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Using the developed taxonomy (De Melo Rodrguez, G., et al. 2024) as shown in figure 2.1., 25 top root causes and contributing factors to accidents were identified. As shown in table 1, the analysis of 40 case studies from a pool of over 200 maritime accidents revealed recurring patterns in non-conformities and deficiencies observed in both ISM Code audits and Port State Control (PSC) inspections.

In tables 1 and 2, it is interesting to note that the majority of safety issues are QA related while non-QA plays a major role either as the main root cause of accidents or as a contributing factor to it. In almost all cases there were deficiencies due to Human Vulnerabilities, Decision Making and Communication. In almost half of the accidents, it was noted that knowledge/skills/competence to be an issue. This clearly indicates that quality assurance of shipping companies is a problem area needing attention. 

Table 1 - The First Set of Micro Analysis of Accident Reviews

Table 2 - The Second Set of Micro Analysis of Accident Reviews

A review of table 1 shows the leadership concern, "Inadequate risk assessment, inadequate team composition, inappropriate pressure to perform a task and a directed task with inadequate qualification, experience or equipment." was discovered to be the main reason for mishaps.

The analysis revealed that in the majority of accidents, three key areas were consistently the main cause or a primary contributing factor: leadership, supervision, and person-to-person communication. Table 3 below presents the full taxonomy of the 25 root causes and contributing factors, grouped by category, that were identified and used for the analysis. Effective communication is still a major cause or contributing factor to accidents and incidents at sea. In a study carried out by Ziarati (2008), it was established that one third of the accidents are caused or impacted by poor linguistic deficiencies

Table 3. Taxonomy of the Top 25 Root Causes and Contributing Factors to Accidents