guidance for r-cat rca

MOL Tankship Management (Asia) Pte Ltd Sheet 1 of 3

Root Cause analysis using the R-CAT Technique

Near Miss Analysis

Step 1 What Happened

Step 2 Causes 12

Step 3 Risks

Step 4 RCA ( from M-SCAT & Other ) (Control Action Needs (CAN) - From RCAT Sheet (2)

Step 5 Corrective Action (To be done by Ship / Shore)12

3

AB -A was removing old grease from the Mooring Winch by using a hand scrapper while winch was turning.The scrapper was caught between the clutch bar and the engaging slot, causing a cut injury to his right hand index finger and the area between index finger.


Evaluation of Loss Potential Control Action Needs

Loss Severity Potential Probability of Recurrence

Type of Contact

Immediate / Direct Causes

Basic / Underlying Causes

F8

This is included as the RA did not cover removal of old grease, though it did include that the winch should be stopped when greasing and a long handle brush be used. Similar caution was not included for grease removal and the person doing the job did not include the interpretation to removal and had the winch turning to possibly do what is covered in 7.6 above.

F9

Included as the actual check for if the winch was being turned was not done. Though instructions are given implementation and monitoring of same is equally important to achieve the final goal of an incident free work place and practices.


Root Cause analysis using the R-CAT Technique

Near Miss Analysis

Step 1 What Happened

Step 2 Causes 1 Incorrect method used 2 Winch was kept turning increasing risk

Step 3 RisksInjuryDamage to Machinery

Step 4 RCA ( from M-SCAT & Other )1.11 - Shipboard Safety and Environmental protection Committee

14.2 - Hazard identification and risk assessment15.3 - Task Instructions

Step 5 Corrective Action1 The Shipboard committee should review its procedures for job delegation, and use the incident to avoid future occurrence.2 The Method of Risk Assessment should be improved to cover all aspects of the Job. Highly recommend that RA be done

as a group rather than individually for covering all areas.3 Briefing for routine jobs also must be with emphasis. Follow up of instruction Implementation should be improved.

AB -A was removing old grease from the Mooring Winch by using a hand scrapper while winch was turning.The scrapper was caught between the clutch bar and the engaging slot, causing a cut injury to his right hand index finger and the area between index finger and thumb.


Evaluation of Loss Potential Control Action Needs

Loss Severity Potential Probability of Recurrence

(B) Serious (B) Moderate 3

2.5 - Poor Judgement

15.3 - Task Instructions

Type of Contact

Immediate / Direct Causes

Basic / Underlying Causes

4 - Incorrect Use of equipment or Machinery

1.11 - Shipboard Safety and Environmental protection Committee

6 - Failure to follow Maintenance Instructions

7.6 - Improper attempt to save time or effort

14.2 - Hazard identification and risk assessment

12.1 - Inadequate assessment of needs or Risks

13.3.3 - Monitoring Use of procedures / practices / rules

F6

This is included as the RA did not cover removal of old grease, though it did include that the winch should be stopped when greasing and a long handle brush be used. Similar caution was not included for grease removal and the person doing the job did not include the interpretation to removal and had the winch turning to possibly do what is covered in 7.6 above.

F7

Included as the actual check for if the winch was being turned was not done. Though instructions are given implementation and monitoring of same is equally important to achieve the final goal of an incident free work place and practices.

guidance for r-cat rca

Documents