Root Cause Map Maritime Version

Maritime Node No. Maritime Node Name
Current Node: 2,Equipment/Software Issue
1 Structural
2 Machinery/Equipment
3 Outfitting
Current Node: 3,Front-line Personnel Issue
4 Human
Current Node: 4,External Factors
5 External Factors
Current Node: 5,Tolerable Risk
262 Tolerable Risk
Current Node: 6,Cause Cannot Be Determined
19 Other
Current Node: 7,Process/Manufacturing Equipment Issue
2 Machinery/Equipment
Current Node: 8,Software Issue
Not applicable.
Current Node: 9,Material/Product Issue
Not applicable.
Current Node: 10,Utility/Support Equipment Issue
3 Outfitting
Current Node: 11,Other Equipment Issue
1 Structural
Current Node: 12,Company Personnel Issue
10 Permanent/Returning Officers/Crew
11 Newly Assigned/Contract/Temporary Officers/Crew
12 Company Employee
Current Node: 13,Contract Personnel Issue
11 Newly Assigned/Contract/Temporary Officers/Crew
Current Node: 14,Third-party Personnel Issue
13 Other (Third-party Employee)
Current Node: 15,Natural Phenomena
14 Uncharted/Unknown Hazard to Navigation
15 Sea/Weather Condition
Current Node: 16,External Events
18 External Events
Current Node: 17,External Sabotage and Other Criminal Activity
16 Sabotage/Terrorism/War
17 Suicide/Homicide
Current Node: 18,Design Issue
6 Design Problem
20 Design Input/Output
31 Design Review/Verification
Current Node: 19,Design Input Issue
21 Design Input Issue
Current Node: 20,Design Scope Issue
22 Design Scope Unclear
Current Node: 21,Design Input Data Issue
23 Design Input Obsolete
24 Design Input Incorrect
25 Necessary Design Input Not Available
Current Node: 22,Design Output Issue
26 Design Output Issue
Current Node: 23,Design Output Incorrect
28 Design Output Incorrect
30 Design Input Not Addressed in Design Output
Current Node: 24,Design Output Unclear or Inconsistent
27 Design Output Unclear
29 Design Output Inconsistent
Current Node: 25,Design Review/Verification Issue
31 Design Review/Verification
Current Node: 26,No Review/Verification
32 No Independent Review/Verification
Current Node: 27,Review/Verification Issue
33 Review/Verification Issue
Current Node: 28,Equipment Reliability Program Issue
7 Reliability Program Problem
34 Maintenance Program Design
40 Maintenance Program Implementation
Current Node: 29,Equipment Reliability Program Design Issue
7 Reliability Program Problem
34 Maintenance Program Design
Current Node: 30,Critical Equipment Not Identified
37 Critical Equipment/System Not Identified
Current Node: 31,No or Inappropriate Maintenance Selected
35 No Program
36 Program Inadequacy
38 Inappropriate Maintenance Type Applied
Current Node: 32,Risk Acceptance Issue
39 Acceptance Criteria Inadequate
Current Node: 33,Periodic Maintenance Issue
41 Planned Maintenance Issue
Current Node: 34,Scope Issue
43 Scope Issue
Current Node: 35,Frequency Specification Issue
42 Scheduling Issue
Current Node: 36,Implementation Issue
44 Implementation Issue
Current Node: 37,Event-based Maintenance Issue
51 Shore-based Maintenance Issue
Current Node: 38,Scope Issue
54 Scope Issue
Current Node: 39,Event Specification Issue
52 Event Specification Issue
53 Scheduling Issue
Current Node: 40,Monitoring Issue
Not applicable.
Current Node: 41,Implementation Issue
55 Implementation Issue
Current Node: 42,Condition-based Maintenance Issue
45 Condition Monitoring Maintenance Issue
Current Node: 43,Scope Issue
Not applicable.
Current Node: 44,Detection Method Issue
47 Detection Issue
Current Node: 45,Monitoring Issue
46 Scheduling Issue
48 Monitoring Issue
Current Node: 46,Data Interpretation Issue
49 Troubleshooting/Corrective Action Issue
Current Node: 47,Fault-finding Maintenance and Inspection Issue
59 Failure Finding Maintenance Issue
Current Node: 48,Scope Issue
61 Scope Issue
Current Node: 49,Scheduling/Frequency Issue
60 Scheduling Issue
Current Node: 50,Implementation Issue
63 Implementation Issue
Current Node: 51,Corrective Maintenance Issue
56 Corrective Maintenance Issue
Current Node: 52,Troubleshooting/Corrective Action Issue
57 Troubleshooting/Corrective Action Issue
62 Troubleshooting/Corrective Action Issue
Current Node: 53,Repair Implementation Issue
50 Implementation Issue
55 Implementation Issue
58 Repair Implementation Issue
Current Node: 54,Routine Inspection and Servicing Issue
64 Servicing and Routine Inspection Issue
Current Node: 55,Scope Issue
66 Scope Issue
Current Node: 56,Scheduling/Frequency Issue
65 Scheduling/Frequency Issue
Current Node: 57,Troubleshooting/Corrective Action Issue
67 Implementation Issue
Current Node: 58,Documentation and Records Issue
68 Equipment Records
Current Node: 59,Equipment Records and Manuals Issue
69 Equipment Design Records
70 Manufacturer's Manuals
100 Document/Drawing Control Issue
Current Node: 60,Documentation Content Inaccurate or Incomplete
Not applicable.
Current Node: 61,Documents Not Available or Missing
Not applicable.
Current Node: 62,Out-of-date Documents Used
Not applicable.
Current Node: 63,Operational and Maintenance History Issue
71 Equipment Operating/Maintenance History
Current Node: 64,Documentation Content Inaccurate or Incomplete
71 Equipment Operating/Maintenance History
101 Documentation Content Inaccurate or Incomplete
Current Node: 65,Documents Not Available or Missing
71 Equipment Operating/Maintenance History
102 Required Documents Not Available or Missing
Current Node: 66,Out-of-date Documents Used
103 Obsolete Documents Being Used
Current Node: 67,Risk Assessment Records Issue
71 Equipment Operating/Maintenance History
Current Node: 68,Documentation Content Inaccurate or Incomplete
101 Documentation Content Inaccurate or Incomplete
Current Node: 69,Documents Not Available or Missing
102 Required Documents Not Available or Missing
Current Node: 70,Out-of-date Documents Used
103 Obsolete Documents Being Used
Current Node: 71,Personnel Records Issue
184 Training Records System Issue
Current Node: 72,Documentation Content Inaccurate or Incomplete
184 Training Records System Issue
Current Node: 73,Documents Not Available or Missing
102 Required Documents Not Available or Missing
Current Node: 74,Out-of-date Documents Used
186 Training Certificate/Endorsement Expired/Invalid
Current Node: 75,Other Documents and Records Issue
115 Supplier/Contractor Selection Issue
Current Node: 76,Documentation Content Inaccurate or Incomplete
101 Documentation Content Inaccurate or Incomplete
Current Node: 77,Documents Not Available or Missing
102 Required Documents Not Available or Missing
Current Node: 78,Out-of-date Documents Used
103 Obsolete Documents Being Used
Current Node: 79,Material/Parts and Product Issue
105 Vessel Spares/Stores Issue
112 Purchasing Issue
Current Node: 80,Material/Parts Issue
99 Change Not Documented
Current Node: 81,Purchasing Specification Issue
113 Purchasing Specifications Issue
114 Changes to Purchasing Specifications
Current Node: 82,Packaging/Transportation Issue
108 Packaging/Transport Issue
Current Node: 83,Acceptance Criteria Issue
Not applicable.
Current Node: 84,Acceptance Testing Implementation Issue
109 Substitution Issue
111 Inspection on Receipt Issue
116 Receipt Issue
Current Node: 85,Handling and Storage Issue
106 Handling Issue
107 Storage Issue
Current Node: 86,Inventory Level Issue
105 Vessel Spares/Stores Issue
Current Node: 87,Product Control and Acceptance Issue
Not applicable.
Current Node: 88,Product Specification Issue
Not applicable.
Current Node: 89,Product Acceptance Criteria Issue
Not applicable.
Current Node: 90,Inspection Issue
Not applicable.
Current Node: 91,Packaging, Handling, Transportation Issue
108 Packaging/Transport Issue
Current Node: 92,Storage Issue
Not applicable.
Current Node: 93,Inventory Level Issue
Not applicable.
Current Node: 94,Hazard/Defect Identification and Analysis Issue
84 Safety/Hazard/Risk/Security Review Issue
Current Node: 95,Readiness Review Issue
Not applicable.
Current Node: 96,Review Not Performed
Not applicable.
Current Node: 97,Implementation Issue
Not applicable.
Current Node: 98,Change Control Issue
95 Change Control Issue
Current Node: 99,Change Identification Issue
96 Change Not Identified
Current Node: 100,No Change Assessment Performed
97 Change Review Issue
Current Node: 101,Change Assessment Issue
97 Change Review Issue
Current Node: 102,Change Assessment Timing/Implementation Issue
97 Change Review Issue
Current Node: 103,Risk Acceptance Issue
87 Risk Acceptance Criteria Issue
Current Node: 104,Proactive Risk/Safety/Reliability/Quality/Security Analysis Issue
84 Safety/Hazard/Risk/Security Review Issue
Current Node: 105,Analysis Not Performed
79 No/Inadequate Job Safety Analyses
85 Review Skipped or Incomplete
Current Node: 106,Analysis Issue
88 Ineffective Review
Current Node: 107,Recommendation Identification Issue
88 Ineffective Review
Current Node: 108,Recommendation Implementation Issue
86 Recommendations Not Yet Implemented
Current Node: 109,Risk Acceptance Issue
87 Risk Acceptance Criteria Issue
Current Node: 110,Reactive Risk/Safety/Reliability/Quality/Security Analysis Issue
89 Problem Identification/Control Issue
Current Node: 111,Problem/Incident Reporting/Identification Issue
90 Problem Reporting Issue
Current Node: 112,Investigation Issue
91 Problem Analysis Issue
Current Node: 113,Recommendation Identification Issue
93 Corrective Actions Ineffective
Current Node: 114,Recommendation Implementation Issue
94 Corrective Actions Not Implemented
Current Node: 115,Risk Acceptance Issue
Not applicable.
Current Node: 116,Inspection/Audit/Measurement Issue
92 Audit Issue
Current Node: 117,Requirements Not Identified
92 Audit Issue
Current Node: 118,Implementation Issue
92 Audit Issue
Current Node: 119,Recommendation Identification Issue
92 Audit Issue
Current Node: 120,Issue Tracking/Implementation Issue
92 Audit Issue
Current Node: 121,Risk Acceptance Issue
Not applicable.
Current Node: 122,Procedure Issue
80 No/Inadequate Safe Work Practices
120 Procedures
Current Node: 123,Correct Procedure Not Used
121 Not Used
Current Node: 124,No Procedure for Task/Operation
122 No Procedure for Task/Operation
Current Node: 125,Procedure Difficult to Obtain
123 Procedure Not Readily Available or Inconvenient to Obtain
Current Node: 126,Procedure Use Discouraged
Not applicable.
Current Node: 127,Procedure Difficult to Use
Not applicable.
Current Node: 128,Language Issue
124 Language Difficulty
Current Node: 129,Procedure Difficult to Identify
134 Procedure Difficult to Identify
Current Node: 130,Wrong Revision Used
139 Obsolete Version Used
Current Node: 131,Correct Procedure Used Incorrectly
125 Misleading/Confusing
Current Node: 132,Format Inappropriate
126 Format Confusing/Complex/Difficult to Use
Current Node: 133,Confusing/Complex/Difficult to Use
127 Multiple Actions per Step
129 Content Issue
Current Node: 134,More Than One Action Per Step
127 Multiple Actions per Step
Current Node: 135,Inadequate Checklist
128 No Checkoff Space Provided but Should Be
Current Node: 136,Graphics/Drawing Issue
130 Graphics/Drawing Issue
Current Node: 137,Language/Wording Issue
124 Language Difficulty
Current Node: 138,Insufficient or Excessive References
132 Insufficient or Excessive References
Current Node: 139,Too Much/Too Little Detail
133 Too Much/Little Detail
Current Node: 140,Appropriate Procedure Incorrect/Incomplete
135 Wrong/Incomplete
Current Node: 141,Wrong Action Sequence/Ordering
137 Wrong Action Sequence
Current Node: 142,Facts Wrong, Requirements Incorrect, or Content Not Updated
136 Typographical Error
138 Facts Wrong/Requirements Incorrect
Current Node: 143,Inconsistent Procedural Requirements
140 Inconsistency Between Requirements
Current Node: 144,Missing Steps/Content/Situation Not Covered
141 Incomplete/Situation Not Covered
Current Node: 145,Overlap or Gaps Between Procedures
142 Overlap or Gaps Between Procedures
Current Node: 146,Human Factors Issue
143 Human Factors
Current Node: 147,Tools/Equipment Issue
159 Ambient Conditions Issue
Current Node: 148,Appropriate Tools/Equipment Not Used
159 Ambient Conditions Issue
Current Node: 149,Tools/Equipment Not Functioning Properly
159 Ambient Conditions Issue
Current Node: 150,Workplace Layout Issue
165 Workplace Layout
Current Node: 151,Individual Control/Display/Alarm Issue
155 Alarm/Signal Issue
166 Individual Control/Display/Alarm Issue
Current Node: 152,Control/Display/Alarm Integration/Arrangement Issue
167 Control/Display/Alarm Integration/Arrangement Issue
Current Node: 153,Awkward/Inconvenient/Inaccessible Location of Control/Display/Alarm
167 Control/Display/Alarm Integration/Arrangement Issue
168 Awkward/Inconvenient/Inaccessible Location of Control/Display/Alarm
169 Inconsistent/Mirrored Layout
Current Node: 154,Awkward/Inconvenient/Inaccessible Equipment Location
170 Awkward/Inconvenient/Inaccessible Equipment Location
173 Poor Accessibility
174 Inadequate Visibility/Line of Sight
Current Node: 155,Poor/Illegible Labeling of Control/Display/Alarm or Equipment
171 Poor/Illegible Labeling of Equipment or Space
172 Labeling Language Issue
Current Node: 156,Work Environment Issue
158 Work Environment
Current Node: 157,Housekeeping Issue
161 Slippery/Unsteady Work Surfaces
162 Housekeeping Issue
Current Node: 158,Ambient Conditions Issue
159 Ambient Conditions Issue
163 Tool Issue
Current Node: 159,Protective Clothing/Equipment Issue
160 Protective Clothing/Equipment Issue
Current Node: 160,Physical Workload Issue
144 Workload
Current Node: 161,Sustained High Workload/Fatigue
145 Sustained High Workload/Fatigue
Current Node: 162,High Transient Workload
149 High Transient Workload
Current Node: 163,Mental Workload Issue
144 Workload
Current Node: 164,Knowledge-based Behavior Issue
156 Excessive/Complex Calculations Required
157 Knowledge-based Decision Required
Current Node: 165,Rule-based Behavior Issue
Not applicable.
Current Node: 166,Skill-based Behavior Issue
Not applicable.
Current Node: 167,Unrealistic Monitoring Requirement
147 Unrealistic Monitoring Requirements
Current Node: 168,Error Mitigation Issue
175 Intolerant System
Current Node: 169,Errors Not Detectable
176 Errors Not Detectable
Current Node: 170,Errors Could Not Be Corrected/Mitigated
148 Insufficient Time to Respond
177 Errors Cannot Be Corrected/Mitigated
Current Node: 171,Training/Personnel Qualification Issue
178 Training/Personnel Qualifications
193 Emergency Preparedness Training Issue
194 Special Operations Training Issue
Current Node: 172,No Training
179 No Training
181 MS Familiarization Not Provided
Current Node: 173,Decision Not to Train
180 Decision Not to Train
Current Node: 174,Training Need Not Identified
183 Training Need Not Identified
Current Node: 175,Training Requirements Not Completed
182 Training Requirements Not Fulfilled
Current Node: 176,Training Implementation Issue
187 Training Issue
Current Node: 177,Training Program Design/Development Issue
188 Training Program Design/Objectives Issue
189 Content Issue
Current Node: 178,Classroom Training Issue
Not applicable.
Current Node: 179,Laboratory/Practical Training Issue
Not applicable.
Current Node: 180,On-the-job Training Issue
190 On-the-job Training Issue
Current Node: 181,Self Study and Computer-based Training Issue
Not applicable.
Current Node: 182,Continuing Training Issue
192 Continuing Training Issue
Current Node: 183,Training Resources Issue
Not applicable.
Current Node: 184,Qualification Issue
191 Qualification Testing Issue
195 Qualifications Issue
196 No License/Certificate
197 Expired License/Certificate
198 Forged Document
199 Unclear License/Certificate/Endorsement Requirement
Current Node: 185,Supervision Issue
206 Operations/Job Supervision
Current Node: 186,Preparation Issue
207 Preparation
Current Node: 187,Job Plan/Instructions to Workers Issue
209 No Preparation
210 Unclear Instructions to Personnel
Current Node: 188,Ineffective Walkthrough
211 Ineffective Walkthrough
Current Node: 189,Job Scheduling Issue
208 Planning, Scheduling, or Tracking of Work Activities Issue
Current Node: 190,Personnel Selection/Assignment/Scheduling Issue
212 Scheduling/Rotation Issue
213 Personnel Selection/Assignment Issue
Current Node: 191,Responsibility/Authority Issue
200 Responsibility/Authority
201 Responsibility/Authority Not Defined
202 Responsibility/Authority Unclear
203 Ambiguous
204 Conflicting/Overlapping
205 Not Documented
Current Node: 192,Supervision During Work Issue
214 Supervision During Work
218 Fatigue Management Issue
Current Node: 193,Improper Performance Not Corrected
216 Improper Performance Not Corrected
Current Node: 194,Teamwork/Coordination Issue
217 Crew Coordination Issue
219 Ineffective Teamwork
Current Node: 195,Too Much/Too Little Supervision
215 Insufficient Supervision
Current Node: 196,Verbal and Informal Written Communication Issue
220 Communications
Current Node: 197,No Communication or Not Timely
221 No Communications or Untimely
237 Information Not Communicated
238 Information Ignored
Current Node: 198,Method Unavailable or Inadequate
222 Method Unavailable or Inadequate
Current Node: 199,Communication Not Timely/Not Performed
221 No Communications or Untimely
Current Node: 200,Communication Misunderstood/Incorrect
228 Communication Misunderstood/Incorrect
236 Unclear Communications
Current Node: 201,Standard Terminology Not Used
229 Standard Terminology Not Used
239 Ambiguous Information
 
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