Company Operational Manual COM 2.4 Root Cause Analysis CA & PA	Doc No.: COM 2.4 Revision: 01 Date: 15 Oct 2024 Issued by: DPA Approved by: MD

IMMEDIATE CAUSES, SUBSTANDARD ACTS
1. Drugs/Alcohol intoxication	14. Operating equipment without authority
2. Failure to follow Rules or Regulations	15. Removing safety devices
3. Failure to secure	16. Sabotage, wilful damage
4. Failure to use proper personal protective equipment	17. Servicing equipment in operation
5. Failure to warn	18. Using defective equipment
6. Horseplay	19. Using equipment improperly
7. Improper lifting	20. External substandard acts
8. Improper loading	20.1 Pilots
9. Improper placement	20.2 Berthing crew
10. Improper position for task	20.3 Terminal personnel
11. Incorrect navigation or ship handling	20.4 Local authorities
12. Making safety devices inoperable	20.5 Other people not under the control of the company/ shipboard management
13. Operating at improper speed

IMMEDIATE CAUSES, SUBSTANDARD CONDITIONS
21. Cargo	34. Inadequate or improper protective equipment
22. Congestion or restricted action	35. Inadequate ventilation
23. Dangerous atmosphere hazards	36. Inadequate warning systems
24. Defective tools, equipment, or materials	37. Incorrect/inadequate tools, equipment, or materials
25. Electric current hazards	38. Other excessive exposures
26. Exposure to chemicals	39. Outdated charts, publications, and other documentation
27. Exposure to high temperature	40. Poor housekeeping, disorder
28. Exposure to low temperature	41. Wet/slippery surface
29. Exposure to noise	42. External substandard conditions
30. Exposure to radiation	42.1 Adverse weather conditions
31. Fire or explosion hazards	42.2 Adverse sea conditions
32. Inadequate guards or barriers	42.3 Inadequate port and berthing facilities
33. Inadequate or excessive illumination

BASIC/ROOT CAUSES, PERSONAL FACTORS
1. Inadequate Physical/Physiological Capability	4.5 Extreme concentration/perception demands
1.1 Inappropriate height/weight/size/strength/reach, etc.	4.6 “Meaningless”/“degrading” activities
1.2 Restricted range of body movement	4.7 Confusing directions/demands
1.3 Limited ability/inability to sustain body positions	4.8 Conflicting demands/directions
1.4 Substance sensitivity/allergy	4.9 Preoccupation with problems/Distraction by concern
1.5 Sensitivities to sensory extreme (temperature/sound/etc.)	4.10 Frustration
1.6 Vision deficiency	4.11 Mental illness

BASIC/ROOT CAUSES, PERSONAL FACTORS
1.7 Hearing Deficiency	5. Lack of Knowledge
1.8 Other sensory deficiency (touch/taste/smell/balance)	5.1 Inadequate experience
1.9 Respiratory incapacity	5.2 Inadequate orientation
1.10 Other permanent physical disability	5.3 Inadequate initial training
1.11 Temporary disability	5.4 Inadequate update/refresher training
2. Inadequate Mental/Psychological Capability	5.5 Misunderstood instruction/information
2.1 Fears and phobias	5.6 Lack of situational awareness/risk perception/risk awareness
2.2 Emotional disturbance	6. Lack of Skill
2.3 Mental illness	6.1 Inadequate initial instruction/skill training
2.4 Intelligence level	6.2 Inadequate practice
2.5 Inability to comprehend	6.3 Inadequate performance
2.6 Poor coordination	6.4 Inadequate coaching
2.7 Slow reaction time	6.5 Inadequate review instruction
2.8 Low mechanical aptitude	7. Improper Motivation
2.9 Low learning aptitude	7.1 Improper performance/behaviour is tolerated/rewarded
2.10 Memory failure/lapse	7.2 Proper Performance/behaviour is discouraged/punished
3. Physical/Physiological Stress	7.3 Lack of incentive
3.1 Injury or illness	7.4 Improper production incentive
3.2 Fatigue due to task load or duration	7.5 Excessive frustration
3.3 Fatigue due to lack of rest	7.6 Inappropriate aggression
3.4 Fatigue due to sensory overload	7.7 Improper attempt to save time/effort
3.5 Exposure to health hazard	7.8 Improper attempt to avoid discomfort
3.6 Exposure to temperature extreme	7.9 Improper attempt to gain attention
3.7 Oxygen deficiency	7.10 Inadequate discipline

BASIC/ROOT CAUSES, PERSONAL FACTORS
3.8 Atmospheric pressure variation	7.11 Inappropriate peer pressure
3.9 Constrained movement	7.12 Improper leadership example
3.10 Blood sugar insufficiency	7.13 Inadequate performance feedback
3.11 Alcohol/Drugs/Other Self-Imposed Stress	7.14 Inadequate reinforcement of proper behaviour
4. Mental/Psychological Stress	7.15 Abuse (intentionally)
4.1 Emotional overload	7.16 Misuse (unintentionally)
4.2 Fatigue due to mental task load or speed
4.3 Extreme judgment/decision demands
4.4 Routine/monotony/demand for uneventful vigilance

BASIC/ROOT CAUSES, JOB FACTORS
8. Unclear Organizational Structure	13.7 Inadequate assessment of repair needs
8.1 Unclear/conflicting reporting relationship	13.8 Inadequate parts substitution/replacement
8.2 Unclear/conflicting assignment of function/role	13.9 Inadequate inspection method/interval
8.3 Unclear/conflicting accountability/responsibility/task	13.10 Unable to inspect
9. Inadequate leadership	14. Excessive Wear/Tear
9.1 Inadequate asset strategy	14.1 Inadequate planning of use
9.2 Inadequate leadership development	14.2 Improper decision on extension of service life
9.3 Inadequate delegation	14.3 Inadequate inspection/monitoring
9.4 Inadequate standards	14.4 Improper loading/rate of use
9.5 Inadequate communication/implementation of policy/procedure/practice	14.5 Used for wrong purpose/task/activity
9.6 Conflicting policy/procedure/practice	15. Inadequate Tool/Equipment/Machinery/Device
9.7 Inadequate work/process planning/programming	15.1 Inadequate assessment of needs and risks
	15.2 Inadequate human factors/ergonomics considerations

BASIC/ROOT CAUSES, JOB FACTORS
9.8 Condone deviation from policy/procedure/practice	15.3 Inadequate (supplier) standards/specification
9.9 Condone misuse of equipment/tool	15.4 Incorrect measurement/detection/(process) control
9.10 Condone improper/inappropriate behaviour	15.5 Inadequate availability of tool/equipment/machinery/device
9.11 Inadequate management information	15.6 Inadequate inspection/repair/maintenance
10. Inadequate Supervision/Coaching	15.7 Inadequate adjustment/calibration
10.1 Inadequate instruction/orientation/training	15.8 Inadequate salvage and reclamation
10.2 Inadequate information document in supervision/coaching	15.9 Inadequate removal and replacement of unsuitable items
10.3 Lack of supervisory/management job knowledge	16. Inadequate Product
10.4 Inadequate match between qualifications and job/task requirements	16.1 Inadequate assessment of needs and risks
10.5 Inadequate performance measurement and evaluation	16.2 Inadequate product standard/specification/waiver system
10.6 Inadequate performance feedback	16.3 Inadequate product design/development
11. Inadequate Change	16.4 Inadequate product standard
11.1 Inadequate hazard identification/risk evaluation in design	16.5 Inadequate product design validation
11.2 Inadequate identification of failure mode	16.6 Inadequate product design verification
11.3 Inadequate evaluation of customer/stakeholder requirement	16.7 Inadequate product planning
11.4 Inadequate identification of legal requirement	16.8 Inadequate product quality verification prior to shipment
11.5 Inadequate consideration of human/ergonomic factor in design	17. Inadequate Work/Production Standards
11.6 Inadequate design process/standard/specification/criterion	17.1 Inadequate identification of requirements (regulatory/industry code/permit-to-operate)
11.7 Inadequate process control automation	17.2 Inadequate risk identification/evaluation in development of standard
11.8 Inadequate (technical) standard/specification or absence thereof	17.3 Inadequate standard from supplier/contractor
11.9 Inadequate project review	17.4 Inadequate coordination with process design when developing standard
11.10 Inadequate monitoring of construction/fabrication/assembly	17.5 Inadequate employee involvement in developing standard
11.11 Inadequate assessment of operational readiness
11.12 Inadequate commissioning/handover process

BASIC/ROOT CAUSES, JOB FACTORS
11.13 Inadequate monitoring of initial operation	17.6 Conflicting standards/improper prioritization of standards
11.14 Inadequate management of change	17.7 Inadequate publication of standard
12. Inadequate Supply Chain Management	17.8 Inadequate distribution of standard
12.1 Inadequate specifications on requisition/purchase order	17.9 Inadequate translation of appropriate language
12.2 Inadequate research on material/equipment/tool/supply/etc.	17.10 Improper use of language
12.3 Inadequate specification to vendor	17.11 Inadequate training of standard
12.4 Inadequate mode/route of shipment	17.12 Inadequate reinforcing of standard with signs, colour codes and job aids
12.5 Inadequate receiving inspection/acceptance	17.13 Inadequate monitoring of standard compliance
12.6 Inadequate communication of safety and health data	18. Inadequate Communication/Information
12.7 Improper handling of material	18.1 Inadequate information handling
12.8 Improper storage of material	18.2 Unclear information
12.9 Improper transporting of material	18.3 Inadequate transfer of information between processes / organizational units
12.10 Inadequate shelf life/validation for re-use of materials/equipment	18.4 Inadequate transfer of information with client/stakeholder
12.11 Inadequate identification of material	18.5 Inadequate transfer of information with authorities
12.12 Inadequate salvage/waste disposal	18.6 Inadequate transfer of information with suppliers/contractors/third parties
12.13 Inadequate selection of contractor/supplier	18.7 Inadequate communication structure
13. Inadequate Maintenance/Inspection	18.8 Inadequate databases/information system
13.1 Inadequate assessment of preventive maintenance needs	18.9 Inadequate communication method/technique used
13.2 Inadequate preventive lubrication and servicing
13.3 Inadequate adjustment/assembly
13.4 Inadequate preventive cleaning/resurfacing
13.5 Inadequate communication of corrective maintenance needs
13.6 Inadequate scheduling of maintenance work