Direct causes
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Substandard Acts Действия с отклонениями от нормы |
Substandard Conditions Условия/обстоятельства, не отвечающие нормам |
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The underlying root cause(s) is / are not immediately visible.
Root causes
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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:
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Accident / Incident / Near Miss |
Direct causes |
Root causes |
Management Control failure |
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1. Tanker runs aground in the Channel
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Incorrect navigation / ship handling |
Inadequate training and experience in the pilotage of large tankers |
Knowledge and skills training |
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2. Tanker explosion due to defective cargo pump |
Defective equipment |
Inadequate maintenance |
Planning inspection and maintenance |
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3. AB working aloft without safety harness |
Failure to use PPE |
Failure to supervise the use of PPE |
PPE record keeping |
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4. AB trips on uneven floor |
Substandard conditions or inadequate controls / barriers |
Inadequate maintenance of standards |
Planning inspection and maintenance |
The main reasons for doing accident investigation are:
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to learn what happened and determine the immediate and underlying causes,
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to measure / introduce effective preventative measures,
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to prevent the same or worse accidents recurring,
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to establish training needs,
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to learn key lessons in safety management,
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to meet legal and moral responsibilities by implementing a "duty of care" (добросовестное отношение).
The Master is responsible for the reporting of accidents and incidents onboard.
Where there is a designated Safety Officer onboard (usually the Chief Officer), it is his duty to investigate every incident and it is expected that the Master will use the results and records of his investigation when completing his report.
There may be a need to report accidents / incidents to third parties and government authorities. The Master must ensure that:
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all flag requirements are followed for all such reporting cases,
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the port state is notified if an accident occurs in port or territorial waters.
Any other reporting procedures will be communicated to the Master by the Designated Person Ashore.