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Root Cause analysis using the R-CAT Technique

Near Miss Analysis


Step 1

What Happened

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.

Step 2

Causes
1
2

Step 3

Risks

Step 4

RCA ( from M-SCAT & Other )

Step 5

Corrective Action

(Control Action Needs (CAN) - From RCAT Sheet (2)

(To be done by Ship / Shore)

1
2
3

MOL Tankship Management (Asia) Pte Ltd

Sheet 1 of 3

Evaluation of Loss Potential


Loss Severity Potential

Type of
Contact

Immediate / Direct
Causes

Basic / Underlying
Causes

Control Action Needs

Probability of Recurrence

MOL Tankship Management (Asia) Pte Ltd

Sheet 2 of 3

Root Cause analysis using the R-CAT Technique


Near Miss Analysis
Step 1

What Happened

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.

Step 2

Causes
1
2

Incorrect method used


Winch was kept turning increasing risk

Step 3

Risks
Injury
Damage to Machinery

Step 4

RCA ( from M-SCAT & Other )


1.11 - Shipboard Safety and Environmental protection Committee
14.2 - Hazard identification and risk assessment
15.3 - Task Instructions

Step 5

Corrective Action
1 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.

MOL Tankship Management (Asia) Pte Ltd

Sheet 1 of 3

Evaluation of Loss Potential


Loss Severity Potential

(B) Serious

Type of
Contact

Immediate / Direct
Causes

Basic / Underlying
Causes

Control Action Needs

Probability of Recurrence

(B) Moderate

4 - Incorrect Use of 2.5 - Poor Judgement 1.11 - Shipboard Safety and Environmental
equipment or
protection Committee
Machinery
6 - Failure to follow 7.6 - Improper attempt 14.2 - Hazard identification and risk
Maintenance
to save time or effort assessment
Instructions
12.1 - Inadequate
assessment of needs
or Risks

15.3 - Task Instructions

13.3.3 - Monitoring
Use of procedures /
practices / rules

MOL Tankship Management (Asia) Pte Ltd

Sheet 2 of 3