Root Cause Investigation & Corrective Action Worksheet Step 1- The Fishbone Method Describe the incident: Equipment & Maintenance Attitude & Behavior Training Management Support Policies & Procedures Contributing Factor #1 Contributing Factor #2 Contributing Factor #3 Double click on any shape and start typing to add or change text. Then save as pdf or ppt. List the two most likely root causes: ** A Separate RCA and CAP is required for EACH Non-Conformity! Page 1 of 4

List the first most likely root cause from Step 1: Why did the condition exist? Because… Why…?Because… Why…?Because… Why…?Because… Why…?Because… Root Cause Investigation & Corrective Action Worksheet Step 2- The 5 WHY Method List the second most likely root cause from Step 1: Why did the condition exist? Because… Why…?Because… Why…?Because… Why…?Because… Why…?Because… Page 2 of 4

Instructions: Complete and these worksheets to within 30 days of the identification of the Non-Conformity (NC). Attach a copy of this file and other relevant documents to the CAR in Vessel or Facility:CAR# in NS5: NC identified by:___Internal audit ___External audit ___ Incident ___Other Person Responsible for Implementation: (Master or Facility Mgr.) Root Cause Investigation & Corrective Action Worksheet Step 3- The Corrective Action Plan (CAR) KEY DATES NC IdentifiedCAP Due (30 days) CAP turned in to DPA on: (30 days) Implement by: (90 days) Implemented on: (90 days) Correction Completed A. Briefly state the non-conformity B. Root Cause Page 3 of 4

Root Cause Investigation & Corrective Action Worksheet Step 3- The Corrective Action Plan (CAR) cont’d C. Corrective Action Plan to prevent recurrence List the CAP steps that will be taken with responsible persons and due dates. Page 4 of 4 Steps to prevent recurrencePerson ResponsibleDue Date