REIS AE