Title Page
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Vessels name:
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Brief description of incident:
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Conducted on
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Prepared by:
Root cause analyses
GENERAL INFORMATION:
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Vessel name:
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Date of incident:
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Brief description of incident:
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Investigation level:
- Feederlins Safety Committee
- Shipboard
- Classification bureau
- Flagstate
- Port state control
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Attachments:
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Time line:
CONSEQUENCES:
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Personal injury?
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Death?
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Ship damage?
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Property damage?
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Financial damage?
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Environmental damage?
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Media exposure?
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Commercial exposure?
INCIDENT / ACCIDENT:
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Slip / trip / falls?
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Personnel / Equipment contact?
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Exposure - harmful substances?
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Exposure - harmful environment?
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Fire / explosion?
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Collision?
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Grounding?
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Loss of containment?
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Discharge to atmosphere?
DIRECT CAUSE:
DIRECT CAUSE - UNSAFE ACTS:
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Operating equipment without authority?
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Removing / making safety devices in-operable?
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Using defective equipment?
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Improper use of equipment?
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Not using PPE?
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Improper lifting or task position?
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Servicing equipment in operation?
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Horseplay?
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Under influence of drinks or drugs?
DIRECT CAUSE - UNSAFE CONDITIONS:
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In-adequate guards / barriers?
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In-adequate / improper PPE?
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Defective tools / equipment / material?
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Workspace restrictions?
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Hazardous environmental conditions?
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Noise, high / low temperature?
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In-adequate / excessive lighting?
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In-adequate ventilation?
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Poor house keeping?
INDIRECT CAUSE:
INDIRECT CAUSE - HUMAN FACTORS:
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Physically in-adequate?
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Mentally in-adequate?
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Lack of knowledge?
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Lack of skill?
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Stress?
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Improper motivation?
INDIRECT CAUSE - JOB FACTORS:
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In-adequate supervision?
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In-adequate leadership?
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In-adequate engineering?
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In-adequate purchasing?
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In-adequate maintenance?
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In-adequate tools / equipment?
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In-adequate work standards?
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In-adequate design?
ROOT CAUSE:
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Lack of planning / design?
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Lack of standards?
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Lack of compliance?
LESSONS LEARNED:
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Lessons learned:
Proposed follow up and actions:
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Further remarks:
Report made by:
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