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Root Cause Analysis for DPAs

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The ISM Code requires the company to analyse non-conformities and hazardous occurrences and to implement corrective action. What it does not specify is how — and the gap between a genuine analysis and a form completed to close the SMS loop is where repeat incidents live. Every DPA has seen the corrective action that corrects nothing: "crew to be reminded of procedure" for an incident whose procedure was unworkable, or "additional training" for a failure caused by manning, fatigue, or a maintenance backlog nobody would fund. Six months later the same event recurs, and the auditor asks what happened to the previous corrective action. This article is a practical RCA guide for the Designated Person Ashore. It covers evidence collection from shipboard before memories fade and the crew rotates — timelines, logs, alarm printouts, photographs, and structured interviews that separate what people did from what they now wish they had done. It explains when 5-Why is enough and when you need a wider method such as a fishbone or barrier analysis, because some incidents have linear causes and some have a web of failed defences. It addresses the near-miss reporting culture that feeds real analysis — a reporting system that punishes reporters produces silence, and silence looks like safety until it does not. Finally, it sets out how to write corrective actions that survive audit: specific, owned, resourced, time-bound, and verified for effectiveness after implementation. The goal is a management system that learns, not one that files.

ISM Code section 9 requires the company to analyse non-conformities and hazardous occurrences and to implement corrective action. Note what it demands: analysis, then action. Most SMS systems are strong on the second and weak on the first. The result is corrective actions that close the paperwork loop while leaving the causal chain intact, and incidents that recur with depressing regularity.

Evidence first, analysis second

Analysis done from a two-paragraph master's report two weeks after the event is guesswork with letterhead. Get the raw material while it exists:

  • Timeline. Reconstruct the event in minutes, from first abnormal indication to recovery. Timelines expose the gaps where assumptions hide.
  • Records and data. Logbooks, alarm histories, engine and VDR data where available, maintenance records, work and rest hours, the permit forms actually used. Request copies early; ships rotate crew and overwrite data.
  • Physical evidence. Photographs, failed parts preserved rather than discarded, the condition of the equipment involved.
  • Structured interviews. Speak to the people involved individually and promptly, and ask what they saw, what they did, and what made sense to them at the time. The question "why did you do that" invites defence; "walk me through what you were seeing" invites truth.

Guard the interview climate hard. If crew believe the analysis exists to allocate blame, they will hand you a curated story, and you will analyse a fiction.

Choosing a method that fits the incident

5-Why is genuinely useful for linear failures: a pump failed because a seal failed because the wrong seal was fitted because the spares list was wrong — keep asking until you reach something the company can change. Its weakness is that it forces one chain onto incidents that had several. Use it for simple, single-path failures and stop when the answers stop being causal and start being philosophical.

For anything involving multiple defences failing at once — and most serious incidents are exactly that — use a wider net. A fishbone structure pushes you to check methods, machines, materials, people, environment, and management rather than seizing the first plausible cause. Barrier analysis asks the ISM-shaped question directly: which defences were supposed to stop this, why did each one fail, and which were missing entirely. The human error at the sharp end is rarely the root cause; it is usually the last symptom. When your analysis terminates at "officer failed to follow procedure", you have almost always stopped one question too early: why was the procedure not followed — was it workable, trained, resourced, and checked?

Near-miss reporting feeds the machine

Your RCA capability is only as good as your reporting culture. A ship that reports two near-misses a year is not a safe ship; it is a quiet one. The levers are unglamorous: respond to every report with what was done about it, protect reporters visibly, make reporting take minutes not forms, and let the crew see that a near-miss report changed something. The near-miss database is your free sample of future incidents — analyse its patterns even when individual events seem minor, because the pattern is the message.

Corrective actions that survive audit

The test of a corrective action is whether it would prevent recurrence if the same conditions repeated tomorrow. "Remind crew" and "circulate a memo" fail that test by construction. Write actions that are:

  1. Specific and engineered where possible. Prefer changing the equipment, the procedure, the checklist, or the manning over changing people's intentions. A physical or procedural barrier beats a reminder every time.
  2. Owned and resourced. One named owner, a budget or authority where needed, a deadline. An action assigned to "the vessel" is assigned to nobody.
  3. Verified for effectiveness. Close the loop in two steps: confirm the action was implemented, then — after a defined interval — check whether the failure mode recurred or the control actually works in practice. An action closed on implementation alone is a hope, not a fix.
  4. Checked for fleet relevance. If one ship found it, the others probably have it. Fleet circulars and cross-vessel verification are where a DPA earns the title.

The auditor's favourite question — "how do you verify effectiveness of corrective actions?" — should be answerable with records of actions reopened because they did not work. A system that never reopens a corrective action is not succeeding; it is not looking. Build the looking in, and the ISM loop finally closes the way the Code intended.

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