OPTIMISM Training Platform

A review of accidents done by De Melo Rodriguez et al (2024) led to identifying root causes of and contributing factors to accidents at sea. As shown in figure 2.1., this taxonomy breaks down causes into five main domains: Quality Assurance (QA) Errors, non-QA Errors (Mistake), System Work Environment Errors, Nature, and Psychological/Physiological/Behavioural (PPS) Factors. Each of these categories is broken down into specific areas such as policy failures, procedural lapses, supervisory issues, and operational or personal vulnerabilities. For example, QA errors are often associated with inadequate documentation, poor planning, or missing procedures, while non-QA mistakes frequently arise from personal or leadership shortcomings. By mapping out these interconnected causes, the C4FF taxonomy enables a holistic understanding of how safety breakdowns occur and where preventive interventions can be most effective.

Figure 2.1. Root Causes of Accidents (Source: M’aider 2010, ACTs 2015 and ACTS Plus 2017 & OPTIMISM 2024 – www.mairfuture.org).

A - Work Environment

1. Lack of visibility, excessive noise or vibration, hot/cold working environment, bad weather, sudden movements.

2. Inappropriate work environment/ergonomics, poor human–machine interface, automation issues, maintenance and equipment misfunctions.

3. Inadequate system design

4. Issues with procurement/purchasing

B - Personal

1. Inadequate personal fitness

2. Inadequate mental fitness (including bullying and harassment)

3. Inadequate Knowledge

4. Inadequate competence/skills

5. Lack of motivation or complacency

6. Ineffective communication, language differences, non-standard (Non SMCP) or complex communication and the impact of differences in rank.

7. Poor team operation, working towards different goals, no cross-checking, no means of reporting or speaking-up, no quality circles.

8. Incorrect perception, motion illusion, visual pretention/illusion and the misperception of changing environments or instruments. 

9. Lack of focus/incorrect awareness leading to misinterpretation of the operation by a crew member – lack of attention, confusion, distraction, discoordination, stress/poor mental perception.

10. Forgetfulness, inaccurate recall or using outdated information.

C - Leadership

1. Inadequate leadership and personnel management, including no personnel measures against regular risky behaviour, a lack of feedback on safety reporting, no role model and personality conflicts.

2. Inadequate risk assessment, inadequate team composition, inappropriate pressure to perform a task and a directed task with inadequate qualification, experience or equipment.

3. Inadequate leadership of operational tasks, including a lack of correction of unsafe practices, no enforcement of existing rules, allowing unwritten policies to become standards and directed deviations from procedures.

4. Inadequate manning (intentional or unintentional disregard for the guidelines).

D - Organizational

1. Inappropriate policy manual

2. Inappropriate/inadequate procedures

3. Inadequate supervision

4. Problems with safety culture, lack of culture of reporting, learning or just culture, social and status barriers causing misunderstandings.

5. Unsuitable documented policy or procedures, limitations of proactive risk management, reactive safety assurance, lack of safety promotion and training

6. Insufficient resources for safe operations, including personnel, budgets, equipment, training programs, operational information and lack of operational manual of ship installations.

7. Commercial Pressures, business and competition affecting safety, including relations with contractors, trade pressure to keep the plans and costs.