Root Cause Analysis

of Deficiency
 Why Analyze ？
1 ） Target or suit the remedy to the case
对症下药
2 ） Apply corrective action and preventive
action
依情施策
3 ） Improve safety and management
提高安全
4 ） Sharing within fleet and avoiding recurrence
避免重蹈
缺 Regulation and Rules 法规规范要求
陷
產
生 Industry Standards 行业标准
的
依 Best Management Practice 最佳实践或经
據 验
IMPORTANT!
檢查現場或檢查員在船時，第一時
間勇於（禮貌地）質疑缺陷根源，
依據，整改要求
Ask inspector on site before he
leaves: Why/What is the deficiency?
 Negligence/Overlook/Mistake?
People 疏忽疏失 ? 對法規或要求理解認知不
夠

人为 Lack of Safety/Situational Awareness

缺乏安全或情景意识，環保意識等
因素
Without or Fail to Follow the Procedure
缺少或未遵循安全規程或操作规程
Other Lack of Maintenance /Check/Test
缺乏保养 / 检查 / 测试
Factors
Material Defect/Mach. Failure, wear
其它 and tear
材料缺陷 / 设备失效
因素 Bad Weather/Sea Conditions
恶劣天候或海况等
Unknown Factors ，其它未知因素

-- 检讨分析不够深刻？
To dig into depth. 人都會有疏失，
-- 被冤枉的缺陷？ 但不可以經常。
Why it is a deficiency?
-- 找不出原因的缺陷？ Negligent sometimes
Work it out. but not often.
** 有些缺陷，只需要你再對缺陷進行解析，説出你的
認識和理解，也就説明了原因。

** 有些缺陷，可能你之前也已經在關注或整改中，但
是力度不夠，或者需要更高要求，所以導致了缺陷。

** 有些缺陷，當你可以引用相關的法規或標準的要求，
表示你已經認識到其中的不足或偏差……

這些都可以寫在整改報告的缺陷原因分析中。
保養檢查方面 PMS -
maintenance/check

天氣和海況 Weather
and sea condition

產品質量 Quality of the

equipment – purchase
department /supplier
Mooring winch BHC test was conducted by ship on 10‐Jan‐2022
with result 81T, two testing procedures with conflict information
from the company were presented to inspector – one required
60% of mooring rope MBL ,the other was saying 60% of ship design
MBL (actually 90T).

1 沒有遵循最新公司程序或文件

2 對作業程序沒有理解，不熟悉

3 舊的文檔沒有移除，造成誤解
Working aloft permit not enforced whilst setting
up the gangway safety net.
Numerous crew members working aloft without
fall preventive equipment and /or lifejackets.

1 沒有遵循公司安全工作程序

2 個人安全意識不夠；缺少培訓

3 缺少督導（工前會，工作中）
As per vessel records, the portable fire extinguisher located
in emergency fire pump space was inspected by crew on 31-
Mar-2022 and 30-Apr-2022 respectively, but no enclosed
space entry permits for the space were available on board.

1 沒有遵循公司安全工作程序

2 個人安全意識不夠
3 缺少督導（工前會，工作
中）
Mooring winch / windlass hydraulic
oil pipe in forecastle, leaking of
hydraulic oil.
設備保養 -- 是否有保養計劃，是否定期實施
1
2 未遵循檢查程序導致疏漏：到離港前檢查，定期檢查等

3 環保，防污染意識不夠
The navigation stern light fitted on board
was found with visible arc of 225 degrees
instead of 135 degrees.

1 對法規認知不足，導致沒有及早發現

2 新船時各方檢驗的疏漏

3 對船上設備的自我檢查和確認不足
Remotely operated and tested, however an approximate
20mm gap was observed in closed position between the
louvers, on No.1 and No. 2 E/R fan.

1 設備保養，檢查和測試不足

2 對擋板關閉嚴密的法規要求理解不夠

3 公司的技術通函要求沒有貫徹執行
It was observed that stern tube L.O sump tank’s dead-man
weight of a self-closing device was inhibited with waste rag
at open position and the cap on sounding pipe was removed.
(It was rectified immediately after pointed out by inspector).

安全意識不夠
1
2 對測深頭關閉裝置的法規要求理解不夠

3 設備上缺少相關安全警示標識，缺少培訓
Galley fire doors were lashed open.

1 防火安全意識不夠

2 缺少培訓或安全會議上的宣講
3 安全警示標識的張貼和認識
At the time of inspection, the accommodation ladder was unable to be
landed ashore due to crew was not allowed ashore and shore extension
ladder was in use, inspector boarded vessel wearing lifejacket, crew
standby with lifebuoy and sea condition is calm. It is recommended that
the vessel avoid the use of a gangway brow or portable extension
ladder, that is not in apparent good condition, marked with the tare
(unladen) weight, SWL (number of persons) and a valid test date. A risk
assessment be made when using such shore supplied means of access
where the inspection and testing regime is unknown.

檢查員的缺陷描述中其實已經把原因分析了：是
疫情原因，所以不可避免。你同意嗎？