Root Cause

Analysis using
ISHIKAWA
Presented by
Capt. Naveen S Singhal
www.jag-dm.com

or
Fish Bone process
Root Cause Analysis (Ishikawa) 1
Root Cause Analysis in Investigation process
Accident Occurs

Collection of evidence: Records, Pics, Statements etc

Analysis of Root Cause

Action taken to prevent recurrence

Root Cause Analysis (Ishikawa) 2

Topics included in the presentation
 Diff between ROOT & Immediate Cause
 Ishikawa process for RCA
 What is an Indicator for Root Cause

Root Cause Analysis (Ishikawa) 3

Difference between Root & Immediate Cause

Direct/Immediate
cause(s) are on-
the-spot causes
that result in an
accident

Root cause
are ‘system’
related failure

Root Cause Analysis (Ishikawa) 4

ISHIKAWA process for RCA

Scenario: Ship Staff enters Enclosed space

without following the Permit to Work and/or
Conducting Risk Assessment
Root Cause Analysis (Ishikawa) 5
 ISHIKAWA process for RCA
Not included in Monitoring of
Internal audit or drills by Office
Inadequately
Suptd Insp not adequate
trained in Encl space drills
Consequences & training not
of non- well conducted
compliance Sr offrs not
Complacency adequately PTW
monitoring procedure
Comm PTW not followed
Work Env
Others M/C Man Entered
Training Enclosed
space
without
Method permit

Monitoring of Crew did not

PTW process by follow PTW
Office not procedure
adequate Immediate
Not included in Crew not aware
Internal audit or that VOID space
Suptd Insp in Encl space Contributory
Procedures do not
specify that VOID
spaces is an Encl Root Cause
space
Root Cause Analysis (Ishikawa) 6
 What is an Indicator for RCA

When a RCA analysis reaches

a point that reflects on the
‘weakness’ in the SYSTEM,
then it can be presumed that
you have reached the Root
Cause of the problem.

What is SYSTEM: Documentation, processes, Check lists, Formats etc

Root Cause Analysis (Ishikawa) 7

Root Cause Analysis (Ishikawa) 8