Root Cause Analysis After a Shipboard Accident

After most shipboard accidents, someone writes a report. Too often it ends with a sentence like "crew member failed to follow procedure" and a recommendation to "remind crew of the importance of safety." That report found the immediate cause. It did not find the root cause, and it guaranteed the same accident would happen again.

Immediate cause and root cause

The immediate cause is what directly happened: the man slipped, the line parted, the ship turned too late. The root cause is why the conditions for that event existed in the first place. Why was the deck slick? Why was a worn line still in service? Why did nobody on the bridge notice the ship was off track?

Root causes usually sit in the system, not in one person: training, staffing, maintenance, procedures, supervision, schedule pressure, and how management responds to warnings.

How a proper investigation works

Good investigations follow a recognizable pattern.

1. Secure the evidence quickly: photos, equipment, data, logs, and statements.
2. Build the sequence of events from the records, not from memory alone.
3. Ask why at every step. Keep asking until the answer is something the company controls.
4. Look at the barriers. What procedures, equipment, or people should have stopped this, and why did each one fail?
5. Identify corrective actions that address the root causes, with owners and deadlines.
6. Follow up to confirm the actions were taken and worked.

Various structured methods exist (cause-and-effect diagrams, barrier analysis, human factors frameworks). The method matters less than the discipline of not stopping at the first easy answer.

Why investigations stop too early

• Blaming the individual is quick and protects management from harder questions
• The investigator reports to the people whose decisions might be at fault
• Nobody has time, because the vessel has to sail
• The company treats the report as paperwork rather than a tool

Why this matters in litigation

A company's own accident investigation is often one of the most revealing documents in a case. A thorough, honest investigation that found the root cause and fixed it is strong evidence that the company runs a real safety system. A shallow one that blamed the injured worker and changed nothing tells a different story, especially when earlier incident reports show the same problem happening before.

The ISM Code and towing safety management systems require companies to report and analyze accidents and take corrective action. Investigation files, nonconformity reports, and evidence of follow-up should all exist. When they do not, that absence is a finding in itself.

What to request

• The company's accident investigation report and any drafts
• Its investigation procedure
• Corrective action records and evidence they were completed
• Prior incident reports for the vessel and the fleet
• Management review records where the incident was discussed

About the author

Captain Mitchell S. Stoller is a Master Mariner Unlimited, former Exxon tanker master, and former Los Angeles Harbor pilot. About Captain Stoller