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  1. 3 Cause levels. Their definitions and examples.

An accident will normally have three cause levels:

  1. direct / immediate causes

  2. basic / root causes

  3. control management failure.

The direct / immediate cause of an accident can be defined as a problem that, if corrected, could have prevented an incident from occurring or have significantly reduced the incident's consequences.

The basic / root cause can be defined as the most basic cause that can be reasonably identified that management has control to fix, and when fixed, will prevent, or significantly reduce the likelihood of the problem's recurrence. The root causes are the reason why substandard acts / conditions occur; the factors that, when identified, permit meaningful management control.

Control management failure: 'management' refers not to the senior management of the Company but to the management system – be it on the bridge or in the office.

Direct/Surface causes are usually due to substandard acts and substandard conditions.

Direct causes

Substandard Acts

Действия с отклонениями от нормы

Substandard Conditions

Условия/обстоятельства, не отвечающие нормам

  • Incorrect use of PPE

  • Inadequate controls

  • Not following Regulations

  • Inadequate PPE

  • Incorrect use of equipment

  • Adverse weather conditions

  • Broken machinery

  • Poor housekeeping

  • Incorrect navigation

  • Outdated charts

The underlying root cause(s) is / are not immediately visible.

Root causes

  1. Fatigue due to lack of rest (усталость из-за недостатка отдыха)

  1. Inadequate supervision (недостаточный контроль/надзор)

  1. Inadequate training (недостаточная подготовка)

  1. Inadequate standards (стандарты, не отвечающие требованиям)

  1. Infrequent performance (нечастое выполнение (данного вида работ))

  1. Inadequate needs assessment (неправильная оценка критической ситуации)

  1. Inadequate discipline (несоблюдение дисциплины)

  1. Inadequate maintenance (недостаточное обслуживание)

  1. Disabilities (неумение, недостаток квалификации)

  1. Inadequate inspection (недостаточные проверки)

Both causes stem from the failure of the management control system.

By dealing with the root causes and / or control management failures, the direct causes can be eliminated.

This, in turn, removes the likelihood (вероятность) of a hazardous event occurring.

Some examples of direct causes and root causes:

Accident / Incident / Near Miss

Direct causes

Root causes

Management Control failure

1. Tanker runs aground in the Channel

Incorrect navigation / ship handling

Inadequate training and experience in the pilotage of large tankers

Knowledge and skills training

2. Tanker explosion due to defective cargo pump

Defective equipment

Inadequate maintenance

Planning inspection and maintenance

3. AB working aloft without safety harness

Failure to use PPE

Failure to supervise the use of PPE

PPE record keeping

4. AB trips on uneven floor

Substandard conditions or inadequate controls / barriers

Inadequate maintenance of standards

Planning inspection and maintenance

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