Incident Investigation and Practical Risk Assessment

Marine Risk
Management
DNV Training
Course Contents
Morning session (starts 08.30):
 Causes of Incidents
 Loss Causation Model; MSCAT ©DNV
 Investigation & Risk Evaluation
 Analysis; Fact Tree method
 Practical Case Incident Investigation (1)
Afternoon session (ends at 17.00):
 Practical Case Incident Investigation (2)
 Risk Assessment Hazards & Risk; RA tools
 Fault tree method, J.S.A and Toolbox
 Practical Case Risk J.S.A
Version 08/02/2018 Slide 2

Risk management
Risk
Measures
Causes
Incidents

Definitions
 Accident: Undesired occurrence with actual loss

 Incident: Undesired occurrence with actual loss or loss potential
 Near Miss: Undesired occurrence with loss potential
 (All Incidents= All Accidents + All Near Misses)
 Loss The actual impact in terms of life, health, environment or
property

What causes Incidents?
 Human Failure (99%)
 Act of God – 1%

Human Error
 Aware: non compliance with (safety) standards
 Unaware: involuntarily not applying (safety) standards
 Unaware: Risk not identified (no standards available)
But Nobody wants an accident!

An Important Fact of Life
 Human Error cannot be avoided; we all make mistakes

- Compare: The rain cannot be avoided
 Human Error can be managed

- Compare: You can use an umbrella and avoid getting wet
 Build barriers to deal with:

- Violation producing factors
- Error producing factors
- Compare: An umbrella is a barrier against the rain
 If still an accident occurs, investigate why we (wrongly) assumed the

barriers were o.k. and improve these
- Compare: If there is also a storm, an umbrella may not be enough; additional protection –
like a rain coat- is needed

Human Failure: at what
level?
1.Direct Causes
2. Basic Causes or:

Internal Factors
3.Root Causes/” System”
4.”Soil Causes”- or
External Factors
Case
 John –a 2nd Engineer- joined a vessel he did not know, although he sailed
on similar vessels (different type)
 There was a low retention rate in the fleet (long contracts)
 Once on board, he was shown around by the 3rd mate (safety
familiarization)
 Due to shorthanded staff and a lot of activities going on simultaneously
(stores, bunkers, crew-change, inspections and surveys), the situation was
somewhat hectic.
 The Chief Engineer told John to take care of bunkering, but forgot to tell him
about the weird and confusing marking of the valves (P 3 was on the side of
SB valves, not clearly marked)
 John prepared the lines and informed the barge to start pumping at a low
rate; as soon as pumping started an overflow occurred of a tank, which was
already full. John erroneously had opened the wrong tank.

Example:
 Incident: Oil spill during bunkering
 Direct Cause: John opened wrong valve
 Basic Cause 1: Not familiar with this vessel
 Basic Cause 2: Confusing lay out of valves
 Basic Cause 3: Improper Planning of work
 Basic Cause 4: Lack of supervision
 Root Cause 1: Inadequate familiarization System
 Root Cause 2: Inadequate Policy regarding hardware deficiencies
 Root Cause 3: Inadequate Safe Manning policy
 Root Cause 4: Inadequate HRM (high turn over)
 Soil Factor 1: Shortage of competent/ qualified seafarers.
 Soil Factor 2: Business pressure/ competition
Note: Soil Factors are no excuse; just challenges

DNV Loss Causation model
Barriers
LOSS
Policies
Sub-
Job
Controls Standard
Factors
Acts/
Practices
Personal
Factors
Inadequate Sub-
Standard
Program Conditions
Standards
Compliance

Immediate (“Direct”) Causes (MSCAT)
 SUB-STANDARD ACTS/PRACTICES (= BEHAVIOUR), examples:
- Failure to follow Rules or Regulations
- Improper lifting
- Removing safety devices
- Using defective equipment
- Using equipment improperly
- Improper position for task
- Etc.
 SUB-STANDARD CONDITIONS , examples:
- Defective tools, equipment and materials
- Inadequate ventilation
- Wet/slippery surface
- Inadequate guards or barriers
- Poor housekeeping, disorder
- Outdated charts, publications and other documentation
- Incorrect/inadequate tools, equipment and materials
- Etc.

Basic Causes: Personal Factors
 Inadequate Physical capabilities

 Inadequate Mental capabilities
 Physical stress
 Emotional stress
 Lack of Knowledge
 Lack of Skill
 Improper Motivation
 Personality and Attitude

Basic causes: Job Factors
 Inadequate Organization/ delegation/ instruction
 Inadequate Planning/ Preparation
 Inadequate Leadership-Supervision
 Inadequate Equipment/ tools
 Inadequate Engineering, Design
 Inadequate Maintenance
 Inadequate purchasing
 Inadequate work standards
 Excessive wear and tear
 Inadequate assessment of Loss Exposures/ Needs/ Risks

Root Causes
 Shortcomings of the (Safety) Management “System” (Policies and
Standard Practices)
 Strong relationship with Basic Causes
 The System contains “Controls” , which may fail to ensure the
desired effect
 Controls are at the level of Policies, Procedures and Instructions
 Incidents are evidence of inadequacy of controls
Examples:
Inadequate recruitment policy; Excessive documentation; Bureaucratic
organization of work; poor communication ship-shore
Key word: Policy / Policies

Reporting of Incidents

Accidents and Incidents
1 Major Injury/Fatality
10 Slight Injury
Only Material damage

30
Near Miss cases
600
What Incidents to Analyse?
 Major Loss
 Major Potential Loss
 Repetitive
In Other Words: “Significant”

Apply Risk Evaluation

PROBABILITY/ FREQUENCY
Highly Unlikely Possible Likely Highly Likely
Unlikely
5% 15% 35% 75% 95+%
Low Risk/ acceptable Never Occurred in Occurs in Occurs in Predicted to

occurred in Industry Industry Industry occur
Industry once &/or &/or during
Medium Risk over> 5 during last Company Company course of
years 5 years Annually X the work
High Risk/ unacceptable times/year
Health/ Assets Others 1 2 3 4 5
Injury Environm.
Reputation
A No Injury No Asset No Impact
(Scratch- Damage
S type)
B First Aid Damage Spill <5ltr

E Medical
Treatment
<X$ Local reputa-
tion impact
V C Lost Time Damage Spill <50 ltrs

Injury < 10X $ Regional
E coverage
R D Permanent
Disability
Damage
< 20X $
Spill <500 ltrs
National
I media
coverage
T E Single
Fatality
Damage
< 50X $
Spill >500 ltrs
National
Y Headlines
F Multiple Damage Catastrophic

fatality > 50X $ Spill Coverage
Internationall
y

Fact finding

Investigation: step 1
PEOPLE :
 No prosecution, no-blame, fact finding
 A.S.A.P: and avoid groups
 “Active listening” (avoid “why”; follow the event tree approach:
“what was needed for this etc”)
POSITION:
 Equipment, valves, set points, switches etc.
PARTS:
 Condition/ presence of equipment, illumination, spills, state of
housekeeping…
PAPER:
 Recordings, permits, signatures…
Fact tree analysis
 Collecting Facts
• Schematic structure of the tree by asking every time

the following questions:
• What was needed?
• Was this necessary? (failure of “standard” Barriers)
• Was this enough?

“Needed”:
 For an explosion:
- Explosive Mix
- Ignition
 For a collision:
- A ship
- Another object (ship, quay, buoy etc..)
- A certain speed
- Contact
C= A + B; just like that!

“Necessary”:
“Absence of an obvious safeguard” (or: generally accepted
“barrier”)
e.g.
- Explosion in pump room not only “needs” direct facts, like “Mix” and
“Ignition”, but also failure of “necessary” equipment, like Ventilation
and Gas Detection
Always consider evidence of barrier failure

“Enough”:
To verify that the facts needed for the event really are enough
to deliver that result.
If A= B + C; then B + C must deliver A

Needed? Necessary?
1 Needed
Necessary
but not Needed
Needed and
3 5 2 Necessary
1: Explosion in pump Room
Irrelevant
2: Explosive Mix
3: Pump Room 7 8 9
4: Ship Alongside
5: Ignition
6: Survey Overdue
7: No Ventilation
8: No Gas detection
9: Gas leak
Facts:
 Large amount of sea water enters ME crank case
 Chief Engineer stops engine to prevent damage and to pump
contaminated oil out and new lub oil in
 Master is forced to anchor ship about 2’ off a reef
 Current and wind towards reef
 New lub oil in Engine; Chief Engineer informs Master: Engine ready
 Master (under time-pressure) assumes he can start weighing anchor now
and simultaneously start engine
 Engine fails to start with anchor dragging
 Ship is carried by current and wind on the reef and runs aground

agr
Ship ran aground
curr anch pos

EVENT Fact 1 Fact 2 Fact 3 Fact 4 Fact 7 Fact 8
Current and Dragging

Aground wind Anchor 2’off a reef
Dragging Current and Engine fails weighing
anchor wind to start anchor
Position at
2’off a reef ME stopped the time
Master Chief Eng Master under
Weighing assumed told him ER time
anchor Eng will run ready pressure
Engine fails
to start ?
prevent Pump
serious contam. Oil
ME stopped damage out crank c
Seawater
Cont.oil in entered
crankcase Crank case
?
Seaw in Crc
ETC.....

1: Ship runs aground Fact Tree
2: Current and wind
3: Dragging anchor 1
4: Weighing anchor
5: Engine fails to start
9 2 3
6: Master under time pressure
7: Master assuming engine will
Run whilst heaving anchor 10 11 2 5 4
8: Chief Engineer informs bridge
Engine ready ?
14 12
9. Ship anchored 2’ off a reef
10. Main Engine stopped
8 6 7
11. Occurred in narrow waters 13
12. Pumping out contaminated oil ? ? ?
13.Water entered crank case ?
14. Prevent serious damage to ME
Rules of the Game
 Group (brain storming)
 Facts
 Investigation and Analysis come together
 Clarify questions during analysis.
 Causes at 3 levels (Direct & Basic + Root)

Hazard
Description of:
 A source, situation, condition or act….
 With a potential to cause harm/ damage/ loss

Hazards (examples)
 Tension
 Weight
 Height
 Electrical current
 Contact
 Biological agents
 Chemical substances
 Temperature
 Noise
 Gas/ Oxygen
 Pressure
 Vibration
 Motion
 Hostile environment (e.g. Sea)
 Explosive mix
 Chemical reaction

Risk
 Description of a potential Accident (the event)
 With an estimation of probability and consequence.
A more detailed description of what might happen

Risk: two aspects
 Risk as an Event (scenario) (what will exactly happen?);

RISK IDENTIFICATION
 Risk as a value (high, medium, low):
RISK EVALUATION

Risk is Relative; it depends on e.g.:
Internal (Basic) Factors like:
 Level, competence, stability and fitness of crew
 Type, design, age, quality of ship/ material
 Support shore organization
 Availability of proper resources
 Efficiency of documentation/ communication
 Quality of leadership
 Transparancy of organization
In other words: effectiveness of the Barriers
External Factors like:
 Weather, environment in which to operate
 External parties involved
 Effectiveness of communications between parties

Risk Assessment Elements
Relevant
Hazards Controls
Preventive/
Reactive
Causes
Internal &
External Factors
Risk-
Level
Activities; Operations; HAZARDOUS EVENTS
Conditions; Systems
=(Incident)Scenario’s

Risk Assessment is about Barriers
Barriers
LOSS
Policies
Sub-
Job
Controls Standard
Factors
Acts/
Practices
Personal
Factors
Inadequate Sub-
Standard
Systems Conditions
Standards
Compliance

Imperfect Barriers and the Error Trajectory
Equipment
HAZARD
Training
PPE
Standards
Supervision

Bow Tie
FAULT “TREE” EVENT “TREE”
Hazardous
Prevention Event
How to prevent the Incident (hazardous event) &

How to limit the Loss

Bow Tie Principle:
Hazard Barriers
Barriers
Failure Hazard Failure
Causes Barriers event

Causes Barriers Loss
Inci-
Failure dent
Failure
Causes Barriers Causes Barriers
Prevention Reaction
Methods
 Full Risk Assessment
 Job Safety Analysis (JSA)
 Toolbox meeting
When?

When (“Full”)RA, JSA,Toolbox ?
RA:
 Project preparation
 New activities (no standards developed)
 Complex operations (operation centred)
 Hardware modifications
 (Re-)assessment of generic Risk
 JSA:
 Detailed task execution level
 (Operational) Step by step
 Training purposes
Toolbox:
 Immediate pre-execution meeting
 Often PTW is applied

Version
Verification for “all in place 08/02/2018 Slide 42
overf
Bunkering overflow
EVENT Fault 1 Fault 2 Fault 3 Fault 4 Fault 5 Fault 6
Loading no Wrong tank

Overflow 1 stopped 2 3 Too fast 4 etc....
etc....
No reaction Tank full not Valve failure
2 on stop 2a seen 2b 2c
Nobody on Not
deck barge understood
2a 2aa 2ab etc
Checks
Gauge wrong tank Forgets this
2b failure 2ba 2bb tank 2bc etc
wear and Hydraulic

2c tear 2ca failure 2cb etc
Etc...

Fault Tree
1
4 2 3
4a 4b 4c 2c 2b 2a 3a 3b 3c 3d
4ca
2ba 2bb 3ca 3cb 3cc
2bba

Example Work sheet
Activity Hazards Potential Events Consequen Risk Level Additional Residual Responsible Close
(Steps if ces Consider Controls Risk Action taken out
needed) Existing (besides existing
Controls controls)
Welding on Heat Fire due to heat Material Rigging of spark Boatswain

deck (anchor accumulation damage resistant screen
winch) Explosion due to Loss of ship
igniting Injury to
explosive gas crew
Touching hot
surface
UV Light looking in arc Eye Injury Not required
Fumes inhalation of Lung Not required

fumes disease
Physical Overexcerting Back injury Regular breaks (15 Chief Ofifcer

stress due to work min)
position
Electricity Touches high Electrocuti Old welding Chief

Voltage due to on machine will be Engineer
poor insulation replaced by new
and humidity one
Removing old Weight/ Falling from Injuries Hire shore crane Master/
material limited stairs whilst (falling for removing old Agent
space transporting to from material
main deck height)

Risk Level
Exposure
Severity
Likelihood

PROBABILITY/ FREQUENCY
Highly Unlikely Possible Likely Highly Likely
Unlikely
5% 15% 35% 75% 95+%
Low Risk/ acceptable Never Occurred in Occurs in Occurs in Predicted to

occurred in Industry Industry Industry occur
Industry once &/or &/or during
Medium Risk over> 5 during last Company Company course of
years 5 years Annually X the work
High Risk/ unacceptable times/year
Health/ Assets Others 1 2 3 4 5
Injury Environm.
Reputation
A No Injury No Asset No Impact
(Scratch- Damage
S type)
B First Aid Damage Spill <5ltr

E Medical
Treatment
<X$ Local reputa-
tion impact
V C Lost Time Damage Spill <50 ltrs

Injury < 10X $ Regional
E coverage
R D Permanent
Disability
Damage
< 20X $
Spill <500 ltrs
National
I media
coverage
T E Single
Fatality
Damage
< 50X $
Spill >500 ltrs
National
Y Headlines
F Multiple Damage Catastrophic

fatality > 50X $ Spill Coverage
Internationall
y

Toolbox meeting
1. “Walk-through” Task-steps
2. Remember and highlight Hazards and Risks
3. Verify for any not previously identified details
4. Control Measures in Place
5. Ensure all understood/ informed
6. Remind: Changes- Risk (inform supervisor)

End of Course

Incident Investigation and Practical Risk Assessment

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Marine Risk

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 Accident: Undesired occurrence with actual loss

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But Nobody wants an accident!

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 Human Error cannot be avoided; we all make mistakes

 Human Error can be managed

 Build barriers to deal with:

 If still an accident occurs, investigate why we (wrongly) assumed the

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2. Basic Causes or:

3.Root Causes/” System”

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 Inadequate Physical capabilities

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Only Material damage

In Other Words: “Significant”

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Low Risk/ acceptable Never Occurred in Occurs in Occurs in Predicted to

B First Aid Damage Spill <5ltr

V C Lost Time Damage Spill <50 ltrs

F Multiple Damage Catastrophic

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• Schematic structure of the tree by asking every time

• What was needed?

• Was this necessary? (failure of “standard” Barriers)

• Was this enough?

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C= A + B; just like that!

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Always consider evidence of barrier failure

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If A= B + C; then B + C must deliver A

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curr anch pos

Current and Dragging

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 Risk as an Event (scenario) (what will exactly happen?);

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FAULT “TREE” EVENT “TREE”

How to prevent the Incident (hazardous event) &

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Failure Hazard Failure

Causes Barriers event

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