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ANNEX 1: FSA/LSA/BC: HAZARD IDENTIFICATION

ANNEX I: FSA/LSA/BC: HAZARD IDENTIFICATION TABLE OF CONTENT

1 INTRODUCTION ........................................................................................................................... 2 1.1 Purpose..................................................................................................................................... 2 1.2 Background to the Study.......................................................................................................... 2 1.3 Objectives of the Study ............................................................................................................ 2 HAZARD IDENTIFICATION - STRUCTURED WHAT IF TECHNIQUE (SWIFT) .................. 2 2.1 SWIFT Protocol used in the study ........................................................................................... 2 2.2 SWIFT generic checklist.......................................................................................................... 3 Sequence of events from initiating event to rescue.......................................................................... 3 SHIP TYPE- Bulk Carrier ............................................................................................................... 4 RESULTS FROM THE BRAINSTORMING SESSION ................................................................ 6 5.1 Conventional Lifeboat.............................................................................................................. 6 5.2 Hazards Specific to Liferafts (Both Types).............................................................................. 8 5.3 Free ­ Fall Lifeboats ................................................................................................................ 9 List Of HAZARDS identified ........................................................................................................ 11 6.1 Survival Craft ­ Generic ........................................................................................................ 11 6.2 Hazards Specific to Conventional Lifeboats .......................................................................... 15 6.3 Hazards Specific to Liferafts ­ Throw Overboard ................................................................. 19 6.4 Hazards Specific to Liferafts ­ Davit/Crane Launched.......................................................... 22 6.5 Survival at Sea until Rescue for Both Liferaft Types............................................................. 25 6.6 Hazards Specific to Free-Fall Lifeboat .................................................................................. 26 RANKING OF HAZARDS ........................................................................................................... 29 7.1 Frequency Index..................................................................................................................... 29 7.2 Severity Index ........................................................................................................................ 29 7.3 Risk Matrix ............................................................................................................................ 30 7.4 Ranking .................................................................................................................................. 30 OBSERVATIONS ......................................................................................................................... 31 SWIFT TEAM & MEETING ........................................................................................................ 32

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3 4 5

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1 1.1

INTRODUCTION Purpose

This annex comprises the hazard identification on Life Saving Appliances (LSA) for bulk carriers, primarily focused on survival craft, carried out in Norway, March 28th ­ 30th, 2000, applying the "Structured What-IF Technique" (SWIFT). The work has been conducted by a project team from Norwegian Maritime Directorate, Umoe Schat-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 dealing with specific requests of the 1997 SOLAS Conference; with matters arising from the assessors' 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 effort outside IMO, a relevant FSA study. This hazard identification report is a contribution to the Formal Safety Assessment of Bulk Carriers, carried out in Norway, with the aim of contributing to the international FSA study. The project team has carried out a complete 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 the issue 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 from the sponsors of the project, as well as participation from other institutions with specialist 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 Saving Appliances for bulk carrier, primarily focused on survival craft. The hazard identification is carried out as the first step of a Formal Safety Assessment (FSA). Recommendations in this study are therefore meant as recommendations to the later steps of FSA rather than as final recommendations for decision making (Step 5 of FSA). 2 HAZARD IDENTIFICATION - STRUCTURED WHAT IF TECHNIQUE (SWIFT) SWIFT Protocol used in the study

2.1

1. Define sequence of steps in emergency evacuation Consider 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 needed Record 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 factors e.g. crew error, accidents (falls, trapping, trips, access to dangerous areas), illness or injury, abuse of equipment etc. Measurement errors e.g. crew numbers, Equipment/instrumentation malfunction e.g. structural failures, equipment failure, control system failure, communication system error etc Maintenance e.g. dangerous areas, permit systems, control of modifications, mechanical handling, danger to crew etc Utility failure e.g. power, air, fire water, communication systems, lighting etc Integrity failure or loss of containment e.g. fire, loss of containment Emergency operation e.g. evacuation in fire (machinery, cargo area, accommodations area) , drift grounding, powered grounding, capsizing, collision, flooding, cargo related etc External factors or influences e.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 all survival craft considered (conventional life boat, throw over board life raft, davit/crane launched life raft and free fall life boat). Events 1 to 8 are not dependent on survival craft, and hazards 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 raft the event sequence is also different as boarding is carried out after launching.

Table 1:Sequences of events used in the hazard identification

Conventional life boat 1. 2. 3. 4. 5. 6. 7. 8. Initiating event Evaluation of situation Decision to muster Mustering alarm Escape to mustering station Mustering Search for missing persons Selection of life saving appliances Preparation of equipment Decision to abandon ship Boarding Lowering Release Clear ship Survival at sea Rescue Life Rafts ­ Throw over board Life Rafts ­Davit/ Crane Launched Free fall life boat

Same

Same

Same

9. 10. 11. 12. 13. 14. 15. 16.

9. 10. 11. 12. 13. 14. 15.

Preparation of equipment Decision to abandon ship Launching Boarding Clear ship Survival at sea Rescue

9. 10. 11. 12. 13. 14. 15. 16.

Preparation of equipment Decision to abandon ship Boarding Launching Release Clear ship Survival at sea Rescue

9. 10. 11. 12. 13. 14. 15. 16.

Preparation of equipment Decision to board lifeboat Boarding Decision to launch Release/Launching Clear ship Survival at sea (communication) Rescue

Some of the terms that were used in the hazard identification may be defined by reference to Table(1): Evacuation corresponds to events 3 to 14. Assembling or mustering corresponds to events 3 to 6. 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 the exception of bulk carriers less than 85 meters with equivalent life saving arrangements. The hazard 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 and throw 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, the following survival craft arrangements are applicable: ·

1

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

Ships above 500 gross tonnage

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least one of the lifeboats shall be motorised. Open lifeboats are also required to be equipped with three immersion suits. One or more liferafts capable of being launched on either side of the ship and of such aggregate 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 an equivalent arrangement consisting of a rescueboat and liferafts (Ref. to various statements by Flag States).

For bulk carriers, with keel laid on or after 1. July 1986, the following survival craft arrangements are applicable: · One or more enclosed lifeboats of such aggregate capacity on each side of the ship as will accommodate the total number of persons on board. (Ref. SOLAS-1974, as amended 1983, Ch.III, Regulation 26.1.1). One or more liferafts stowed in a position providing for easy side-to-side transfer at a single open deck level, and of such aggregate capacity as will accommodate the total number of persons on board. If not easy transferable from side-to-side on a single open deck level, then the liferafts capacity available on each side shall be for the total number of 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 will accommodate the total number of persons onboard and capable of being free-fall launched over the stern of the ship. One or more liferafts, on each side of the ship, of such aggregate capacity as will accommodate the total number of persons on board. The liferafts on at least one side shall be 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 may have an equivalent arrangement consisting of a rescueboat and liferafts. (Ref. SOLAS1974, as amended 1983, Ch.III, Regulation 26.1.3).

In the hazard identification a "pre/post 1986" recording has been used to emphasise the following: · 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 launching appliances 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 release mechanism 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" are required for the release mechanism of the launching appliances for the davit-launched liferafts.

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 a rescue boat. Immersion suites are required for the personnel designated to the operation of the rescue 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, no separate hazard identification has been carried out. However, the rescue boat of the assisting vessel may be important for a successful rescue operation. It should also be noted that immersion suits and adequate training to use them are recorded as a suitable RCO for many of the hazards identified.

5

RESULTS FROM THE BRAINSTORMING SESSION

The brainstorming session is carried out without critical comments from the other members of the team to the suggested hazards. The team used the identified sequence of events in the brainstorming, and moving to the next event when the hazards associated with the current event were exhausted. Going back to previous events was permitted. The result of the brainstorming may therefore be somewhat hard to follow for persons not participating in the hazard 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 the following session, when the result of brainstorming are recorded in the hazard forms.

5.1

Conventional Lifeboat

1. Damaged survival craft 2. Damaged davit/launch system 3. Inaccessible/Lost/Unavailable (e.g. maintenance, repair, replacement) survival craft and/or davit 4. Excessive heel/trim 5. Excessive acceleration 6. Loss of trained personnel 7. Loss of decision maker 8. Bad weather 9. Green sea 10. Lack of/poor maintenance 11. Lack of/damaged emergency lighting 12. Insufficient time 13. Human error 14. Human error related to evaluation/decision making 15. Human error due to stress 16. Premature evacuation 17. 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 decision 19. Lack of confirming information 20. Confusing/Contradicting information

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21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57.

58. 59. 60. 61. 62. 63. 64. 65. 66. 67.

Too early/False alarms Lack of criteria for decision making Incompetence/Lack of knowledge Faulty/Lack of external communication Faulty/Lack of internal communication Language difficulties Cultural differences Insufficient procedures Commercial pressure Conflict of interests (safety vs. business interruption) Reluctance with respect to making decisions (too optimistic, realising danger associated with evacuation, need for resources in danger limitation activities, human factor, etc.) Defect mustering alarm Cannot hear mustering alarm (certain locations, noise) Lack of redundant warning/alarm system Misunderstanding alarm Suspect false alarm or drill (delayed or no action) Ignoring alarm (e.g. continue rescue/fire fighting) Inaccessible alarm initiation (e.g. fire on bridge) Blocked escape routes (e.g. toxic fumes, smoke or physical damage) Injured/Incapacitated personnel (including panic) ­ especially master, decision-makers, designated persons. Inadequate emergency lighting Insufficient emergency power Inadequate procedures/emergency plans Inaccessible mustering station Lack of alternative escape routes ("replacing complicated escape routes") Long escape routes Communication problems at mustering station (e.g. difficult to hear) Inadequate procedures for mustering/counting of persons Inadequate/Lack of training Unprotected mustering area Size 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 be impossible to rescue) Incorrect selection of survival craft under the current circumstances (Inadequate knowledge of survival craft systems or situation) Time delay due to decision to change of survival craft 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) Time delay, hazard to personnel, equipment error in releasing lashing and connecting painter (if applicable) (post 86) Delayed decision due to uncertain outcome preventing successful evacuation Faulty decision with respect to abandoning ship (due to incompetence, lack of knowledge, etc.) Risk to personnel during boarding, e.g. injuries, fall into water(pre 86) Too crowded in lifeboat (e.g. stretchers, injured personnel, oversized people) One or more person left onboard ship during lowering (pre 86) Malfunction of winch Unintended release of one or both hooks during lowering Obstacles during lowering Impact from waves

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68. Impact against ship side, i.e. wind, wave, rolling ship (different consequences: pre and post 86) 69. Excessive time consumption when lowering lifeboat 70. 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 failure 76. Inadequate lifeboat manoeuvring performance 77. Capsizing/Flooding of lifeboat (pre 86) 78. Failure in releasing skates (if applicable) (post 86) 79. Fire at sea 80. Stranding of lifeboat 81. 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/Seasickness 85. Risk of injury to personnel during stay in lifeboat and stranding 86. Risk of flooding related to rescue/pick up personnel from water 87. Inability to pick up persons from the water 88. Failure of/Insufficient location/detection signals 89. 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 vessel 91. 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 launched liferafts, respectively. Hazards 1 to 58 are identical to those listed for conventional lifeboats. 59. Delayed decision due to uncertain outcome preventing successful evacuation 60. 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 davit launched and throw over board) 66. Too crowded in liferaft, e.g. unsuitable for stretchers, injured personnel (especially for throw 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 persons 78. Unsuccessful release of painter (throw over board) 79. Forgetting to release painter (throw over board) 80. Inadequate liferaft manoeuvring performance 81. Capsizing/Flooding of liferaft 82. Fire at sea 83. Stranding of liferaft 84. 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. Hypothermia 87. Excessive heat/Dehydration/Seasickness 88. Risk of injury to personnel during stay in liferaft and stranding 89. Risk of flooding related to rescue/pick up personnel from water 90. Inability to pick up persons in the water 91. Failure of/Insufficient location/detection signals 92. 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 vessel 94. 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 are considered identical to conventional lifeboat evacuation. For hazards 1 to 3 the hazards may be listed with the same generic wording, but are different in terms of causes and consequences 1. Damaged survival craft 2. Damaged launching appliance 3. 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 to Free-fall lifeboats were recorded for event 9 to 16, starting with hazard no 59 (in agreement with 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 craft 64. Time delay, hazard to personnel, equipment error in releasing lashing (if applicable ) 65. Delayed decision due to uncertain outcome preventing successful evacuation 66. Faulty decision with respect to abandoning ship (due to incompetence, lack of knowledge, etc.) 67. Malfunction of release hook 68. Unintended/Too early release of hook 69. Hazard to personnel if incorrectly seated (especially to previously injured personnel) 70. Hazards due to open hatches 71. Obstacles during launching (free-fall and water impact) 72. Machinery/Rudder/Propeller failure 73. Inadequate lifeboat manoeuvring performance 74. Fire at sea 75. Stranding of lifeboat 76. 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/Seasickness 79. Risk of injury to personnel during stay in lifeboat and stranding 80. Risk of flooding related to rescue/pick up personnel from water 81. Inability to pick up persons in the water 82. Failure of/Insufficient location/detection signals 83. 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 vessel 85. 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 a continuous escalation of events may be identified. Also, hazards were grouped together when similar, or could have been dealt with by similar risk control options. The numbering is sequential. The numbering is not related in any way to the numbering in the previous paragraph. The hazards are ranked individually according to their potential to threaten human lives. The ranking does not account for the fact that lifeboats are primary and life rafts secondary means of evacuation. The presumption of the ranking is that the survival craft in question 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) and Risk Indices (RI) are listed in the following order: Conventional Lifeboat Pre 1986, Conventional Lifeboat Post 1986, Throw Overboard Liferaft, Davit/Crane Launched Liferaft and free-fall lifeboat. The ranking was carried out after the complete list of hazards had been prepared. See Chapter 7 for the definitions of FI, SI and RI.

Hazard definition Causes Damage to/Loss of survival craft and/or davit/launching appliance Collision, fire, explosion, extreme weather, sabotage, icing ID No FI 1 4.7/4.7 4.6/4.7 3.9 2.7/4.7 2.7/2.7 2.9 7.4/7.4 7.3/7.4 6.7

Consequences

Not usable survival craft, reduced possibilities to evacuate

SI

Current safeguards

Location, design

RI

Recommendations

Consider protection of survival craft and area, heating system

Hazard definition Causes

Inaccessible/Lost/Unavailable survival craft and/or davit/launching appliance Maintenance, repair, replacement

ID No FI

2 4.3/4.3 3.9/3.9 4.0 2.0/4.3 2.8/2.8 2.4 6.3/6.3 6.6/6.6 6.4

Consequences

Partly or totally unusable

SI

Current safeguards

Procedures, Control

RI

Recommendations

Consider planned maintenance (vital maintenance done in port)

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Hazard definition Causes

Launching zone restricted Grounding, collision, fire, ice

ID No FI

3 4.1/4.1 4.4/4.4 4.0 2.7/2.7 2.6/2.6 2.9 6.9/6.9 7.1/7.1 6.9

Consequences

Unable to launch, danger if launching

SI

Current safeguards

Use other/alternative survival craft(s)

RI

Recommendations

Consider immersion suits for all personnel

Hazard definition Causes

Excessive heel/trim/acceleration (loads) Structural damage, extreme weather, cargo shifting, ballast operations

Consequences

Current safeguards

Recommendations

4.7/4.7 4.8/4.9 4.1 Difficult or impossible to escape/muster and/or launch, loss of SI 3.0/3.0 emergency power (lighting) 2.9/2.9 2.3 Criteria for design of escape routes/muster stations, design of RI 7.7/7.7 survival craft and launching appliance 7.6/7.7 6.4 Improve legislation, improve design and performance standard of survival craft and emergency power, install survival craft less affected by excessive heel/trim/acceleration

ID No FI

4

Hazard definition Causes

Loss of trained personnel/decision maker Injuries/fatalities, incapacitated

Consequences

Current safeguards

Recommendations

4.7/4.7 4.5/4.5 4.6 Delayed/lacking/faulty decisions SI 2.4/2.4 2.6/2.6 2.0 Substitutes for key persons according to regulations (SOLAS RI 7.1/7.1 III/37.5) in emergency plans and procedures 7.1/7.1 6.6 Ensure implementation according to the regulation above: muster list and emergency instructions (audited/approved, e.g. ISM). Clear authorities/responsibilities, redundancy of trained personnel

ID No FI

5

Hazard definition Causes

Extreme weather/Green seas/Darkness External circumstances

ID No FI

6 5.6/5.6 5.6/5.6 5.0 2.7/2.7 2.7/2.7 2.1 8.3/8.3 8.3/8.3 7.1

Consequences

Delay mustering/launching or mustering/launching difficulties

SI

Current safeguards

Design

RI

Recommendations

Protected/Sheltered escape routes, mustering and survival craft areas

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Hazard definition Causes

Consequences

Current safeguards

Recommendations

3.4/3.4 3.1/3.1 2.7 Training/education, competence, information systems, RI 9.1/9.1 communication systems, safety culture 8.6/8.7 7.8 Consider training/education with respect to crisis management/knowledge assessment of ship performance and accident escalation, improve the current safeguards (listed above), install/improve sensors and alarms (e.g. water filling and filling rate) Lack of response to general emergency alarm and PA system Defect or inaccessible alarm system, cannot hear alarm (confined locations/noise), misunderstanding alarm, suspect false alarm or drill, ignoring alarm ( e.g. continue rescue/fire fighting) Intended mustering not initiated or delayed (for some) ID No FI 8 5.0 (all)

Human error related to evaluation/decision making (untimely/improper decision) Stress, reluctance to make decisions (too optimistic, realising danger associated with evacuation, need for resources in danger limitation activities, etc.), lack of/faulty/excessive (quality of) information (e.g. due to language/culture, faulty/lack of external(SAR)/internal communication, insufficient procedures, earlier false alarms ("cry wolf"), lack of criteria for decision making, incompetence/lack of knowledge) Premature/Delayed/Too late mustering

ID No FI

7 5.7/5.7 5.5/5.6 5.1

SI

Hazard definition Causes

Consequences Current safeguards Recommendations

2.0 (all) Both general emergency alarm and PA system are required RI 7.0 (all) Consider fully redundant systems (i.e. remove common critical failures for general emergency alarm and PA system) Unable to get to mustering station in time Blocked escape route (e.g. toxic fumes, smoke, physical damage, water ingress), injured/incapacitated personnel/panic (especially master, decision makers , designated persons), inadequate emergency lighting, insufficient emergency power, inadequate procedures/emergency plans, inaccessible mustering station, lack of alternative escape routes ("replacing complicated escape routes"), long escape routes Delayed/No mustering of all personnel ID No FI 9 5.4/5.4 5.0/5.1 5.2

SI

Hazard definition Causes

Consequences

Current safeguards

Recommendations

2.4/2.4 2.4/2.4 2.4 Design standards RI 7.9/7.9 7.4/7.6 7.6 Consider improved guidance systems (e.g. emergency lighting), escape analysis for improving design, escape sets (breathing apparatus), improved procedures/emergency plans

SI

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Hazard definition Causes

Consequences

Delays/Obstacles during mustering (including search for missing persons) Communication problems at mustering station (e.g. difficult to hear) Inadequate procedures for mustering/counting of persons Inadequate/Lack of training Unprotected mustering area Size 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 be impossible to rescue) Time delay due to decision to change survival craft Further delays of abandoning ship

ID No FI

10 5.4/5.4 5.3/5.3 5.3

Current safeguards

Recommendations

2.6/2.6 2.4/2.4 2.3 Design standards and procedures RI 8.0/8.0 7.7/7.7 7.6 Consider sheltering/protection of mustering area, single mustering station (i.e. reduce number of mustering stations) with back-up mustering station. Improved and more frequent/realistic drills, improved procedures, improved communication systems

SI

Hazard definition Causes

Incorrect selection of survival craft under the current circumstances Inadequate knowledge of survival craft systems or situation

Consequences

Current safeguards

Recommendations

4.7/4.7 5.1/5.1 3.4 Unsuccessful evacuation SI 3.0/3.0 2.9/2.9 3.1 Competence, training and education RI 7.7/7.7 7.9/7.9 6.6 Consider procedures for identifying primary/most effective mean of evacuation for various hazardous scenarios

ID No FI

11

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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 listed for 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 launching appliances ID No 12.1

Causes

Consequences Current safeguards Recommendations

FI 6.6/6.1 Need for removing lifeboat cover (if applicable), fitting bottom plug (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) Time consuming and possibly further delay of abandoning ship, SI 2.4/2.0 damage to equipment Drills, procedures RI 9.0/8.1 Consider equipment that is easier to operate, less time consuming or requires no preparation, improved drills and procedures

Hazard definition Causes

Consequences Current safeguards Recommendations

Hazards to personnel during preparation of survival craft and ID 13.1 launching appliances No Need for removing lifeboat cover (if applicable), release lashing, FI 5.7/5.3 swing-out of davit, lowering to embarkation deck, bowsing (pre 86) Need for releasing lashing and connecting painter (if applicable) (post 86) Injuries, fatalities SI 2.1/1.9 Drills, procedures RI 7.9/7.1 Consider equipment that is safer to operate or requires no preparation, improved drills and procedures, provision of improved immersion suits

Hazard definition Causes

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

Consequences Current safeguards Recommendations

Lack of competence, lack of knowledge (related to specific 4.6/4.7 situation), panic, wrong assessment of situation, realisation of time factor (e.g. time consuming to evacuate) Unnecessary risk of evacuation, risk to remaining personnel SI 3.1/2.4 Qualification and training RI 7.7/7.1 Consider improved training programs and information systems, consider requiring survival craft that necessitates less time to evacuate

ID No FI

14.1

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Hazard definition Causes

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

Consequences Current safeguards Recommendations

6.0/5.7 Commercial pressure Conflict of interests (safety vs. business interruption) Lack of competence, lack of knowledge (related to specific situation), apathy, reluctance to make decisions, wrong assessment of situation Delayed decision due to uncertain outcome Lack of confidence in survival craft Tradition ("the ship is the best survival craft") Fatalities, wet evacuation (people in water), injuries SI 3.9/3.9 ISM (e.g. with respect to avoiding undue commercial pressure and RI 9.9/9.6 creating safety culture), qualification and training Consider improved ISM implementation, qualifications and training, providing immersion suits to all personnel

ID No FI

15.1

Hazard definition Causes

Time consuming boarding, lowering, release and clear ship Large number of sequences necessary Delay due to too crowded in survival craft (e.g. stretchers, injured personnel, oversized people) Malfunction of winch and brake release system Obstacles during lowering Delay 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 failure Failure in releasing skates (if applicable) (post 86) Too short time for safe evacuation, interrupted and/or unsuccessful evacuation Qualifications and training, design, maintenance, quality of equipment Consider improvement of the current safeguards Consider less time consuming survival craft and launching appliance

ID No FI

16.1 6.4/5.9

Consequences Current safeguards Recommendations

SI RI

3.1/3.1 9.4/9.1

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Hazard definition Causes

Consequences Current safeguards Recommendations

Danger to personnel during boarding, lowering, release and clear ID 17.1 ship No FI 6.4/5.7 Too crowded in lifeboat (e.g. stretchers, injured personnel, oversized people) One or more person left onboard ship during lowering (pre 86) Malfunction of winch Unintended release of one or both hooks during lowering Obstacles during lowering Impact from waves Impact against ship side, i.e. wind, wave, rolling ship (different consequences: 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 failure Inadequate lifeboat manoeuvring performance Capsizing/Flooding of lifeboat (pre 86) Failure in releasing skates (if applicable) (post 86) Excessive height (related to sinking ship situation) Injured personnel, incapacitated key personnel, fatalities, persons in SI 3.1/3.1 the water Qualifications and training, design, maintenance, quality of RI 9.5/8.6 equipment Consider improvement of the current safeguards Consider improved protection of people (i.e. enclosed) and less manual operations/simplified operations, more user-friendly and redundant/more reliable winch/brake Consider immersion suits and adequate training to use them for all personnel

Hazard definition Causes

Consequences Current safeguards Recommendations

Damage to survival craft during boarding, lowering, release and ID 18.1 clear ship No FI 5.6/5.3 Malfunction of winch Unintended release of one or both hooks during lowering Obstacles during lowering Impact from waves Impact against ship side, i.e. wind, wave, rolling ship (different consequences: 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 failure Inadequate lifeboat manoeuvring performance Capsizing/Flooding of lifeboat (pre 86) Failure in releasing skates (if applicable) (post 86) Reduction/Loss of sea-keeping and survival capabilities SI 2.9/2.6 Qualifications and training, design, maintenance, quality of RI 8.5/7.9 equipment Consider improvement of the current safeguards Consider less manual operations/simplified/fewer operations, more user-friendly and redundant/more reliable winch/brake Consider improving survival craft design (stability, impact protection, etc.)

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Hazard definition Causes

Danger to personnel while in survival craft, until rescue

Consequences

Current safeguards Recommendations

6.3/4.9 Fire at sea, toxic fumes, smoke, heat Bad weather conditions (pre 86), Extreme weather conditions (post 86) Stranding of lifeboat Insufficient supply of water, food, medical supplies/equipment, fuel, etc. Exposure to heat/cold weather and water Flooding related to rescue/pick up personnel from water Inability to pick up persons in the water SI 2.7/1.9 Dehydration/Seasickness Injury to personnel during stay in lifeboat and stranding Persons in the water Hypothermia (primarily pre 86) Water filling of survival craft (primarily pre 86) Fatalities Qualifications and training, design, maintenance, quality of RI 9.0/6.7 equipment Consider improvement of the current safeguards Consider improving survival craft design (stability, impact protection, fire/heat protection, etc.), consider manual desalinator Consider providing survival suits

ID No FI

19.1

Hazard definition Causes

Danger to people (in survival craft) during rescue operation

Consequences

Current safeguards Recommendations

5.7/5.7 Malfunction/Lack of alerting and communication system (by either alerting before evacuation or by bringing EPIRB to survival craft) Failure of/Insufficient location/detection signals Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e. insufficient communication, manoeuvrability, training, transfer system) Lack of personnel pickup and transfer facilities on assisting vessel Faulty or poor design of Life Saving Appliances (including human error prone design) Seasickness and incapacitated persons Impact/collision with assisting vessel SI 2.9/2.7 Injury to personnel during pick-up, transfer and treatment Persons in the water Hypothermia Water filling of survival craft Fatalities Qualifications, procedures and training, design, maintenance, RI 8.6/8.4 quality of equipment Consider improvement of the current safeguards Consider improving survival craft design Consider improvement of rescue equipment and procedures on assisting vessel Consider providing immersion suits

ID No FI

20.1

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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, which is treated later for both types of liferafts.

Hazard definition Causes Time consuming preparation of liferaft ID No FI 12.2

Consequences Current safeguards Recommendations

5.3 Need for: · release lashing · secure painter · throw over board · inflate · bowse · secure raft Liferaft does not inflate properly or upside down Time consuming and possibly further delay of abandoning ship, SI 2.4 damage to equipment Training, procedures RI 7.7 Consider equipment that is easier to operate (e.g. racks), less time consuming or requires no preparation, improved service control, self-righting liferaft, improved drills (annual realistic drills prior to re-certification or use dummy-raft for drills) and procedures

Hazard definition Causes

Hazards to personnel during preparation of liferaft

Consequences Current safeguards Recommendations

5.1 Need for (manually): · release lashing · secure painter · throw over board · inflate · bowse · secure raft Liferaft does not inflate properly or upside down Injuries, fatalities, personnel in water SI 2.4 Current design, training, procedures RI 7.5 Consider remote release (operated from bridge/locally) Consider equipment that is safer to operate or requires no preparation, improved service control, self-righting liferaft, improved drills and procedures, provision for immersion suits

ID No FI

13.2

Hazard definition Causes

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

Consequences Current safeguards Recommendations

5.0 Lack of competence, lack of knowledge (related to specific situation), panic, wrong assessment of situation, realisation of time factor (e.g. time consuming to evacuate) Unnecessary risk of evacuation, risk to remaining personnel SI 2.9 Qualification and training RI 7.9 Consider improved training programs and information systems, consider requiring liferaft that necessitates less time to evacuate

ID No FI

14.2

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Hazard definition Causes

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

Consequences Current safeguards Recommendations

5.7 Commercial pressure Conflict of interests (safety vs. business interruption) Lack of competence, lack of knowledge (related to specific situation), apathy, reluctance to make decisions, wrong assessment of situation Delayed decision due to uncertain outcome Lack of confidence in survival craft Tradition ("the ship is the best survival craft") Fatalities, wet evacuation (people in water), injuries SI 3.9 ISM (e.g. with respect to avoiding undue commercial pressure and RI 9.6 creating safety culture), qualification and training, free-float liferaft Consider improved ISM implementation, qualifications and training, more reliable free-float liferaft

ID No FI

15.2

Hazard definition Causes

Time consuming boarding and clear ship

Consequences Current safeguards Recommendations

Boarding one by one by ladder or jump into water, then entering liferaft Delay due to stretchers, injured personnel, incapacitated personnel, oversized people Unsuccessful release of painters Forgetting to release painter Difficulties in clearing ship (drift) Too short time for safe evacuation, interrupted and/or unsuccessful SI evacuation Qualifications and training, design, maintenance, quality of RI equipment Consider improvement of the current safeguards Consider marine escape/slide system personal descent system for boarding Consider less time consuming survival craft

ID No FI

16.2 5.6

3.1 8.6

Hazard definition Causes

Danger to personnel during boarding and clear ship

Consequences Current safeguards Recommendations

6.4 Boarding one by one by ladder or jump into water, then entering liferaft (fall into water, impact injuries, exposure to environment) Difficulties due to stretchers, injured personnel, incapacitated personnel, oversized people Unsuccessful release of painters Forgetting to release painter Difficulties in clearing ship/drift (remaining at ship side, impacts, fire at sea/fire storm (suction)) Injured personnel, incapacitated key personnel, fatalities, persons in SI 3.1 the water Qualifications and training, design, maintenance, quality of RI 9.4 equipment Consider improvement of the current safeguards Consider marine escape/slide system or personal descent system for boarding Consider less manual operations/simplified operations, more user-friendly Consider immersion suits for all personnel

ID No FI

17.2

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Hazard definition Causes

Damage to survival craft during launching, boarding and clear ship

Consequences Current safeguards Recommendations

5.5 Obstacles during launching Impact against ship side, i.e. wind, wave (water filling), rolling ship Unsuccessful release of painter Forgetting to release painter Impacts caused by persons jumping overboard No liferaft manoeuvring performance Capsizing/Flooding of liferaft Loss of buoyancy, reduction/loss of sea-keeping and survival SI 3.0 capabilities, loss in fires at sea Qualifications and training, design, service, quality of equipment, RI 8.5 towing possibilities Consider improvement of the current safeguards Consider less manual operations/simplified/fewer operations, more user-friendly Consider improving survival craft design (damage stability, impact protection, etc.)

ID No FI

18.2

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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, which is treated later for both types of liferafts.

Hazard definition Time consuming preparation of survival craft and launching appliances ID No 12.3

Causes

Consequences Current safeguards Recommendations

Need for release lashing, hook on, swing-out of davit, lowering to FI 5.9 embarkation deck, inflation, bowsing No/insufficient inflation Time consuming and possibly further delay of abandoning ship, SI 2.1 damage to equipment, unusable liferaft Training, procedures RI 8.0 Consider equipment that is easier to operate, less time consuming or requires no preparation, redundant inflation system, improved training/drills and procedures

Hazard definition Causes

Consequences Current safeguards Recommendations

Hazards to personnel during preparation of survival craft and ID 13.3 launching appliances No FI 5.3 Need for release lashing, hook on, swing-out of davit, lowering to embarkation deck, inflation, bowsing No/insufficient inflation Injury to personnel, fatalities, fall into water SI 2.4 Training, procedures RI 7.7 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

Hazard definition Causes

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

Consequences Current safeguards Recommendations

Lack of competence, lack of knowledge (related to specific 4.8 situation), panic, wrong assessment of situation, realisation of time factor (e.g. time consuming to evacuate) Unnecessary risk of evacuation, risk to remaining personnel SI 3.0 Qualification and training RI 7.8 Consider improved training programs and information systems, consider requiring survival craft that necessitates less time to evacuate

ID No FI

14.3

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Hazard definition Causes

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

Consequences Current safeguards Recommendations

5.8 Commercial pressure Conflict of interests (safety vs. business interruption) Lack of competence, lack of knowledge (related to specific situation), apathy, reluctance to make decisions, wrong assessment of situation Delayed decision due to uncertain outcome Lack of confidence in survival craft Tradition ("the ship is the best survival craft") Fatalities, wet evacuation (people in water), injuries SI 3.7 ISM (e.g. with respect to avoiding undue commercial pressure and RI 9.5 creating safety culture), qualification and training, free-float liferaft Consider improved ISM implementation, qualifications and training, more reliable free-float liferaft Time consuming boarding, lowering, release and clear ship Large number of sequences necessary Delay due to too crowded in survival craft (e.g. stretchers, injured personnel, oversized people) Malfunction of winch and brake release system Obstacles during lowering Delay due to waiting for winch operator left onboard (pre 86 in some cases/NOR) Premature release of hook Unsuccessful release of hooks (differences between pre 98 (off-load hooks) and post 98 (on-load release of hooks)) Difficulties in clearing ship/drift (remaining at ship side, impacts, fire at sea/fire storm (suction)) Too short time for safe evacuation, interrupted and/or unsuccessful evacuation Qualifications and training, design, service and maintenance, quality of equipment Consider improvement of the current safeguards Consider less time consuming survival craft and launching appliance ID No FI 16.3 5.7

ID No FI

15.3

Hazard definition Causes

Consequences Current safeguards Recommendations

SI RI

2.9 8.6

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Hazard definition Causes

Consequences Current safeguards Recommendations

Danger to personnel during boarding, lowering, release and clear ID ship No FI Exposure to environment/ship motions during boarding Large number of sequences necessary Too crowded in survival craft (e.g. stretchers, injured personnel, oversized people) Malfunction of winch and brake release system Obstacles during lowering (puncture of liferaft, overturning) Impact during lowering Premature release of hook Unsuccessful release of hook (differences between pre 98 (off-load hook) 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) Injured personnel, incapacitated key personnel, fatalities, persons in SI water, loss in fires at sea Qualifications and training, design, maintenance, quality of RI equipment Consider improvement of the current safeguards Consider improved protection of people and less manual operations/simplified operations, more user-friendly and redundant/more reliable winch/brake Consider immersion suits for all personnel

17.3 6.2

3.2 9.4

Hazard definition Causes

Consequences Current safeguards Recommendations

Damage to survival craft during boarding, lowering, release and ID 18.3 clear ship No FI 5.1 Unsuccessful release of bowsing Forgetting to release bowsing Malfunction of winch Unintended release of hook during lowering Obstacles during lowering Impact from waves Impact against ship side, i.e. wind, wave, rolling ship Unsuccessful release of hook (pre 98 (off-load hook) and post 98 (on-load release of hook)) No manoeuvring performance Capsizing/Flooding of liferaft Reduction/Loss of sea-keeping and survival capabilities, loss in SI 3.0 fires at sea Qualifications and training, design, maintenance, quality of RI 8.1 equipment Consider improvement of the current safeguards Consider less manual operations/simplified/fewer operations, more user-friendly and redundant/more reliable winch/brake Consider improving survival craft design (damage stability, impact protection, etc.)

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6.5

Survival at Sea until Rescue for Both Liferaft Types

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

Hazard definition Causes Danger to personnel while in survival craft, until rescue ID No FI 19.2 19.3 5.6 5.7

Consequences

Current safeguards Recommendations

Fire at sea, toxic fumes, smoke, heat Bad weather condition Stranding of liferaft Insufficient supply of water, food, medical supplies/equipment, etc. Exposure to heat/cold weather and water Flooding related to rescue/pick up personnel from water Inability to pick up persons in the water Capsize and flooding SI 2.9 Dehydration/Seasickness 2.9 Injury to personnel during stay in liferaft and stranding Persons in the water Hypothermia Water filling of survival craft Fatalities Qualifications and training, design, maintenance, quality of RI 8.4 equipment 8.6 Consider improvement of the current safeguards Consider improving survival craft design (stability (sea-anchor), fire/heat protection, personal protection equipment (immersion suits) to all personnel, etc.), provide manual desalinator Consider providing immersion suits

Hazard definition Causes

Danger to people (in survival craft) during rescue operation

Consequences

Current safeguards Recommendations

Malfunction/Lack of alerting and communication system (by either alerting before evacuation or by bringing EPIRB to survival craft) Failure of/Insufficient location/detection signals Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e. insufficient communication, lack of manoeuvrability, training, transfer system) Lack of personnel pickup and transfer facilities on assisting vessel Faulty or poor design of Life Saving Appliances (including human error prone design) Seasickness and incapacitated persons Impact/collision with assisting vessel (rupture of liferaft) Capsize due to down-wind from helicopter Not possible to tow to sheltered waters/long distances SI Injury to personnel during pick-up, transfer and treatment Persons in the water Hypothermia Water filling of survival craft Fatalities Qualifications, procedures and training, design, RI service/maintenance, quality of equipment Consider improvement of the current safeguards Consider improving survival craft design (including stability) Consider improvement of rescue equipment and procedures on assisting vessel Consider providing immersion suits

ID No FI

20.2 20.3 5.2 5.4

2.6 2.6

7.8 7.9

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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 Causes Consequences Current safeguards Recommendations Time for preparation of survival craft and launching appliances (if ID 12.4 applicable) No Need for releasing lashing (if applicable) FI 4.1 Possible delay to abandoning ship SI 1.4 Training/Drills, procedures (related to lashings, re-installation, RI 5.6 maintenance) Consider equipment that has no need for preparation, improved training/drills and procedures

Hazard definition Causes Consequences Current safeguards Recommendations

Hazards to personnel during preparation of survival craft and ID launching appliances No Need for releasing lashing (if applicable) FI Injury of personnel SI Training/Drills, procedures (related to lashings, re-installation, RI maintenance) Consider equipment that has no need for preparation, consider improved training/drills and procedures, providing immersion suits

13.4 4.3 1.3 5.6

Hazard definition Causes

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

Consequences Current safeguards Recommendations

4.3 Lack of competence, lack of knowledge (related to specific situation), panic, wrong assessment of situation, realisation of time factor (e.g. time necessary to evacuate) Unnecessary risk of evacuation, risk to remaining personnel SI 1.7 Qualification and training, possibility of boarding before decision RI 6.0 to abandon ship Consider improved training programs and information systems, installation of remote control of ship giving enhanced possibility of boarding before decision to abandon ship, improved procedures for boarding before decision to abandon ship

ID No FI

14.4

Hazard definition Causes

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

Consequences Current safeguards Recommendations

4.7 Commercial pressure Conflict of interests (safety vs. business interruption) Lack of competence, lack of knowledge (related to specific situation), apathy, reluctance to make decisions, wrong assessment of situation Delayed decision due to uncertain outcome Lack of confidence in survival craft Tradition ("the ship is the best survival craft") Fatalities, wet evacuation (people in water), injuries SI 3.6 ISM (e.g. with respect to avoiding undue commercial pressure and RI 8.3 creating safety culture), qualification and training Consider improved ISM implementation, qualifications and training, providing immersion suits to all personnel

ID No FI

15.4

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Hazard definition Causes

Time consumed during boarding, release and clear ship

Consequences Current safeguards Recommendations

Need for proper seating and securing personnel 4.3 Delay due to too crowded in survival craft (e.g. stretchers, injured personnel, oversized people) Malfunction of hook Too short time for safe evacuation, interrupted and/or unsuccessful SI 2.7 evacuation Qualifications and training, design, maintenance, quality of RI 7.0 equipment Consider improvement of the current safeguards, redundancy in provision for trained key personnel

ID No FI

16.4

Hazard definition Causes

Danger to personnel during boarding, release and clear ship Too crowded in lifeboat (e.g. stretchers, injured personnel, oversized people) Unintended release of hook during boarding Obstacles during water impact Excessive accelerations (e.g. injured personnel, improperly secured personnel) Unsuccessful release of hook Excessive height and rotation (related to sinking ship situation) Injured personnel, incapacitated key personnel, fatalities, persons in the water Qualifications and training, design, maintenance, quality of equipment Consider improvement of the current safeguards Consider improved protection of people Consider immersion suits for all personnel Consider redundancy in provision of trained key personnel

ID No FI

17.4 4.1

Consequences Current safeguards Recommendations

SI RI

2.1 6.3

Hazard definition Causes Consequences Current safeguards Recommendations

Damage to survival craft during boarding, release and clear ship

Obstacles during water impact 3.1 Excessive height and rotation (related to sinking ship situation) Reduction/Loss of sea-keeping and survival capabilities SI 2.6 Qualifications and training, design, maintenance, quality of RI 5.6 equipment Consider improvement of the current safeguards Consider improving survival craft design (damage stability, impact protection, etc.)

ID No FI

18.4

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Hazard definition Causes

Danger to personnel while in survival craft, until rescue

Consequences

Current safeguards Recommendations

4.7 Fire at sea, toxic fumes, smoke, heat Extreme weather conditions Stranding of lifeboat Insufficient supply of water, food, medical supplies/equipment, fuel, etc. Exposure to heat/cold weather and water Flooding related to rescue/pick up personnel from water Inability to pick up persons in the water SI 1.9 Dehydration/Seasickness Injury to personnel during stay in lifeboat and stranding Persons in the water (Hypothermia) (Water filling of survival craft) Fatalities Qualifications and training, design, maintenance, quality of RI 6.6 equipment Consider improvement of the current safeguards Consider improving survival craft design (damage stability, impact protection, fire/heat protection, etc.), provide manual desalinator, immersion suits for all personnel

ID No FI

19.4

Hazard definition Causes

Danger to people (in survival craft) during rescue operation

Consequences

Current safeguards Recommendations

5.3 Malfunction/Lack of alerting and communication system (by either alerting before evacuation or by bringing Emergency Position Indicating Radio Beacon (EPIRB) to survival craft) Failure of/Insufficient location/detection signals Risk related to transfer to assisting vessel/ helicopter, especially in bad weather (i.e. insufficient communication, manoeuvrability, training, transfer system) Lack of personnel pickup and transfer facilities on assisting vessel Faulty or poor design of Life Saving Appliances (including human error prone design) Seasickness and incapacitated persons Impact/collision with assisting vessel SI 2.4 Injury to personnel during pick-up, transfer and treatment Persons in the water Hypothermia Water filling of survival craft Fatalities Qualifications, procedures and training, design, maintenance, RI 7.7 quality of equipment Consider improvement of the current safeguards Consider improving survival craft design Consider improvement of rescue equipment and procedures on assisting vessel Consider providing immersion suits

ID No FI

20.4

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7

RANKING OF HAZARDS

This chapter is a special version of a ranking procedure prepared for the hazards associated with abandoning ships by use of survival crafts. Hazards are ranked according to their contribution to the risk. Hazards are ranked individually, implying that adding the risk would overestimate 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 the same hazard contributes in many different potential accident scenarios. It is thus observed that ranking individual hazards is no substitution for risk analysis. It is just a fast way of agreeing in the HAZID team on a qualitative ranking of the hazards according to their potential to cause harm to people, property and the environment. In the case of Life Saving 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 the case of Life Saving Appliances this is not a practical measure. The definition used is therefore the number of occurrences per event (the number of occurrences each time evacuation is necessary)

Table(2): Definition of frequency index (FI)

FI FREQUENCY DEFINITION F (per evacuation) 1 0.1 0.01 10-4 10-6

7 6 5 3 1

"Sure" Frequent Reasonably probable Remote Extremely remote

Will happen almost every time Happen in one of 10 times Happens in one of 100 times Happens in one of 10.000 times (If tried on all ships it would happen in one case) Happens in on of a million times

This scale converts to annual frequencies as used in MSC 72/16 assuming 10 events annually. 7.2 Severity Index

The following severity index is used

Table(3): Definition of severity (consequence) index (SI)

SI 1 2 3 4 SEVERITY Minor Significant Severe Catastrophic EFFECTS ON HUMAN SAFETY Single or minor injuries Multiple or severe injuries Single fatality or multiple severe injuries Multiple fatalities S (fatalities) 0.01 0.1 1 10

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

FI 7 6 5 4 3 2 1 FREQUENCY "Sure" Frequent Reasonably probable Remote Extremely remote 1 Minor 8 7 6 5 4 3 2 SEVERITY (SI) 2 3 Significant Severe 9 10 8 9 7 8 6 7 5 6 4 5 3 4 4 Catastrophic 11 10 9 8 7 6 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 the facilitator 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 board liferafts, 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).

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Table(5) : Result of ranking

ID

Conventional Conventional

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Lifeboat Pre 86 7.4 6.3 6.9 7.7 7.1 8.3 9.1 7.0 7.9 8.0 7.7 9.0 7.9 7.7 9.9 9.4 9.5 8.5 9.0 8.6

Lifeboat Post 86 7.4 6.3 6.9 7.7 7.1 8.3 9.1 7.0 7.9 8.0 7.7 8.1 7.1 7.1 9.6 9.1 8.9 7.9 6.7 8.4

Davit/Crane Throw Overboard Launched Liferaft Liferaft 7.3 7.4 6.6 6.6 7.1 7.1 7.6 7.7 7.1 7.1 8.3 8.3 8.6 8.7 7.0 7.0 7.4 7.6 7.7 7.7 7.9 7.9 7.7 8.0 7.5 7.7 7.9 7.8 9.6 9.5 8.6 8.6 9.4 9.4 8.5 8.1 8.4 8.6 7.8 7.9

Free Fall Lifeboat 6.7 6.4 6.9 6.4 6.6 7.1 7.8 7.0 7.6 7.6 6.6 5.6 5.6 6.0 8.3 7.0 6.3 5.6 6.6 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 effective RCOs related to rescue phase The hazard identification resulted in a focus on decision making (the decision to muster and in particular the decision to abandon the ship) The decision of abandoning the ship is very dependent on quality of survival craft and safety culture. If the crew is properly trained and trusts the safety of the survival craft, the decision 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. The pressure to cut cost results in non-optimum solutions. Closed lifeboats require training and limit the individualist behaviours. Individualistic behaviour and individual control of the situation is a strong incentive for many. The members of the hazard identification team represent different stakeholders. It was noted that the hazard identification resulted in clarification of responsibilities and understanding of the regulations. Immersion suits to all personnel should be considered

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ANNEX 1: FSA/LSA/BC: HAZARD IDENTIFICATION

9

SWIFT TEAM & MEETING

The hazard identification has been carried out in accordance with the IMO `INTERIM GUIDELINES 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 Veritas office at Høvik (Oslo) March 28th ­ 30th, 2000. The planning was carried out by the chairman and facilitator prior to the meeting. The members of SWIFT team were selected to represent all competence areas relevant to the hazards presented. Members: 1. 2. 3. 4. 5. 6. 7. 8. 9. Mr. P. Brinchmann, Umoe Schat-Harding AS, Life boat and Davit design Mr. P. Werenskiold, Life Raft Design (etc.) Mr. T. Trygve Scheel, NMD, Regulations Capt. Ø. Holte, Senior Surveyor Mr. F. Gross, Marine Engineer Mr.H. Andersen, Chief Engineer Mr. S. Gaarder, Psychologist Facilitator: Dr. R. Skjong Recorder: Ms. B. H. Wentworth

Short CVs may be found in ANNEX VII

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