ANNEX I: FSA/LSA/BC: HAZARD IDENTIFICATION TABLE OF CONTENTresearch.dnv.com/skj/FsaLsaBc/ANNEX-I.pdf · annex 1: fsa/lsa/bc: hazard identification 16/02/2001 annex i, page 1

ANNEX 1: FSA/LSA/BC: HAZARD IDENTIFICATION

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ANNEX I: FSA/LSA/BC: HAZARD IDENTIFICATION

TABLE OF CONTENT

1 INTRODUCTION ........................................................................................................................... 21.1 Purpose..................................................................................................................................... 21.2 Background to the Study.......................................................................................................... 21.3 Objectives of the Study ............................................................................................................ 2

2 HAZARD IDENTIFICATION - STRUCTURED WHAT IF TECHNIQUE (SWIFT) .................. 22.1 SWIFT Protocol used in the study ........................................................................................... 22.2 SWIFT generic checklist.......................................................................................................... 3

3 Sequence of events from initiating event to rescue.......................................................................... 34 SHIP TYPE- Bulk Carrier ............................................................................................................... 45 RESULTS FROM THE BRAINSTORMING SESSION................................................................ 6

5.1 Conventional Lifeboat.............................................................................................................. 65.2 Hazards Specific to Liferafts (Both Types).............................................................................. 85.3 Free – Fall Lifeboats ................................................................................................................ 9

6 List Of HAZARDS identified ........................................................................................................ 116.1 Survival Craft – Generic ........................................................................................................ 116.2 Hazards Specific to Conventional Lifeboats .......................................................................... 156.3 Hazards Specific to Liferafts – Throw Overboard ................................................................. 196.4 Hazards Specific to Liferafts – Davit/Crane Launched.......................................................... 226.5 Survival at Sea until Rescue for Both Liferaft Types............................................................. 256.6 Hazards Specific to Free-Fall Lifeboat .................................................................................. 26

7 RANKING OF HAZARDS ........................................................................................................... 297.1 Frequency Index..................................................................................................................... 297.2 Severity Index ........................................................................................................................ 297.3 Risk Matrix ............................................................................................................................ 307.4 Ranking.................................................................................................................................. 30

8 OBSERVATIONS ......................................................................................................................... 319 SWIFT TEAM & MEETING ........................................................................................................ 32


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1 INTRODUCTION

1.1 Purpose

This annex comprises the hazard identification on Life Saving Appliances (LSA) forbulk carriers, primarily focused on survival craft, carried out in Norway, March 28th –30th, 2000, applying the “Structured What-IF Technique” (SWIFT). The work hasbeen conducted by a project team from Norwegian Maritime Directorate, UmoeSchat-Harding, Norwegian Union of Marine Engineers, MARINTEK and DNV.

1.2 Background to the Study

Since MSC 69 and in the context of bulk carrier safety, IMO/MSC has been dealingwith specific requests of the 1997 SOLAS Conference; with matters arising from theassessors’ report on the survey of the bulk carrier Derbyshire; and, since MSC 70,with a proposal by the United Kingdom to conduct, through a collaborative effortoutside IMO, a relevant FSA study. This hazard identification report is a contributionto the Formal Safety Assessment of Bulk Carriers, carried out in Norway, with theaim of contributing to the international FSA study. The project team has carried out acomplete FSA, the hazard identification being the first step.The report is a concrete response to MSC 71/23 §4.4, “MSC 70 further agreed that theissue of life-saving appliances should also be included in the FSA study”.The project is carried out by Det Norske Veritas (DNV), with active contribution fromthe sponsors of the project, as well as participation from other institutions withspecialist competence on life saving and/or bulk carrier design.The project is sponsored by: DNV, International Transport Workers’ Federation,Norwegian Union of Marine Engineers, Norwegian Shipowners’ Association,Norwegian Maritime Directorate and Umoe Schat -Harding.

1.3 Objectives of the Study

The objective of the HAZID study was to identify hazards relating to Life SavingAppliances for bulk carrier, primarily focused on survival craft. The hazardidentification is carried out as the first step of a Formal Safety Assessment (FSA).Recommendations in this study are therefore meant as recommendations to the latersteps of FSA rather than as final recommendations for decision making (Step 5 ofFSA).

2 HAZARD IDENTIFICATION - STRUCTURED WHAT IF TECHNIQUE(SWIFT)

2.1 SWIFT Protocol used in the study

1. Define sequence of steps in emergency evacuationConsider each step in sequence.


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2. Brainstorm possible hazards, e.g. “What if...?”, “How could...?”List but do not discuss hazards yet.

Once ideas are exhausted, use previous accident experience to check for completeness.

3. Structure the hazards into a logical sequence for discussion.Start with the major ones, so that escalation of initiating ones can be cross-referenced.

4. Consider each hazard in turn.Consider possible consequences if the event occurs.Consider safeguards that are in place to prevent the event occurring.Consider whether additional safeguards are neededRecord discussion on SWIFT log-sheets

5. Reconsider whether any hazards have been omitted, using a generic checklist

6. Explain risk ranking method

7. Carry out risk ranking

2.2 SWIFT generic checklist

• Operating errors and other human factorse.g. crew error, accidents (falls, trapping, trips, access to dangerous areas), illness orinjury, abuse of equipment etc.

• Measurement errorse.g. crew numbers,

• Equipment/instrumentation malfunctione.g. structural failures, equipment failure, control system failure, communication systemerror etc

• Maintenancee.g. dangerous areas, permit systems, control of modifications, mechanical handling,danger to crew etc

• Utility failuree.g. power, air, fire water, communication systems, lighting etc

• Integrity failure or loss of containmente.g. fire, loss of containment

• Emergency operatione.g. evacuation in fire (machinery, cargo area, accommodations area) , drift grounding,powered grounding, capsizing, collision, flooding, cargo related etc

• External factors or influencese.g. weather, other accidents on-board or near to the ship, terrorism etc

3 SEQUENCE OF EVENTS FROM INITIATING EVENT TO RESCUE

The sequence of events in Table 1 was considered a sufficient generic description for allsurvival craft considered (conventional life boat, throw over board life raft, davit/cranelaunched life raft and free fall life boat). Events 1 to 8 are not dependent on survival craft, andhazards have been listed for all. From event 9 onwards the details of the procedures, the


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hazards, the causes and/or the consequences are different. For the throw overboard life raftthe event sequence is also different as boarding is carried out after launching.

Table 1:Sequences of events used in the hazard identificationConventional life boat Life Rafts – Throw

over boardLife Rafts –Davit/Crane Launched

Free fall life boat

1. Initiating event2. Evaluation of

situation3. Decision to muster4. Mustering alarm5. Escape to

mustering station6. Mustering7. Search for missing

persons8. Selection of life

saving appliances

Same Same Same

9. Preparation ofequipment

10. Decision toabandon ship

11. Boarding12. Lowering13. Release14. Clear ship15. Survival at sea16. Rescue



11. Launching12. Boarding13. Clear ship14. Survival at sea15. Rescue



11. Boarding12. Launching13. Release14. Clear ship15. Survival at sea16. Rescue


10. Decision to boardlifeboat

11. Boarding12. Decision to launch13. Release/Launching14. Clear ship15. Survival at sea

(communication)16. Rescue

Some of the terms that were used in the hazard identification may be defined by reference toTable(1):Evacuation corresponds to events 3 to 14. Assembling or mustering corresponds to events 3 to6. Embarkation or boarding correspond to event 11 (12 for throw overboard life rafts).Abandoning corresponds to events 11 to 13.

4 SHIP TYPE- BULK CARRIER

The hazard identification is considered representative for all SOLAS bulk carriers1, with theexception of bulk carriers less than 85 meters with equivalent life saving arrangements. Thehazard identification has been carried out for the four types of survival craft in use:Conventional (open or enclosed) lifeboats, free-fall lifeboat, davit-launched liferafts andthrow over board life rafts. In this context the following should be noted:

For bulk carriers of 1600 gross tonnage and upwards with keel laid before 1- July 1986, thefollowing survival craft arrangements are applicable:

• One lifeboat (open or enclosed) on each side of the ship of such aggregate capacity as willaccommodate all persons on board. (Ref. SOLAS-1974, Ch.III, Regulation 35). Where at

1 Ships above 500 gross tonnage


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least one of the lifeboats shall be motorised. Open lifeboats are also required to beequipped with three immersion suits.

One or more liferafts capable of being launched on either side of the ship and of suchaggregate capacity as will accommodate the total number of persons onboard. (Ref.SOLAS-1974, as amended 1996, Ch.III, Regulation 31.3.1).

• In lieu of meeting the above, bulk carriers of less than 1600 gross tonnage may have anequivalent arrangement consisting of a rescueboat and liferafts (Ref. to various statementsby Flag States).

For bulk carriers, with keel laid on or after 1. July 1986, the following survival craftarrangements are applicable:

• One or more enclosed lifeboats of such aggregate capacity on each side of the ship as willaccommodate the total number of persons on board. (Ref. SOLAS-1974, as amended1983, Ch.III, Regulation 26.1.1).

One or more liferafts stowed in a position providing for easy side-to-side transfer at asingle open deck level, and of such aggregate capacity as will accommodate the totalnumber of persons on board. If not easy transferable from side-to-side on a single opendeck level, then the liferafts capacity available on each side shall be for the total numberof persons onboard. (Ref. SOLAS-1974, as amended 1983, Ch.III, Regulation 26.1.1).

• In lieu of meeting the requirements above, one or more free-fall lifeboats as willaccommodate the total number of persons onboard and capable of being free-falllaunched over the stern of the ship.

One or more liferafts, on each side of the ship, of such aggregate capacity as willaccommodate the total number of persons on board. The liferafts on at least one side shallbe served by launching appliances. (Ref. SOLAS-1974, as amended 1983, Ch.III,Regulation 26.1.2).

• In lieu of meeting any of the above, bulk carriers of less than 85 metres in length mayhave an equivalent arrangement consisting of a rescueboat and liferafts. (Ref. SOLAS-1974, as amended 1983, Ch.III, Regulation 26.1.3).

In the hazard identification a “pre/post 1986” recording has been used to emphasise thefollowing:

• Bulk carriers with keel laid prior to 1. July 1986:

• The lifeboats are normally open.

• Only “off-load” hook was required for the release mechanism of the launchingappliances for the lifeboats.

• Bulk carriers with keel laid on or after 1. July 1986:

• Totally enclosed lifeboats are required.

• Two release capabilities; “off.-load” and “on-load” are required for the releasemechanism of the launching appliances for the lifeboats (except in single fall).


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• Bulk carriers with keel laid after 1. July 1998, SOLAS 1996 Amendments (Recorded as“Post 1998”):

• Two release capabilities; “automatic release when waterborne” and “on-load” arerequired for the release mechanism of the launching appliances for the davit-launchedliferafts.

With reference to above, free-fall lifeboats are optional, and therefore a Risk Control Option(RCO) to be considered in step 3 of the FSA.Bulk carriers with keel laid on or after 1. July 1986 are also required to be equipped with arescue boat. Immersion suites are required for the personnel designated to the operation of therescue boat. This implies that bulk carriers are normally equipped with three immersion suits.As rescue boats and immersion suites are not considered primary Life Saving Appliances, noseparate hazard identification has been carried out. However, the rescue boat of the assistingvessel may be important for a successful rescue operation. It should also be noted thatimmersion suits and adequate training to use them are recorded as a suitable RCO for many ofthe hazards identified.

5 RESULTS FROM THE BRAINSTORMING SESSION

The brainstorming session is carried out without critical comments from the other members ofthe team to the suggested hazards. The team used the identified sequence of events in thebrainstorming, and moving to the next event when the hazards associated with the currentevent were exhausted. Going back to previous events was permitted. The result of thebrainstorming may therefore be somewhat hard to follow for persons not participating in thehazard identification. The result of the brainstorming is included for the sake of completeness.In the hazard identification the fragmented ideas from the brainstorming is sorted out in thefollowing session, when the result of brainstorming are recorded in the hazard forms.

5.1 Conventional Lifeboat

1. Damaged survival craft2. Damaged davit/launch system3. Inaccessible/Lost/Unavailable (e.g. maintenance, repair, replacement) survival craft

and/or davit4. Excessive heel/trim5. Excessive acceleration6. Loss of trained personnel7. Loss of decision maker8. Bad weather9. Green sea10. Lack of/poor maintenance11. Lack of/damaged emergency lighting12. Insufficient time13. Human error14. Human error related to evaluation/decision making15. Human error due to stress16. Premature evacuation17. Lack of information for making a correct decision (e.g. information about ship, situation,

area (open sea/coastal areas), escalation, external resources/other ships, etc.)18. Incorrect information for making a correct decision19. Lack of confirming information20. Confusing/Contradicting information


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21. Too early/False alarms22. Lack of criteria for decision making23. Incompetence/Lack of knowledge24. Faulty/Lack of external communication25. Faulty/Lack of internal communication26. Language difficulties27. Cultural differences28. Insufficient procedures29. Commercial pressure30. Conflict of interests (safety vs. business interruption)31. Reluctance with respect to making decisions (too optimistic, realising danger associated

with evacuation, need for resources in danger limitation activities, human factor, etc.)32. Defect mustering alarm33. Cannot hear mustering alarm (certain locations, noise)34. Lack of redundant warning/alarm system35. Misunderstanding alarm36. Suspect false alarm or drill (delayed or no action)37. Ignoring alarm (e.g. continue rescue/fire fighting)38. Inaccessible alarm initiation (e.g. fire on bridge)39. Blocked escape routes (e.g. toxic fumes, smoke or physical damage)40. Injured/Incapacitated personnel (including panic) – especially master, decision-makers,

designated persons.41. Inadequate emergency lighting42. Insufficient emergency power43. Inadequate procedures/emergency plans44. Inaccessible mustering station45. Lack of alternative escape routes (“replacing complicated escape routes”)46. Long escape routes47. Communication problems at mustering station (e.g. difficult to hear)48. Inadequate procedures for mustering/counting of persons49. Inadequate/Lack of training50. Unprotected mustering area51. Size of mustering area (too small/blocked)52. Mustering at the wrong mustering station (suspect missing persons)53. Communication (mustering stations – bridge)54. Time delay due to search for missing persons (who may be impossible to rescue)55. Incorrect selection of survival craft under the current circumstances (Inadequate

knowledge of survival craft systems or situation)56. Time delay due to decision to change of survival craft57. Time delay, hazard to personnel, equipment error in removing lifeboat cover (if

applicable), fitting bottom plug (if applicable), release lashing, swing-out of davit,lowering to embarkation deck, bowsing (pre 86)

58. Time delay, hazard to personnel, equipment error in releasing lashing and connectingpainter (if applicable) (post 86)

59. Delayed decision due to uncertain outcome preventing successful evacuation60. Faulty decision with respect to abandoning ship (due to incompetence, lack of knowledge,

etc.)61. Risk to personnel during boarding, e.g. injuries, fall into water(pre 86)62. Too crowded in lifeboat (e.g. stretchers, injured personnel, oversized people)63. One or more person left onboard ship during lowering (pre 86)64. Malfunction of winch65. Unintended release of one or both hooks during lowering66. Obstacles during lowering67. Impact from waves


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68. Impact against ship side, i.e. wind, wave, rolling ship (different consequences: pre andpost 86)

69. Excessive time consumption when lowering lifeboat70. Delay/Hazard to lifeboat due to waiting for person left onboard (pre 86) + Hazard to this

person (pre 86)71. Unsuccessful release of hooks (pre 86 (off-load hooks) and post 86 (on-load release of

hooks with hydrostatic sensor))72. Injuries to personnel during hook release (pre 86)73. Unsuccessful release of painter (post 86)74. Forgetting to release painter (post 86)75. Machinery/Rudder/Propeller failure76. Inadequate lifeboat manoeuvring performance77. Capsizing/Flooding of lifeboat (pre 86)78. Failure in releasing skates (if applicable) (post 86)79. Fire at sea80. Stranding of lifeboat81. Malfunction/Lack of alerting and communication system (either by master before

evacuation or by bringing EPIRB)82. Insufficient supply of water, food, medical supplies/equipment, fuel, etc.83. Hypothermia (primarily pre 86)84. Excessive heat/Dehydration/Seasickness85. Risk of injury to personnel during stay in lifeboat and stranding86. Risk of flooding related to rescue/pick up personnel from water87. Inability to pick up persons from the water88. Failure of/Insufficient location/detection signals89. Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e.

insufficient communication, manoeuvrability, training, transfer system)90. Lack of personnel pickup and transfer facilities on assisting vessel91. Faulty or poor design of Life Saving Appliances (including human error prone design)

5.2 Hazards Specific to Liferafts (Both Types)

This sub-chapter corresponds to events 9 to 15 or 16, for throw overboard and davit launchedliferafts, respectively. Hazards 1 to 58 are identical to those listed for conventional lifeboats.

59. Delayed decision due to uncertain outcome preventing successful evacuation60. Faulty decision with respect to abandoning ship (due to incompetence, lack of knowledge,

etc.)61. Time delay, hazard to personnel, equipment error in (davit launched):

• hook-on• releasing liferaft container• swing-out of davit• lowering, lashing• inflation• bowsing

62. Time delay, hazard to personnel, equipment error in (throw over board):• release lashing• secure painter• throw over board• inflate

63. Inflate upside down (throw over board)64. Failure to bowse and secure raft (e.g. due to strong wind, waves, etc.)


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65. Risk to personnel during boarding, e.g. injuries, fall into water (difference between davitlaunched and throw over board)

66. Too crowded in liferaft, e.g. unsuitable for stretchers, injured personnel (especially forthrow over board)

67. Malfunction of winch (davit launched)68. Unintended release of hook during lowering (davit launched)69. Obstacles during lowering (davit launched)70. Impact from waves during lowering (davit launched)71. Impact against ship side, i.e. wind, wave, rolling ship (davit launched)72. Excessive time consumption when lowering (sequence) (davit launched)73. Unsuccessful release of hook (difference between pre and post 98) (davit launched)74. Injuries to personnel/Fall into water during hook release (davit launched)75. Hazard to liferaft during boarding (throw over board)76. Hazards to personnel during embarkation (jump into the water, climbing ladders) (throw

over board)77. Delay/Hazard to liferaft due to waiting for persons left onboard + Hazard to these persons78. Unsuccessful release of painter (throw over board)79. Forgetting to release painter (throw over board)80. Inadequate liferaft manoeuvring performance81. Capsizing/Flooding of liferaft82. Fire at sea83. Stranding of liferaft84. Malfunction/Lack of alerting and communication system (either by master before

evacuation or by bringing EPIRB)85. Insufficient supply of water, food, medical equipment, etc.86. Hypothermia87. Excessive heat/Dehydration/Seasickness88. Risk of injury to personnel during stay in liferaft and stranding89. Risk of flooding related to rescue/pick up personnel from water90. Inability to pick up persons in the water91. Failure of/Insufficient location/detection signals92. Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e.

insufficient communication, manoeuvrability, training, transfer system)93. Lack of personnel pickup and transfer facilities on assisting vessel94. Faulty or poor design of Life Saving Appliances (including human error prone design)95. In connection with free-float function: Malfunction - release and inflation

5.3 Free – Fall Lifeboats

Hazards corresponding to events 9 to 16 are listed. Events 1 to 8 and hazard 1 to 58 areconsidered identical to conventional lifeboat evacuation. For hazards 1 to 3 the hazards maybe listed with the same generic wording, but are different in terms of causes andconsequences

1. Damaged survival craft2. Damaged launching appliance3. Launching zone restricted (e.g. drift grounding, collision)

If was also noted that hazard no 52 does not apply to free-fall lifeboats. Hazards specific toFree-fall lifeboats were recorded for event 9 to 16, starting with hazard no 59 (in agreementwith the previous listing)

59. Size of mustering area (too small/blocked)


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60. Communication (mustering stations – bridge)61. Time delay due to search for missing persons (who may be impossible to rescue)62. Incorrect selection of survival craft under the current circumstances (Inadequate

knowledge of survival craft systems or situation)63. Time delay due to decision to change of survival craft64. Time delay, hazard to personnel, equipment error in releasing lashing (if applicable )65. Delayed decision due to uncertain outcome preventing successful evacuation66. Faulty decision with respect to abandoning ship (due to incompetence, lack of knowledge,

etc.)67. Malfunction of release hook68. Unintended/Too early release of hook69. Hazard to personnel if incorrectly seated (especially to previously injured personnel)70. Hazards due to open hatches71. Obstacles during launching (free-fall and water impact)72. Machinery/Rudder/Propeller failure73. Inadequate lifeboat manoeuvring performance74. Fire at sea75. Stranding of lifeboat76. Malfunction/Lack of alerting and communication system (either by master before

evacuation or by bringing EPIRB)77. Insufficient supply of water, food, medical supplies/equipment, fuel, etc.78. Excessive heat/Dehydration/Seasickness79. Risk of injury to personnel during stay in lifeboat and stranding80. Risk of flooding related to rescue/pick up personnel from water81. Inability to pick up persons in the water82. Failure of/Insufficient location/detection signals83. Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e.

insufficient communication, manoeuvrability, training, transfer system)84. Lack of personnel pickup and transfer facilities on assisting vessel85. Faulty or poor design of Life Saving Appliances (including human error prone design)


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6 LIST OF HAZARDS IDENTIFIED

The hazards are structured into a logical sequence following the sequence of events, so that acontinuous escalation of events may be identified. Also, hazards were grouped together whensimilar, or could have been dealt with by similar risk control options. The numbering issequential. The numbering is not related in any way to the numbering in the previousparagraph. The hazards are ranked individually according to their potential to threaten humanlives. The ranking does not account for the fact that lifeboats are primary and life raftssecondary means of evacuation. The presumption of the ranking is that the survival craft inquestion are used or attempted used.

6.1 Survival Craft – Generic

This sub-chapter represents all survival craft, and corresponds to event #1 to event #8(corresponding to hazards 1 to 58 above). Frequency Indices (FI), Severity Indices (SI) andRisk Indices (RI) are listed in the following order: Conventional Lifeboat Pre 1986,Conventional Lifeboat Post 1986, Throw Overboard Liferaft, Davit/Crane Launched Liferaftand free-fall lifeboat. The ranking was carried out after the complete list of hazards had beenprepared. See Chapter 7 for the definitions of FI, SI and RI.

Hazard definition Damage to/Loss of survival craft and/or davit/launching appliance IDNo

1

Causes Collision, fire, explosion, extreme weather, sabotage, icing FI 4.7/4.74.6/4.73.9

Consequences Not usable survival craft, reduced possibilities to evacuate SI 2.7/4.72.7/2.72.9

Current safeguards Location, design RI 7.4/7.47.3/7.46.7

Recommendations Consider protection of survival craft and area, heating system

Hazard definition Inaccessible/Lost/Unavailable survival craft and/or davit/launchingappliance

IDNo

2

Causes Maintenance, repair, replacement FI 4.3/4.33.9/3.94.0

Consequences Partly or totally unusable SI 2.0/4.32.8/2.82.4

Current safeguards Procedures, Control RI 6.3/6.36.6/6.66.4

Recommendations Consider planned maintenance (vital maintenance done in port)


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Hazard definition Launching zone restricted IDNo

3

Causes Grounding, collision, fire, ice FI 4.1/4.14.4/4.44.0

Consequences Unable to launch, danger if launching SI 2.7/2.72.6/2.62.9

Current safeguards Use other/alternative survival craft(s) RI 6.9/6.97.1/7.16.9

Recommendations Consider immersion suits for all personnel

Hazard definition Excessive heel/trim/acceleration (loads) IDNo

4

Causes Structural damage, extreme weather, cargo shifting, ballastoperations

FI 4.7/4.74.8/4.94.1

Consequences Difficult or impossible to escape/muster and/or launch, loss ofemergency power (lighting)

SI 3.0/3.02.9/2.92.3

Current safeguards Criteria for design of escape routes/muster stations, design ofsurvival craft and launching appliance

RI 7.7/7.77.6/7.76.4

Recommendations Improve legislation, improve design and performance standard of survival craft andemergency power, install survival craft less affected by excessiveheel/trim/acceleration

Hazard definition Loss of trained personnel/decision maker IDNo

5

Causes Injuries/fatalities, incapacitated FI 4.7/4.74.5/4.54.6

Consequences Delayed/lacking/faulty decisions SI 2.4/2.42.6/2.62.0

Current safeguards Substitutes for key persons according to regulations (SOLASIII/37.5) in emergency plans and procedures

RI 7.1/7.17.1/7.16.6

Recommendations Ensure implementation according to the regulation above: muster list and emergencyinstructions (audited/approved, e.g. ISM). Clear authorities/responsibilities,redundancy of trained personnel

Hazard definition Extreme weather/Green seas/Darkness IDNo

6

Causes External circumstances FI 5.6/5.65.6/5.65.0

Consequences Delay mustering/launching or mustering/launching difficulties SI 2.7/2.72.7/2.72.1

Current safeguards Design RI 8.3/8.38.3/8.37.1

Recommendations Protected/Sheltered escape routes, mustering and survival craft areas


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Hazard definition Human error related to evaluation/decision making(untimely/improper decision)

IDNo

7

Causes Stress, reluctance to make decisions (too optimistic, realisingdanger associated with evacuation, need for resources in dangerlimitation activities, etc.), lack of/faulty/excessive (quality of)information (e.g. due to language/culture, faulty/lack ofexternal(SAR)/internal communication, insufficient procedures,earlier false alarms (“cry wolf”), lack of criteria for decisionmaking, incompetence/lack of knowledge)

FI 5.7/5.75.5/5.65.1

Consequences Premature/Delayed/Too late mustering SI 3.4/3.43.1/3.12.7

Current safeguards Training/education, competence, information systems,communication systems, safety culture

RI 9.1/9.18.6/8.77.8

Recommendations Consider training/education with respect to crisis management/knowledge assessmentof ship performance and accident escalation, improve the current safeguards (listedabove), install/improve sensors and alarms (e.g. water filling and filling rate)

Hazard definition Lack of response to general emergency alarm and PA system IDNo

8

Causes Defect or inaccessible alarm system, cannot hear alarm (confinedlocations/noise), misunderstanding alarm, suspect false alarm ordrill, ignoring alarm ( e.g. continue rescue/fire fighting)

FI 5.0(all)

Consequences Intended mustering not initiated or delayed (for some) SI 2.0(all)

Current safeguards Both general emergency alarm and PA system are required RI 7.0(all)

Recommendations Consider fully redundant systems (i.e. remove common critical failures for generalemergency alarm and PA system)

Hazard definition Unable to get to mustering station in time IDNo

9

Causes Blocked escape route (e.g. toxic fumes, smoke, physical damage,water ingress), injured/incapacitated personnel/panic (especiallymaster, decision makers , designated persons), inadequateemergency lighting, insufficient emergency power, inadequateprocedures/emergency plans, inaccessible mustering station, lack ofalternative escape routes (“replacing complicated escape routes”),long escape routes

FI 5.4/5.45.0/5.15.2

Consequences Delayed/No mustering of all personnel SI 2.4/2.42.4/2.42.4

Current safeguards Design standards RI 7.9/7.97.4/7.67.6

Recommendations Consider improved guidance systems (e.g. emergency lighting), escape analysis forimproving design, escape sets (breathing apparatus), improved procedures/emergencyplans


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Hazard definition Delays/Obstacles during mustering (including search for missingpersons)

IDNo

10

Causes Communication problems at mustering station (e.g. difficult tohear)Inadequate procedures for mustering/counting of personsInadequate/Lack of trainingUnprotected mustering areaSize of mustering area (too small/blocked)Mustering at the wrong mustering station (suspect missing persons)Communication (mustering stations – bridge)Time delay due to search for missing persons (who may beimpossible to rescue)Time delay due to decision to change survival craft

FI 5.4/5.45.3/5.35.3

Consequences Further delays of abandoning ship SI 2.6/2.62.4/2.42.3

Current safeguards Design standards and procedures RI 8.0/8.07.7/7.77.6

Recommendations Consider sheltering/protection of mustering area, single mustering station (i.e. reducenumber of mustering stations) with back-up mustering station. Improved and morefrequent/realistic drills, improved procedures, improved communication systems

Hazard definition Incorrect selection of survival craft under the current circumstances IDNo

11

Causes Inadequate knowledge of survival craft systems or situation FI 4.7/4.75.1/5.13.4

Consequences Unsuccessful evacuation SI 3.0/3.02.9/2.93.1

Current safeguards Competence, training and education RI 7.7/7.77.9/7.96.6

Recommendations Consider procedures for identifying primary/most effective mean of evacuation forvarious hazardous scenarios


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6.2 Hazards Specific to Conventional Lifeboats

This chapter contains hazards specific to conventional lifeboats for event #9 to event # 16,corresponding to hazards 59 to 91. Frequency Index, Severity index and Risk index are listedfor pre/post 1986.From hazard no 12 onwards the ID is written as ID No 12.x, 13.x etc. The meaning of x is:1= Conventional lifeboat, 2=Trow overboard liferaft, 3=Davit/Crane launched liferaft,4=Free-fall lifeboat.

Hazard definition Time consuming preparation of survival craft and launchingappliances

IDNo

12.1

Causes Need for removing lifeboat cover (if applicable), fitting bottomplug (if applicable), release lashing, swing-out of davit, lowering toembarkation deck, bowsing (pre 86)Need for releasing lashing and connecting painter (if applicable)(post 86)

FI 6.6/6.1

Consequences Time consuming and possibly further delay of abandoning ship,damage to equipment

SI 2.4/2.0

Current safeguards Drills, procedures RI 9.0/8.1Recommendations Consider equipment that is easier to operate, less time consuming or requires no

preparation, improved drills and procedures

Hazard definition Hazards to personnel during preparation of survival craft andlaunching appliances

IDNo

13.1

Causes Need for removing lifeboat cover (if applicable), release lashing,swing-out of davit, lowering to embarkation deck, bowsing (pre 86)Need for releasing lashing and connecting painter (if applicable)(post 86)

FI 5.7/5.3

Consequences Injuries, fatalities SI 2.1/1.9Current safeguards Drills, procedures RI 7.9/7.1Recommendations Consider equipment that is safer to operate or requires no preparation, improved drills

and procedures, provision of improved immersion suits

Hazard definition Faulty decision to abandon ship (i.e. too early or unnecessary) IDNo

14.1

Causes Lack of competence, lack of knowledge (related to specificsituation), panic, wrong assessment of situation, realisation of timefactor (e.g. time consuming to evacuate)

FI 4.6/4.7

Consequences Unnecessary risk of evacuation, risk to remaining personnel SI 3.1/2.4Current safeguards Qualification and training RI 7.7/7.1Recommendations Consider improved training programs and information systems, consider requiring

survival craft that necessitates less time to evacuate


16/02/2001 Annex I, Page 16

Hazard definition Faulty decision to not abandon ship (i.e. too late) IDNo

15.1

Causes Commercial pressureConflict of interests (safety vs. business interruption)Lack of competence, lack of knowledge (related to specificsituation), apathy, reluctance to make decisions, wrong assessmentof situationDelayed decision due to uncertain outcomeLack of confidence in survival craftTradition (“the ship is the best survival craft”)

FI 6.0/5.7

Consequences Fatalities, wet evacuation (people in water), injuries SI 3.9/3.9Current safeguards ISM (e.g. with respect to avoiding undue commercial pressure and

creating safety culture), qualification and trainingRI 9.9/9.6

Recommendations Consider improved ISM implementation, qualifications and training, providingimmersion suits to all personnel

Hazard definition Time consuming boarding, lowering, release and clear ship IDNo

16.1

Causes Large number of sequences necessaryDelay due to too crowded in survival craft (e.g. stretchers, injuredpersonnel, oversized people)Malfunction of winch and brake release systemObstacles during loweringDelay due to waiting for winch operator left onboard (pre 86)Unsuccessful release of hooks (pre 86 (off-load hooks) and post 86(on-load release of hooks with hydrostatic sensor))Unsuccessful release of painter (post 86)Forgetting to release painter (post 86)Machinery/Rudder/Propeller failureFailure in releasing skates (if applicable) (post 86)

FI 6.4/5.9

Consequences Too short time for safe evacuation, interrupted and/or unsuccessfulevacuation

SI 3.1/3.1

Current safeguards Qualifications and training, design, maintenance, quality ofequipment

RI 9.4/9.1

Recommendations Consider improvement of the current safeguardsConsider less time consuming survival craft and launching appliance


16/02/2001 Annex I, Page 17

Hazard definition Danger to personnel during boarding, lowering, release and clearship

IDNo

17.1

Causes Too crowded in lifeboat (e.g. stretchers, injured personnel,oversized people)One or more person left onboard ship during lowering (pre 86)Malfunction of winchUnintended release of one or both hooks during loweringObstacles during loweringImpact from wavesImpact against ship side, i.e. wind, wave, rolling ship (differentconsequences: pre and post 86)Unsuccessful release of hooks (pre 86 (off-load hooks) and post 86(on-load release of hooks with hydrostatic sensor))Injuries to personnel during hook release (pre 86)Unsuccessful release of painter (post 86)Forgetting to release painter (post 86)Machinery/Rudder/Propeller failureInadequate lifeboat manoeuvring performanceCapsizing/Flooding of lifeboat (pre 86)Failure in releasing skates (if applicable) (post 86)Excessive height (related to sinking ship situation)

FI 6.4/5.7

Consequences Injured personnel, incapacitated key personnel, fatalities, persons inthe water

SI 3.1/3.1


RI 9.5/8.6

Recommendations Consider improvement of the current safeguardsConsider improved protection of people (i.e. enclosed) and less manualoperations/simplified operations, more user-friendly and redundant/more reliablewinch/brakeConsider immersion suits and adequate training to use them for all personnel

Hazard definition Damage to survival craft during boarding, lowering, release andclear ship

IDNo

18.1

Causes Malfunction of winchUnintended release of one or both hooks during loweringObstacles during loweringImpact from wavesImpact against ship side, i.e. wind, wave, rolling ship (differentconsequences: pre and post 86)Unsuccessful release of hooks (pre 86 (off-load hooks) and post 86(on-load release of hooks with hydrostatic sensor))Unsuccessful release of painter (post 86)Forgetting to release painter (post 86)Machinery/Rudder/Propeller failureInadequate lifeboat manoeuvring performanceCapsizing/Flooding of lifeboat (pre 86)Failure in releasing skates (if applicable) (post 86)

FI 5.6/5.3

Consequences Reduction/Loss of sea-keeping and survival capabilities SI 2.9/2.6Current safeguards Qualifications and training, design, maintenance, quality of

equipmentRI 8.5/7.9

Recommendations Consider improvement of the current safeguardsConsider less manual operations/simplified/fewer operations, more user-friendly andredundant/more reliable winch/brakeConsider improving survival craft design (stability, impact protection, etc.)


16/02/2001 Annex I, Page 18

Hazard definition Danger to personnel while in survival craft, until rescue IDNo

19.1

Causes Fire at sea, toxic fumes, smoke, heatBad weather conditions (pre 86), Extreme weather conditions (post86)Stranding of lifeboatInsufficient supply of water, food, medical supplies/equipment,fuel, etc.Exposure to heat/cold weather and waterFlooding related to rescue/pick up personnel from waterInability to pick up persons in the water

FI 6.3/4.9

Consequences Dehydration/SeasicknessInjury to personnel during stay in lifeboat and strandingPersons in the waterHypothermia (primarily pre 86)Water filling of survival craft (primarily pre 86)Fatalities

SI 2.7/1.9


RI 9.0/6.7

Recommendations Consider improvement of the current safeguardsConsider improving survival craft design (stability, impact protection, fire/heatprotection, etc.), consider manual desalinatorConsider providing survival suits

Hazard definition Danger to people (in survival craft) during rescue operation IDNo

20.1

Causes Malfunction/Lack of alerting and communication system (by eitheralerting before evacuation or by bringing EPIRB to survival craft)Failure of/Insufficient location/detection signalsRisk related to transfer to assisting vessel/ helicopter, especially inbad weather (i.e. insufficient communication, manoeuvrability,training, transfer system)Lack of personnel pickup and transfer facilities on assisting vesselFaulty or poor design of Life Saving Appliances (including humanerror prone design)Seasickness and incapacitated personsImpact/collision with assisting vessel

FI 5.7/5.7

Consequences Injury to personnel during pick-up, transfer and treatmentPersons in the waterHypothermiaWater filling of survival craftFatalities

SI 2.9/2.7

Current safeguards Qualifications, procedures and training, design, maintenance,quality of equipment

RI 8.6/8.4

Recommendations Consider improvement of the current safeguardsConsider improving survival craft designConsider improvement of rescue equipment and procedures on assisting vesselConsider providing immersion suits


16/02/2001 Annex I, Page 19

6.3 Hazards Specific to Liferafts – Throw Overboard

This sub-chapter contains hazards specific to throw overboard liferafts for event #9 to event#13, Corresponding to previous hazards >59, but excluding survival at sea and rescue, whichis treated later for both types of liferafts.

Hazard definition Time consuming preparation of liferaft IDNo

12.2

Causes Need for:• release lashing• secure painter• throw over board• inflate• bowse• secure raftLiferaft does not inflate properly or upside down

FI 5.3

Consequences Time consuming and possibly further delay of abandoning ship,damage to equipment

SI 2.4

Current safeguards Training, procedures RI 7.7Recommendations Consider equipment that is easier to operate (e.g. racks), less time consuming or

requires no preparation, improved service control, self-righting liferaft, improveddrills (annual realistic drills prior to re-certification or use dummy-raft for drills) andprocedures

Hazard definition Hazards to personnel during preparation of liferaft IDNo

13.2

Causes Need for (manually):• release lashing• secure painter• throw over board• inflate• bowse• secure raftLiferaft does not inflate properly or upside down

FI 5.1

Consequences Injuries, fatalities, personnel in water SI 2.4Current safeguards Current design, training, procedures RI 7.5Recommendations Consider remote release (operated from bridge/locally)

Consider equipment that is safer to operate or requires no preparation, improvedservice control, self-righting liferaft, improved drills and procedures, provision forimmersion suits


14.2


FI 5.0

Consequences Unnecessary risk of evacuation, risk to remaining personnel SI 2.9Current safeguards Qualification and training RI 7.9Recommendations Consider improved training programs and information systems, consider requiring

liferaft that necessitates less time to evacuate


16/02/2001 Annex I, Page 20


15.2


FI 5.7

Consequences Fatalities, wet evacuation (people in water), injuries SI 3.9Current safeguards ISM (e.g. with respect to avoiding undue commercial pressure and

creating safety culture), qualification and training, free-float liferaftRI 9.6

Recommendations Consider improved ISM implementation, qualifications and training, more reliablefree-float liferaft

Hazard definition Time consuming boarding and clear ship IDNo

16.2

Causes Boarding one by one by ladder or jump into water, then enteringliferaftDelay due to stretchers, injured personnel, incapacitated personnel,oversized peopleUnsuccessful release of paintersForgetting to release painterDifficulties in clearing ship (drift)

FI 5.6


SI 3.1


RI 8.6

Recommendations Consider improvement of the current safeguardsConsider marine escape/slide system personal descent system for boardingConsider less time consuming survival craft

Hazard definition Danger to personnel during boarding and clear ship IDNo

17.2

Causes Boarding one by one by ladder or jump into water, then enteringliferaft (fall into water, impact injuries, exposure to environment)Difficulties due to stretchers, injured personnel, incapacitatedpersonnel, oversized peopleUnsuccessful release of paintersForgetting to release painterDifficulties in clearing ship/drift (remaining at ship side, impacts,fire at sea/fire storm (suction))

FI 6.4


SI 3.1


RI 9.4

Recommendations Consider improvement of the current safeguardsConsider marine escape/slide system or personal descent system for boardingConsider less manual operations/simplified operations, more user-friendlyConsider immersion suits for all personnel


16/02/2001 Annex I, Page 21

Hazard definition Damage to survival craft during launching, boarding and clear ship IDNo

18.2

Causes Obstacles during launchingImpact against ship side, i.e. wind, wave (water filling), rolling shipUnsuccessful release of painterForgetting to release painterImpacts caused by persons jumping overboardNo liferaft manoeuvring performanceCapsizing/Flooding of liferaft

FI 5.5

Consequences Loss of buoyancy, reduction/loss of sea-keeping and survivalcapabilities, loss in fires at sea

SI 3.0

Current safeguards Qualifications and training, design, service, quality of equipment,towing possibilities

RI 8.5

Recommendations Consider improvement of the current safeguardsConsider less manual operations/simplified/fewer operations, more user-friendlyConsider improving survival craft design (damage stability, impact protection, etc.)


16/02/2001 Annex I, Page 22

6.4 Hazards Specific to Liferafts – Davit/Crane Launched

This sub-chapter contains hazards for davit or crane launched liferafts for event #9 to event#14, corresponding to previous hazards >59, but excluding survival at sea and rescue, whichis treated later for both types of liferafts.

Hazard definition Time consuming preparation of survival craft and launchingappliances

IDNo

12.3

Causes Need for release lashing, hook on, swing-out of davit, lowering toembarkation deck, inflation, bowsingNo/insufficient inflation

FI 5.9

Consequences Time consuming and possibly further delay of abandoning ship,damage to equipment, unusable liferaft

SI 2.1

Current safeguards Training, procedures RI 8.0Recommendations Consider equipment that is easier to operate, less time consuming or requires no

preparation, redundant inflation system, improved training/drills and procedures


IDNo

13.3

Causes Need for release lashing, hook on, swing-out of davit, lowering toembarkation deck, inflation, bowsingNo/insufficient inflation

FI 5.3

Consequences Injury to personnel, fatalities, fall into water SI 2.4Current safeguards Training, procedures RI 7.7Recommendations Consider equipment that is safer to operate (e.g. improved davit system) or requires

no preparation, redundant inflation system, improved training/drills and procedures,provision of improved immersion suits, safety harness


14.3


FI 4.8

Consequences Unnecessary risk of evacuation, risk to remaining personnel SI 3.0Current safeguards Qualification and training RI 7.8Recommendations Consider improved training programs and information systems, consider requiring

survival craft that necessitates less time to evacuate


16/02/2001 Annex I, Page 23


15.3


FI 5.8


creating safety culture), qualification and training, free-float liferaftRI 9.5

Recommendations Consider improved ISM implementation, qualifications and training, more reliablefree-float liferaft

Hazard definition Time consuming boarding, lowering, release and clear ship IDNo

16.3

Causes Large number of sequences necessaryDelay due to too crowded in survival craft (e.g. stretchers, injuredpersonnel, oversized people)Malfunction of winch and brake release systemObstacles during loweringDelay due to waiting for winch operator left onboard (pre 86 insome cases/NOR)Premature release of hookUnsuccessful release of hooks (differences between pre 98 (off-loadhooks) and post 98 (on-load release of hooks))Difficulties in clearing ship/drift (remaining at ship side, impacts,fire at sea/fire storm (suction))

FI 5.7


SI 2.9

Current safeguards Qualifications and training, design, service and maintenance,quality of equipment

RI 8.6

Recommendations Consider improvement of the current safeguardsConsider less time consuming survival craft and launching appliance


16/02/2001 Annex I, Page 24

Hazard definition Danger to personnel during boarding, lowering, release and clearship

IDNo

17.3

Causes Exposure to environment/ship motions during boardingLarge number of sequences necessaryToo crowded in survival craft (e.g. stretchers, injured personnel,oversized people)Malfunction of winch and brake release systemObstacles during lowering (puncture of liferaft, overturning)Impact during loweringPremature release of hookUnsuccessful release of hook (differences between pre 98 (off-loadhook) and post 98 (on-load release of hook))Difficulties in clearing ship/drift (remaining at ship side, impacts,fire at sea/fire storm (suction))Excessive height (related to sinking ship situation)

FI 6.2

Consequences Injured personnel, incapacitated key personnel, fatalities, persons inwater, loss in fires at sea

SI 3.2


RI 9.4

Recommendations Consider improvement of the current safeguardsConsider improved protection of people and less manual operations/simplifiedoperations, more user-friendly and redundant/more reliable winch/brakeConsider immersion suits for all personnel

Hazard definition Damage to survival craft during boarding, lowering, release andclear ship

IDNo

18.3

Causes Unsuccessful release of bowsingForgetting to release bowsingMalfunction of winchUnintended release of hook during loweringObstacles during loweringImpact from wavesImpact against ship side, i.e. wind, wave, rolling shipUnsuccessful release of hook (pre 98 (off-load hook) and post 98(on-load release of hook))No manoeuvring performanceCapsizing/Flooding of liferaft

FI 5.1

Consequences Reduction/Loss of sea-keeping and survival capabilities, loss infires at sea

SI 3.0


RI 8.1

Recommendations Consider improvement of the current safeguardsConsider less manual operations/simplified/fewer operations, more user-friendly andredundant/more reliable winch/brakeConsider improving survival craft design (damage stability, impact protection, etc.)


16/02/2001 Annex I, Page 25

6.5 Survival at Sea until Rescue for Both Liferaft Types

The ranking is for throw overboard and davit launched liferafts, respectively


19.219.3

Causes Fire at sea, toxic fumes, smoke, heatBad weather conditionStranding of liferaftInsufficient supply of water, food, medical supplies/equipment, etc.Exposure to heat/cold weather and waterFlooding related to rescue/pick up personnel from waterInability to pick up persons in the waterCapsize and flooding

FI 5.65.7

Consequences Dehydration/SeasicknessInjury to personnel during stay in liferaft and strandingPersons in the waterHypothermiaWater filling of survival craftFatalities

SI 2.92.9


RI 8.48.6

Recommendations Consider improvement of the current safeguardsConsider improving survival craft design (stability (sea-anchor), fire/heat protection,personal protection equipment (immersion suits) to all personnel, etc.), providemanual desalinatorConsider providing immersion suits


20.220.3

Causes Malfunction/Lack of alerting and communication system (by eitheralerting before evacuation or by bringing EPIRB to survival craft)Failure of/Insufficient location/detection signalsRisk related to transfer to assisting vessel/ helicopter, especially inbad weather (i.e. insufficient communication, lack ofmanoeuvrability, training, transfer system)Lack of personnel pickup and transfer facilities on assisting vesselFaulty or poor design of Life Saving Appliances (including humanerror prone design)Seasickness and incapacitated personsImpact/collision with assisting vessel (rupture of liferaft)Capsize due to down-wind from helicopterNot possible to tow to sheltered waters/long distances

FI 5.25.4


SI 2.62.6

Current safeguards Qualifications, procedures and training, design,service/maintenance, quality of equipment

RI 7.87.9

Recommendations Consider improvement of the current safeguardsConsider improving survival craft design (including stability)Consider improvement of rescue equipment and procedures on assisting vesselConsider providing immersion suits


16/02/2001 Annex I, Page 26

6.6 Hazards Specific to Free-Fall Lifeboat

This sub-chapter lists hazards for free-fall lifeboats, corresponding to event #9 to event #16.

Hazard definition Time for preparation of survival craft and launching appliances (ifapplicable)

IDNo

12.4

Causes Need for releasing lashing (if applicable) FI 4.1Consequences Possible delay to abandoning ship SI 1.4Current safeguards Training/Drills, procedures (related to lashings, re-installation,

maintenance)RI 5.6

Recommendations Consider equipment that has no need for preparation, improved training/drills andprocedures


IDNo

13.4

Causes Need for releasing lashing (if applicable) FI 4.3Consequences Injury of personnel SI 1.3Current safeguards Training/Drills, procedures (related to lashings, re-installation,

maintenance)RI 5.6

Recommendations Consider equipment that has no need for preparation, consider improvedtraining/drills and procedures, providing immersion suits


14.4

Causes Lack of competence, lack of knowledge (related to specificsituation), panic, wrong assessment of situation, realisation of timefactor (e.g. time necessary to evacuate)

FI 4.3

Consequences Unnecessary risk of evacuation, risk to remaining personnel SI 1.7Current safeguards Qualification and training, possibility of boarding before decision

to abandon shipRI 6.0

Recommendations Consider improved training programs and information systems, installation of remotecontrol of ship giving enhanced possibility of boarding before decision to abandonship, improved procedures for boarding before decision to abandon ship


15.4


FI 4.7


creating safety culture), qualification and trainingRI 8.3

Recommendations Consider improved ISM implementation, qualifications and training, providingimmersion suits to all personnel


16/02/2001 Annex I, Page 27

Hazard definition Time consumed during boarding, release and clear ship IDNo

16.4

Causes Need for proper seating and securing personnelDelay due to too crowded in survival craft (e.g. stretchers, injuredpersonnel, oversized people)Malfunction of hook

FI 4.3


SI 2.7


RI 7.0

Recommendations Consider improvement of the current safeguards, redundancy in provision for trainedkey personnel

Hazard definition Danger to personnel during boarding, release and clear ship IDNo

17.4

Causes Too crowded in lifeboat (e.g. stretchers, injured personnel,oversized people)Unintended release of hook during boardingObstacles during water impactExcessive accelerations (e.g. injured personnel, improperly securedpersonnel)Unsuccessful release of hookExcessive height and rotation (related to sinking ship situation)

FI 4.1


SI 2.1


RI 6.3

Recommendations Consider improvement of the current safeguardsConsider improved protection of peopleConsider immersion suits for all personnelConsider redundancy in provision of trained key personnel

Hazard definition Damage to survival craft during boarding, release and clear ship IDNo

18.4

Causes Obstacles during water impactExcessive height and rotation (related to sinking ship situation)

FI 3.1

Consequences Reduction/Loss of sea-keeping and survival capabilities SI 2.6Current safeguards Qualifications and training, design, maintenance, quality of

equipmentRI 5.6

Recommendations Consider improvement of the current safeguardsConsider improving survival craft design (damage stability, impact protection, etc.)


16/02/2001 Annex I, Page 28


19.4

Causes Fire at sea, toxic fumes, smoke, heatExtreme weather conditionsStranding of lifeboatInsufficient supply of water, food, medical supplies/equipment,fuel, etc.Exposure to heat/cold weather and waterFlooding related to rescue/pick up personnel from waterInability to pick up persons in the water

FI 4.7

Consequences Dehydration/SeasicknessInjury to personnel during stay in lifeboat and strandingPersons in the water(Hypothermia)(Water filling of survival craft)Fatalities

SI 1.9


RI 6.6

Recommendations Consider improvement of the current safeguardsConsider improving survival craft design (damage stability, impact protection,fire/heat protection, etc.), provide manual desalinator, immersion suits for allpersonnel


20.4

Causes Malfunction/Lack of alerting and communication system (by eitheralerting before evacuation or by bringing Emergency PositionIndicating Radio Beacon (EPIRB) to survival craft)Failure of/Insufficient location/detection signalsRisk related to transfer to assisting vessel/ helicopter, especially inbad weather (i.e. insufficient communication, manoeuvrability,training, transfer system)Lack of personnel pickup and transfer facilities on assisting vesselFaulty or poor design of Life Saving Appliances (including humanerror prone design)Seasickness and incapacitated personsImpact/collision with assisting vessel

FI 5.3


SI 2.4

Current safeguards Qualifications, procedures and training, design, maintenance,quality of equipment

RI 7.7

Recommendations Consider improvement of the current safeguardsConsider improving survival craft designConsider improvement of rescue equipment and procedures on assisting vesselConsider providing immersion suits


16/02/2001 Annex I, Page 29

7 RANKING OF HAZARDS

This chapter is a special version of a ranking procedure prepared for the hazards associatedwith abandoning ships by use of survival crafts. Hazards are ranked according to theircontribution to the risk. Hazards are ranked individually, implying that adding the risk wouldoverestimate the total risk in cases where the potential accident scenarios have many “events”in the associated event tree. Adding the risk could underestimate the risk in cases where thesame hazard contributes in many different potential accident scenarios.It is thus observed that ranking individual hazards is no substitution for risk analysis. It is justa fast way of agreeing in the HAZID team on a qualitative ranking of the hazards according totheir potential to cause harm to people, property and the environment. In the case of LifeSaving Appliances only the potential to cause harm to (or not saving) people are considered.This chapter provides notes for the risk ranking element of a Structured What-If Checklist(SWIFT) review.

7.1 Frequency Index

Frequency is commonly defined as the number of events per time unit (e.g. annual). In thecase of Life Saving Appliances this is not a practical measure. The definition used is thereforethe number of occurrences per event (the number of occurrences each time evacuation isnecessary)

Table(2): Definition of frequency index (FI)FI FREQUENCY DEFINITION F

(perevacuation)

7 “Sure” Will happen almost every time ≈16 Frequent Happen in one of 10 times 0.15 Reasonably probable Happens in one of 100 times 0.013 Remote Happens in one of 10.000 times

(If tried on all ships it would happen in one case)10-4

1 Extremely remote Happens in on of a million times 10-6

This scale converts to annual frequencies as used in MSC 72/16 assuming 10 eventsannually.

7.2 Severity Index

The following severity index is used

Table(3): Definition of severity (consequence) index (SI)SI SEVERITY EFFECTS ON HUMAN SAFETY S

(fatalities)1 Minor Single or minor injuries 0.012 Significant Multiple or severe injuries 0.13 Severe Single fatality or multiple severe injuries 14 Catastrophic Multiple fatalities 10


16/02/2001 Annex I, Page 30

The severity index should correspond to the most likely scenario where the hazard in questionresults in an accident.By deciding to use a logarithmic scale the Risk index for ranking purposes may be calculatedas

RI = FI + SI

E.g. An event rated “remote” (FI=3) with severity “significant” (SI=2) would have RI=5

7.3 Risk Matrix

The risk matrix (risk indices in bold) used is therefore:

Table(4): Risk MatrixSEVERITY (SI)

1 2 3 4FI FREQUENCY Minor Significant Severe Catastrophic7 “Sure” 8 9 10 116 Frequent 7 8 9 105 Reasonably probable 6 7 8 94 5 6 7 83 Remote 4 5 6 72 3 4 5 61 Extremely remote 2 3 4 5

Risk reduction options affecting hazards with higher RI are considered most desirable.

7.4 Ranking

All hazards were ranked individually by each member of the team (excluding thefacilitator and recorder). An average risk index was estimated for each hazard.The resulting ranking based on the sum of the risk indices was (highest risk first):Conventional lifeboat pre 1986, conventional lifeboat post 1986, throw over boardliferafts, davit/crane launched liferafts, free-fall lifeboats.Individual risk ranking was transferred to the hazard log-sheets.

The main result of the ranking is listed in Table(5).


16/02/2001 Annex I, Page 31

Table(5) : Result of rankingID Conventional

LifeboatPre 86

ConventionalLifeboatPost 86

ThrowOverboard

Liferaft

Davit/CraneLaunchedLiferaft

FreeFall

Lifeboat1 7.4 7.4 7.3 7.4 6.72 6.3 6.3 6.6 6.6 6.43 6.9 6.9 7.1 7.1 6.94 7.7 7.7 7.6 7.7 6.45 7.1 7.1 7.1 7.1 6.66 8.3 8.3 8.3 8.3 7.17 9.1 9.1 8.6 8.7 7.88 7.0 7.0 7.0 7.0 7.09 7.9 7.9 7.4 7.6 7.6

10 8.0 8.0 7.7 7.7 7.611 7.7 7.7 7.9 7.9 6.612 9.0 8.1 7.7 8.0 5.613 7.9 7.1 7.5 7.7 5.614 7.7 7.1 7.9 7.8 6.015 9.9 9.6 9.6 9.5 8.316 9.4 9.1 8.6 8.6 7.017 9.5 8.9 9.4 9.4 6.318 8.5 7.9 8.5 8.1 5.619 9.0 6.7 8.4 8.6 6.620 8.6 8.4 7.8 7.9 7.7

The ID numbers (1-20) are identical to the Hazard ID in the hazard listing in Chapter 6

8 OBSERVATIONS

• The hazard identification left an impression of a possibility for identifying cost effectiveRCOs related to rescue phase

• The hazard identification resulted in a focus on decision making (the decision to musterand in particular the decision to abandon the ship)

• The decision of abandoning the ship is very dependent on quality of survival craft andsafety culture. If the crew is properly trained and trusts the safety of the survival craft, thedecision of abandoning ship is made easier.

• Some participants developed a scepticism towards the use of liferafts• The human factor specialist observed that human factors were naturally integrated in

discussions, including human and technical factors interface• The designer in the team observed that the many dangers during boarding, lowering,

release and clear ship corresponds to issues considered important during design. Thepressure to cut cost results in non-optimum solutions.

• Closed lifeboats require training and limit the individualist behaviours. Individualisticbehaviour and individual control of the situation is a strong incentive for many.

• The members of the hazard identification team represent different stakeholders. It wasnoted that the hazard identification resulted in clarification of responsibilities andunderstanding of the regulations.

• Immersion suits to all personnel should be considered


16/02/2001 Annex I, Page 32

9 SWIFT TEAM & MEETING

The hazard identification has been carried out in accordance with the IMO ‘INTERIMGUIDELINES FOR THE APPLICATION OF FORMAL SAFETY ASSESSMENT (FSA)TO THE IMO RULE MAKING PROCESS’

The team carried out the HAZID in a three day SWIFT meeting at the Det Norske Veritasoffice at Høvik (Oslo) March 28th – 30th, 2000. The planning was carried out by the chairmanand facilitator prior to the meeting.

The members of SWIFT team were selected to represent all competence areas relevant to thehazards presented.

Members:

1. Mr. P. Brinchmann, Umoe Schat-Harding AS, Life boat and Davit design2. Mr. P. Werenskiold, Life Raft Design (etc.)3. Mr. T. Trygve Scheel, NMD, Regulations4. Capt. Ø. Holte, Senior Surveyor5. Mr. F. Gross, Marine Engineer6. Mr.H. Andersen, Chief Engineer7. Mr. S. Gaarder, Psychologist8. Facilitator: Dr. R. Skjong9. Recorder: Ms. B. H. Wentworth

Short CVs may be found in ANNEX VII

Documents

ANNEX I: FSA/LSA/BC: HAZARD IDENTIFICATION TABLE OF CONTENTresearch.dnv.com/skj/FsaLsaBc/ANNEX-I.pdf · annex 1: fsa/lsa/bc: hazard identification 16/02/2001 annex i, page 1