2011 Marine SeminarROOT CAUSES

OCT 2011

R. NahonJ. Couyou

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BASICS . . .

CA = CuA + PA

MNC OBSNC

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How to deal with a Non Conformity . . .

► Drill schedule not followed . . .

ISM ref / Grading

Curative Action (CA)

Root cause

Preventive Action

► Engine SMS Manual: Different revision status . . .

ISM ref / Grading

Curative Action (CA)

Root cause

Preventive Action

► No superintendent’s inspection on record . . .

ISM ref / Grading

Curative Action (CA)

Root cause

Preventive Action

► Lifeboat was found holed…

ISM ref / Grading

Curative Action (CA)

Root cause

Preventive Action

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Form K

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HOW TO WRITE (CORRECTLY) A FORM K

► Describe CORRECTLY (someone will have to read/understand it after a considerable time in the future)

► Relate it to the ISM Code (… to something !.. Maintenance, Document Control, Accident etc.)

► Use “Comments” in a ‘Spartan’ way…

► Always use the “other reference” section (..relate to SMS !.)

► Use the full “limit date” (phrase NC suitably or otherwise issue Major Non Conformity)

► Assign ISM Code ref. No. that “best” fits “your” Description

► Grade/Downgrade a NC/MNC “properly”…!

► Accept a “RELEVANT” Corrective Action with a Preventive Action- R.C.?

► Do not repeat the “same” ISM Code ref. numbers in several NCs

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From Batalas website

A perfect nonconformity report

Unless you have a sadistic streak, you will not take pleasure in raising a nonconformity report. However, the lack of enthusiasm is no excuse for a poorly written report.

The most common faults found on nonconformity reports are:

►the failure to explain the requirement

►a weak and ambiguous statement of the evidence

►inability to link the evidence with the requirement

Explaining the requirement

►if the requirement relates to a lengthy clause of the standard select the appropriate words, paraphrase if necessary in your own words providing the meaning has not changed

►if the requirement relates to your own management system be precise as to the exact element of the management system, process, procedure, etc. Do not just write the procedure number.

►always include a reference number of the clause of the standard or the management systems reference number

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From Batalas website

Recording the evidence

►always state the actual evidence, avoid summary evidence e.g. ‘a sample of records were inaccurate’

►never use the phrase ‘there was insufficient evidence’

►keep to the facts, do not make assumption e.g. ‘the statistical information was difficult to understand and would therefore be of little use’

Checking the link

Does the evidence show proof of nonconformity against the recorded requirement?

The ultimate test

It should be possible for anyone in the organisation to comprehend a nonconformity report without having to resort to a string of supplementary questions in order to understand the report. If you have to ask what, how, when, etc. then the report is incomplete and ineffective.

FLAG

POSSIBLE ROOT CAUSES

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SOME ABBREVIATIONS

Maintenance

S.M.M.

Training

Records

Meetings …

(MRM,I.A.,SCM etc.)

Reports

Rules and Regs.

Company

Investigation

(Analysis)

Form

(Checklist)

ROOT CAUSE

Monitoring

“Graded” NC ?

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SOME ABBREVIATIONS

… too much

… think first

… report

… confused

… shipboard

… sufficient ?

P

Procedure !

… re-think ! read again what you have written

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POSSIBLE ROOT CAUSES . . . ( 5 Ys technique )

MATERIALS

Defective raw material

Wrong type for the job

Lack of raw material

MAN POWER

Inadequate capability

Lack of knowledge

Lack of skill

Stress

Improper motivation

MANAGEMENT SYSTEM

Training or education lacking

Poor employee involvement

Poor recognition of hazard

Previous identified hazards not eliminated

METHODS

No or poor procedures

Practices are not as per written procedures

Poor communication

General cases

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► MNC 1 - During PSC and BV survey following PSC detention following deficiencies have been found: Several ventilation flaps and windows around superstructure not closable, several doors, flaps with damaged or missing rubber seal, nearly all fire dampers in funnel of engineroom inoperative, nearly all doors in superstructure and funnel not watertight closable, several lamp covers in superstructure and engineroom missing, several covers for plugs around the superstructure missing some electrical cables not fixed, several bars rotten, exhaust gas insulation of aux. engines wetted through with oil due to strong oil leakages and missing screen plates, bilges of aux. engines and steering gear dirty with oil, pressure gauges at aux. eng. And main engine partly inoperative or not readable, both aux. engines with oil and exhaust leakages, fuel oil leakages found at ME, several rotation protections at pumps and engines missing, bunker plate stb. side strong corroded, steriliser for portable water inoperative-hot water pressure tank leaking, material wastage of vertical pates close to leading wheels of hatch covers, coaming flanges damaged by corrosion.

► CA – a.m. deficiencies to be rectified before departure or to be postponed by BV surveyor acc. to visa page issued. Corrective action plan has been prepared after detention and internal NC forms issued.

SMCA ON JANUARY 2011

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SMCA on JAN 2011 (Cont’d)

► MNC 1 – downgraded into a NC2 with the same wording of the MNC!!! ( the system by default keeps the same wording UNLESS the Auditor intervenes and changes the wording himself …as/if necessary)

► CA - External additional ISM audit to be carried out by BV until 12.04.2011. Internal ISM audit to be carried out by company before external additional ISM by BV. Training of responsible crew with regard to maintenance procedures to be carried out icw. internal ISM audit. Inspection by company’s Superintendent to be carried out within next 3 months, inspection report to be presented during next external ISM audit.

FIRST THEN

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SMCA on JAN 2011 (Cont’d)

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SMCA on JAN 2011 (Cont’d)

Same text

by default!!

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SMCA on JAN 2011 (Cont’d)

► MNC 3 – During PSC and BV survey following PSC detention following deficiencies have been found: doors to superstructure not closing according to ISPS code, some breathing apparatus with insufficient pressure or empty, several lights in mast aft not working or damaged, voyage plan not according to IMO Res 893(21), latest NTMs not available and several NPs expired, several lifejackets without clips and not correct marked, EEBD in rope store missing, 15 ppm arrangement shows 9 ppm permanently-calibration required, fire alarm in aux. engine station inadequate, medical equipment in engine room partly expired, oil record book entries no records since August 2009.

► CA - a.m. deficiencies to be rectified before departure. Corrective action plan has been prepared after detention and internal NC forms issued.

…CONFUSION…

[ three (3) in one (1) ]

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SMCA on JAN 2011 (Cont’d)

► MNC3– downgraded into a NC4 with the same wording of the MNC!!! (Again no intervention by the Auditor in the NC4 text)

► CA - Training for responsible personnel deck and engine to be carried out by DPA, e.g. procedures for checking of safety equipment deck and engine, nautical publications, maintaining of records. External additional ISM audit to be carried out by BV until 12.04.2011. Internal ISM audit to be carried out by company before external additional ISM by BV.

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SMCA on JAN 2011 (Cont’d)

► MNC5– Second starting device of emergency generator found inoperative. Automatic start of EG inoperative. Water cooler of EG found disconnected. ( the word MAINTENANCE is not mentioned anywhere)

► CA - to be repaired before departure

► MNC5– downgraded into a NC6 with the same wording of the MNC!!!

► CA - Responsible engine personnel to be trained by DPA regarding company procedure for critical equipment .

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SMCA on JAN 2011

Audit report IS NOT a Survey report!

The word MAINTENANCE not even mentioned in the MNCs!!!!!

3 MNCs related to maintenance {and shipboard operations (MNC3) }

Audit findings (& NC) are… a copy of the PSC findings!! What is the added value?

The Classification Society to look for punctual repairs…

What about maintenance system? The ship’s maintenance plan? Controls (check periodicities, check list, warnings, etc) Responsible? Training needs?

CAs as curative actions!

ROOT CAUSES!!!

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For discussion

How would you propose the wording be for these MNCs ?

And for the NCs ?

What would you expect the CAs to be proposed by the ship/Company ?

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SMCA on JAN 2011 (Cont’d)

► OBS 8– funnel to be secured by steel lamellas before departure.

► CA – None (obs)

OBS not worded properly . . .

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SMCI on MAR 2011

► MNC 1 - Detected objective Evidence on non full ( ? ) compliance with STCW I/10. e.g Administration Endorsement or application for Chief Engineer could not be produced on board.

► Action taken by Company: Declaration of reception of an Application for endorsement valid until 18 June 2011 was received.

► NC 2 (downgraded MNC1) - Detected objective Evidence on non full compliance with STCW I/10. e.g Administration Endorsement or application for Chief Engineer could not be produced on board.

► CA - Objective evidence of chief engineer's endorsement provided. Matter to be investigated by Company's management, necessary training and instructions about STCW and Flag requirements are to be implemented to responsible Crewing office personnel.

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SMCA on JAN 2011

NC grading MNC ? (numerous ?, repeated ?)

NC wording (in most cases) should not be the same as the MNC wording

Has CA addressed the ROOT CAUSE (s) of the problem ?

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For discussion

How would you propose the wording be for this MNC ?

And for the NC ?

What would you expect the CA to be proposed by the ship/Company

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SMCI on NOV 2010

► NC 7 – Findings(?) raised in internal audit 21/08/2010 not resolved

► CA - Timely resolution of findings to be ensured

CuA ? P ?

► P

CA saying the obvious !

NC wording

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SMCI on NOV 2010

► NC 8 - No plan or record of exercises relating to identified shipboard emergencies

► CA - Exercises to be planned, carried out & recorded

NCs not properly graded!

CA saying the obvious

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SMCI on NOV 2010

► NC 9 - Critical equipment not maintained. One of three freefall lifeboat air cylinders defective.

CA - Defective cylinder to be repaired. Effective schedule for maintenance to be implemented (Action taken by the Company: Shore side technicians contracted & cylinder repaired)

► NC 10 - Critical equipment not maintained. Freefall lifeboat SART defective

CA - Defective SART to be renewed (Action taken by the Company: New SART purchased)

► NC 11 - Critical equipment not maintained. VDR defective

CA - VDR to rectify

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SMCI on NOV 2010

NCs 9, 10 and 11 related to same finding critical equipment not maintained

NC 10 cleared during the same audit ? how to show compliance with the preventive actions (that should have been proposed)?

CA not addressing the ROOT CAUSES

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BSI AUDIT IN HO – JUN 11

NC 1: Statement of masters overriding authority not located/provided

CA: Statement of masters overriding authority to be inserted into SMM

CA = CuA + PA

NCs not properly written!

CA not addressing the ROOT CAUSE!

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BSI AUDIT IN HO – JUN 11

NC 3: Master not familiar with SMM

CA: Master to familiarise himself (?) with the ISM Code

& SMM

CA = CuA + PA

NCs not properly graded!

CA not addressing the ROOT CAUSE!

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BSI AUDIT IN HO – JUN 11

NC 4: Critical equipment reliability not ensured. LRIT & SSAS not functioning. Both share one antenna.

CA: Manufacturers agent to repair.

CA = CuA + PA

NC not properly graded

CA not addressing the ROOT CAUSE!

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BSI AUDIT IN HO – JUN 11

► NC 6 - No record of spare parts delivery.

► CA - Spares to be provided as required

CA = CuA + PANC not properly

worded!

CA not addressing the ROOT CAUSE!

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SMCR on JAN 2011

► NC 2 - No record evidence that oil analysis for main engines and other machineries are carried out in proper intervals. Last result on board dated 24 April 2010 & previous result dated 17 September 2008.

► CA - Company will make sure that oil analysis will be carried out as per the planned maintenance program.

CA = CuA + PA

…make sure…! How?

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SMCI on MAR 2011

► NC 1 - Objective evidence that oil record book not filled properly.

► CA - Company will provide guidance to all chief engineer to make proper entry and record.

► NC 2 - No record evidence that maintenance routine for main engines & auxiliary engines have been carried out as per planned maintenance program.

► CA - Company will ensure all PMS must be carried out accordingly by chief engineers and record to be maintained

CA = CuA + PA

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SMCP on APR 2011

► NC 3 - No objective evidence that crew appraisal report was done by the master as per SMM Chapter 2 sec. 2.3.17

► CA - Company to inform all vessel's masters to carry out appraisal report as per SMM Chapter 2 sec. 2.3.17 and to keep updated record on board.

CA = CuA + PA

CA not addressing the Curative action!

CSOM / CM check lists

PROPER Follow Up

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ISM Check List (one example...)

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DOCP on APR 2011 - (written by CSOM)

► NC 1 - The Safety Management System has not been updated according to new requirements from 01 July 2010. Last revision: 10.12.2009..

► CA - To be amended accordingly and forwarded to BV.

CA = CuA + PA

NC grading!! MNC?

CA not addressing the ROOT CAUSES!

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DOCP on APR 2011 - (written by CSOM)

►NC 2 - Example:

" F ": Bosun onboard July 2010 does not comply with ILO 180 ( too little rest )

Same for OS J.

Observed that officers do not always make a comment, why too little rest within 24 hours ( " F " )

Some Philippines ratings mark 3 rest periods within 24 hours ( "F" and “ Fa“)

►CA - Correct recording to be stressed out for all Masters.

CA = CuA + PA

•NC should be better written (what is the finding? It gives only examples

•CA not addressing the Curative action!

Better Examples ?

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DOCP – JUNE 2009

► MNC 1 - There was no evidence found ,regarding the proper evaluation of SMS of the Company as per requirements of ISM Code and Company Manual M-01, Chapter 15 re: Management Review. No evidence was found that the SMS Management Reviews for the years 2008 and 2009 had been performed.

► CA: An “extraordinary” Management Review to be performed- as per requirements of M-01, Chapter 15- as soon as possible and evidence provided.

DP and Managing Director to analyse and evaluate the proper status of the SMS onboard ships and in the company by performing Management Reviews every 4 months in next 1 year period.

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DOCP – JUNE 2009

► MNC 2 - There was no evidence about effective(?) internal audits of SMS as per requirements on ISM code chapter 12.1 and company manual M-01, Chapter 14. No internal audits in the company were found performed in the years 2008 and 2009.

► CA: Internal audit to be performed as per requirements of M-01, Chapter 14 and evidence provided.

Internal Company audits schedule to be revised so that Internal Audits be performed every 6 months in next 1 year period , to ascertain SMS current proper status. The DP will analyze and evaluate the audit results and the effectiveness of SMS by preparing necessary data for an “extraordinary” Management Review Meeting.

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DOCP – AUGUST 2011

► NC 1 – Documented evidence was found that the Agenda of the Company Management Review of 25/07/2011(and hence subsequent report) was found not to be as per relevant PR 12 of the SMS “00 Manual” (p.6/7) requirements .

► CA: The C.M.R. of 25/07/2011 will be repeated ,with all agenda items of PR 12 / SMS “00 Manual”, and evidence provided. All C.M.R. team members (including DP) will be retrained/familiarised with the C.M.R. Procedure requirements, currently in force. (revised)

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DOCP – AUGUST 2011

► NC 2 – No documented evidence was found that a ship-shore exercise had been carried out, between the Company and any Company ship, for the current year.

► CA: A ship-shore exercise will be carried out and evidence provided. The Company’s “Drills Schedule” will be amended to include (always) the annually planned ship-shore exercises.

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SMCP – JUNE 2011

► NC 1 - There is no evidence that the following crew members on board have valid medical certificates :

1. Mr. Jerome Saracho - (AB)

2. Mr. Eldie A. Magnetico- (Mechanic)

3. Mr. Raymond M. Matias- (Mechanic)

► CA: Above crew members will be re-examined ashore, by an authorised doctor, before the vessel leaves this port and relevant medical certificates will be issued. Crew Department to plan well in advance and revise relevant Crewing Procedure to include the requirement ,that crew members whose certificates expire during sailing period ,to be re-examined at first available port.

Assuming that the auditor was satisfied that the Master has checked certificates according to procedures (and has reported accordingly)

Lessons Learned

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BASIC LESSONS TO BE LEARNT

The NCs raised after a vessel detention is not supposed to be a copy of the PSC deficiency list

Remember an AUDIT differs from a SURVEY

A NC resulted from a downgraded MNC shall not have the same text of the MNC as it is supposed to tackle the root cause (s)

A NC shall not be cleared during the same audit (time for implementation of the proposed CA (s) is needed)

A NC MUST be concise, properly written in order to enable the many involved, including the clearing auditors, to fully understand it

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BASIC LESSONS TO BE LEARNT

Preventive Action (s) MUST always address the root cause (s)

The way a NC is graded always depends on the threat related to the finding (ref. to “definitions ,section 1.1 of the ISM Code), including any flags’ requirements (e.g. Liberia)

Do not issue a number of Forms K with the same ISM Code ref.

Do not forget to fill in the “other ref.” space of the Form K

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