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02-Risk Assessment - Bowtie Methodology
02-Risk Assessment - Bowtie Methodology
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Disclaimer
This Summary report and any files included or referred with it are intended solely for the use
of the individual or entity to whom they are addressed. The views, thoughts, and opinions
expressed in this report belong solely to the author(s) for and behalf of DYNAMARINe and are
based on the facts and data conveyed by the client. Author(s) do not make any warranties
about the completeness of the information conveyed through this Guide which is subject to
amendment without any prior notice. Any action you take upon the information on this Guide
is strictly at your own risk, and we will not be liable for any losses and damages in connection
with the use of this Guide
And has received accreditations for their STS services from LR and ABS
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Introduction
The bowtie method is a risk assessment methodology that is used to assist in the development
of the risk assessment for a specific hazard and event.
A bow-tie diagram is a type of diagram used to model and visualize risk management and
preparedness. The diagram visualizes an event with its perceived threats, consequences,
damage mitigation measures and preventive measures.
Threats and preventive measures are placed in the left part of the diagram, as part of the
preventive controls for potential causes. Consequences and damage mitigation measures are
placed on the right side, as part of the potential impact and corresponding plan for recovery
preparedness.
The objective of this guide is to assist the user in developing a risk assessment in line with
the latest OCIMF STS Transfer Guide 1 using the bowtie methodology. Thus, ensuring that
causal factors, leading to an incident, will be properly addressed and potential consequences
will be taken into account and mitigated through proper control measures.
1
Ship to Ship Transfer Guide for Petroleum, Chemicals and Liquefied Gases, First Edition (OCIMF, CDI,
ICS, SIGTTO).
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Service Provider to
have conducted an
DYNAMARINe to adequate number
of STS Operations Service Provider
be consulted for
Service Provider is under similar to be licensed by
past relevant Service Provider to
not experienced circumstances the local comply with OCIMF
incident data STS SPSA
with the location authorities
POAC to have a
POAC to be
DYNAMARINe to good
regularly
be consulted for understanding POAC to comply
assessed by the
Inexperienced past relevant with the Location with MARPOL
STS Service
incident data Assessment Requirements
POAC Provider
Enviromental
Regular weather Weather limitations
to be established Weather
forecast to be
based on Mooring Limitations to be
received prior to
Adverse the STS
Study by the STS established prior
weather Service Provider to the STS
Operation
operation
conditions
AIS broadcasting
STS operation to
of Restricted
be conducted at Vessel Position to
Ability to
safe location be monitored
Maneuver by
away from through both
both involved
separation zones ECDIS and Radar
Traffic vessels
During the
clearance phase, Improper
information on Location
Location Assessment or
Assessment to be
Location
requested by the
AIS broadcasting In case of Double Assessment not Delays
charterer
of Restricted Banking, passing received
Ability to ship effect to be
Maneuver by Consider discussed with
both involved additional lines the STS
Passing Ship STS Operation -
vessels in Mooring Plan Superintendent
Effect Planning
During the
clearance phase,
information on
Unsuitable Location
Assessment to be
STS STS Operation always
STS Service Provider requested by the to be at Charterer's
to advise Under Keel Location charterer Risk and Expenses C/P Disputes
navigational Clearance to be
hazards in the area DYNAMARINe to
Appropriate and considered
through the be consulted for
avigational Hazards up-to-date during the
Location past relevant
in the vicinity of charts to be compatibility
Assessment incident data
the location available assessment
No crew changes
or relevant
inspections to
take place unless
the STS location
STS location be
is deemed Increased DA
assessed /
DYNAMARINe to
reviewed
suitable expenses
be consulted for
Improper through the
past relevant
Location feedback of
incident data
DYNAMARINe
Assessment
DYNAMARINe to
Service Provider
STS Location not
be consulted for
to be licensed by
authorized by the past relevant
the local
local incident data
authorities
Administration
Availability of Oil
Spill Response
Equipment to be
Contingency Plan confirmed with the
to adapt to STS Service
Inadequate Oil circumstances Provider prior to
Spill Response and location the STS operation
quipment/Facilitie
STS Equpment Certificates of
maintenance to be assessed Past Performance data
STS equipment not to prior STS operation, in line to be assessed
STS Equipment to be visually
properly maintained with industry standards through OSIS
inspected by the Master
(DYNAMARINe)
STS operation -
STS Planning Planning
documentation in line Improper Provider
The Service provider does not with industry Relevant ISO certifications or Assesment
have an SMS System, requirements to be latest Audit Report by a Past Performance and
including but not limited to: received and asssessed third-party to be requested Incident data to be
JPO, Risk Assessment, prior to the STS prior to the STS operation assessed through OSIS
Mooring Plan, Location operation (DYNAMARINe)
Assessment
Substandard STS
Service Provider
During the clearance
phase, information on
STS Service Provider to
STS Service Provider to STS Operation always to be at be requested by the C/P Disputes
Past Performance and
have a documented Charterer's Risk and Expenses
charterer
Substandard tug or Incident data to be
SMS in line with
Service boats assessed through OSIS
OCIMF SPSA guidelines
(DYNAMARINe)
No crew changes or
relevant inspections to
Evidence towards take place unless the Increased DA
rectification of past Past Performance and STS location is deemed expenses
Past STS Data issues/Incident Incident data to be suitable
performance issues investigation to be assessed through OSIS
provided (DYNAMARINe)
Efficient
Adverse weather communication to be Weather forecast Bridge watch to report
Weather thresholds to Weather suspend criteria to
conditions established between should be monitored in case of weather
be monitored have been agreed at the JPO
ships regularly deterioration
Collision during
berthing Check and replace damaged
Primary/ Secondary
Initiate contingency Request tug assistance in case Suspend/Abort equipment, including any
planning of primary fender failure berthing maneuver fittings of both vessels
fender damage
Diesel generator Diesel generator load
Vessel Blackout/ Main Main Engine to be parallel operation to analysis to be assessed Main Engine maintenance to
Engine Failure tested prior to be tested prior to accordingly prior to comply with PMS
Maneuvering Maneuvering Maneuvering
Emergency drill to be
Tool-box meeting to be
Inexperienced Deck
conducted well in advance of POAC to advise
conducted well in
the STS operation in line with regarding the roles DYNAMARINe to be consulted
Officers industry guidelines advanced of the STS for past relevant incident data
and duties of the crew
operation
Maneuvering to be in
accordance with the
JPO in order to ensure The angle of approach When manoeuvring at
adopted by the close quarters the
the appropriate
Improper maneuvering ship effect of ship
contact angle with the
maneuvering should not be interaction should be
fenders excessive anticipated
Emergency
disconnection Emergency cast off
Personnel to report at the rally Vessel Collison
point and assess the damage procedure to be procedures to be
initiated initiated
STS Operation -
Approaching &
Secondary fender
Mooring
height to be
Mooring fittings of Mooring line tension to be Emergency cast off Mooring Line
re-adjusted based on Portable chock for the Vessel’s crew to coordinate monitored and cast-off
Primary and secondary both vessels to be procedures to be breakdown
Back-up pennant to be the new vessel secondary fender to be Fender rigging to be with the Mooring Master procedures to be discussed
fender positioning to Compression on assessed initiated
Improper fender utilized for the freeboards after the utilized in case of conducted under the
completion of cargo be in line with industry individual fenders to
rigging foremost primary unsuitable mooring supervision of the STS
operations guidelines be regularly monitored
fender fittings Superintendent
Fender and/or
Fender Line
Breakdown
Emergency shut-down Emergency cast off
procedures to be Vessel’s crew to coordinate
procedures to be Loss of containment
with the Mooring Master
Mooring chocks to be initiated initiated
inspected prior STS
operations to ensure
that no any grooves
are present which can
Improper condition of lead to breakdown of Fender rigging to be
conducted under the
vessel mooring lines due to increased
supervision of the STS
fittings friction Superintendent
Notify relevant team to
be ready to transfer
casualty to the ship’s Emergency cast off
Vessel’s crew to coordinate Appropriate PPE to be hospital with Personnel Injury
procedures to be
with the Mooring Master worn appropriate means
initiated
Fender requirements to
be assessed during the
Inadequate fendering Fender Selection in accordance External condition of fenders
with industry guidelines ship compatibility should be visually assessed
process
Fender diameter to be
less than half the
freeboard of the ship
to prevent inadvertent
Large roll angles or boarding of the ship
Fender diameter to ensure
different roll periods sufficient stand-off distance by the fender
First Aid team to
Notify relevant team to
proceed to the scene
be ready to transfer
of the incident with all
casualty to the ship’s Emergency cast off
Appropriate PPE to be medical equipment in
Snap back zones to be Personnel
Vessel’s crew to coordinate hospital with
procedures to be case of Personnel Injury/Fatality
with the Mooring Master worn appropriate means considered
initiated Injury
Monitor weather
conditions and assess
Check the operation Additional stress to
the deployment of Parted mooring
condition of all
additional mooring
line/tail to be replaced other mooring lines
mooring lines/winches
lines
Number of lines to be
Mooring Plan to be in
adequate taking into Tool-box meeting to be
accordance with the OCIMF Ship compatibility to be
consideration vessels arranged upon
Mooring Pattern STS Transfer Guidelines and assessed in advance of
MEG4 requirements
sizes and weather embarkation of the STS
the STS operation
conditions Superintendent
Emergency shut-down
Systems prepared to drain and
disconnect hoses at short procedures to be Loss of containment
STS Operations - notice initiated
Efficient
Mooring Operations
Abnormal weather communication to be Weather forecast Bridge watch to report
Weather thresholds to Weather suspend criteria to
conditions established between should be monitored in case of weather
be monitored have been agreed at the JPO
ships regularly deterioration
Emergency
Vessel’s crew to coordinate
disconnection Mooring fittings of Damage to STS
with the Mooring Master prior
procedure to be both vessels to be Equipment
to any action
initiated assessed
Back up VHF
radio/frequencies and
Test the
Communications emergency
means between vessels communication
before the means (i.e. whistle) for First Assessment with respect
commencement of the the entire period of to the extend of the damage
Tool-box meeting to be operations to ensure the operation should Timely inform
Request Expert advice
and resume STS operation if Delays
Fail of arranged upon timely responses from be agreed with the STS feasible Charterers
communication embarkation of the STS the Master/Vessels
Superintendent Superintendent
Assessment, Training
and Incident
Investigation Timely inform Reputation damages
procedures to be
Charterers
examined
Ensure that adequate
Tool-box meeting to be number of crew is
Work/ Rest hours to be arranged upon onboard in case of
Fatigue kept as per SMS embarkation of the STS consecutive STS
policies Superintendent operations
Tool-box meeting to
ensure that procedures
Non proper usage of PPE should be checked and safe working
PPE prior STS operation practices are followed
Ensure adequate
lighting at boat station First Aid team to
and crane / gangway Notify relevant team to Prepare midship cranes
proceed to the scene
SMPEP procedures to be ready to transfer (man rated) with
stations. Switch on all of the incident with all
be activated in line Vessel’s crew to coordinate casualty to the ship’s stretcher / basket for
available deck lights (if medical equipment in
with the procedures with the Mooring Master prior hospital with
case of Personnel
lowering the casualty Fatality
also agreed at the JPO night or Polar night) to any action appropriate means to the boat
Injury
Back up VHF
radio/frequencies and
Test the
emergency Communications
communication means between vessels
means (i.e. whistle) for before the
the entire period of commencement of the
the operation should Tool-box meeting to be Confirm that all crew operations to ensure
Communication arranged upon involved can easily timely responses from
be agreed with the STS Start establishing facts,
Failure embarkation of the STS communicate in same the Master/Vessels collecting evidence for
Superintendent Superintendent language Incident investigation to be
SMPEP procedures to subsequent
MOC to take into investigation (take
conducted. Findings to be
be activated in line If injury due to defective
account findings photos, secure
considered and preventive Change in company
with the procedures equipment etc., keep parts on actions to be established
also agreed at the JPO
following the Incident statements etc) board for inspection
procedures
Investigation
STS Operations -
Mooring Operations
Mooring chocks to be
inspected prior STS
Wires to be treated operations to ensure
regularly with suitable that no any grooves
lubricants as SMPEP procedures to
are present which can
Mooring lines of the Certificates and recommended and be activated in line Assessment of the Inform engine room
Inadequate lead to breakdown of
vessels to be ckecked maintenance/inspection meeting any with the procedures injury and resume STS and have engine on Vessel Delays
maintenance of environmental lines due to increased Inform charterers
prior to the STS records to be easily also agreed at the JPO operation if feasible stand-by for maneuver
equipment operation accesible regulations friction
Condition of mooring
lines along with their
The moorings lines should be operating records to
checked and tended regularly be inspected by the
Confirmation that crew is to ensure proper tension is Mooring Master prior
aware of snap back zones (all to the commencement
Mooring line maintained throughout the
deck is considered as snapback transfer operation of the Operation
breakdown areas)
Fatality
Ensure that careful
Manifold pressures and observation of the
cargo quantities vessel’s tank ullage
should be recorded at flow rates and
regular intervals by Deck pipelines, Tank pressures is
both vessels and any Containment and Spillage maintained during the If possible, extend oil
Lids and Butterworth
discrepancies Cleaning Equipment to be entire delivery to avoid Cargo Transfer related boom immediately to
plates to be checked Ship's crew to ensure
Hardware failure investigated checked prior to each STS any possibility of equipment to be SOPEP procedures to prevent dissipation of
prior to each cargo operation that the spilled
immediately overflow maintained as per PMS Cessation of cargo be activated in line oil, and try to recover
operation substance is isolated
transfer operation and Locate source of with the procedures as much oil as possible Emergency Response Appropriate Coastal States to Oil Pollution
using oil absorbent from cargo and or
closure manifold valves leakage also agreed at the JPO team to be notified be notified without delay
personnel
SOPEP to be reviewed
STS Service Provider to
Clear and detailed periodically to
Vessel's Oil Spill Response Oil Spill Drill to be carried out advise location specific
operating procedures incorporate experience
equipment to be fit for regularly in order to evaluate requirements and
Inadequate to be established for gained from regular Assessment, Training
purpose and in line with the effectiveness of the response equipment
procedures all phases of the STS drills and actual and Incident
industry standards resposne plan availability Cessation of cargo
opeation incidents Investigation
transfer operation and Locate source of Timely inform Reputation damages
procedures to be
closure manifold valves leakage Charterers
examined
Emergency duties
should be assigned to
personnel. An
First Assessment with respect
appropriate drill to the extend of the damage
should be held, where and resume STS operation if Timely inform Delays
Officers to be checked practicable, within Request Expert advice
for pre-employment
feasible Charterers
24-hours and in any
training to ensure that case not more than 7
they meet both Officers to regularly
Failure to follow days before
company and statutory attend Company and
commencing STS
procedures standards industry organized
transfer operations
seminars
The STS
Superintendent should
Adverse weather confirm correct
Weather thresholds to Weather suspend criteria to
conditions connection at the Stop cargo transfer and Vessel’s crew to coordinate Contingency Planning, MARPOL antipollution
be monitored have been agreed at the JPO Oil Pollution/Loss of
manifold inform the involved
with the Mooring Master prior as agreed in the JPO, equipment to be
containment
to any action to be initiated mobilized
parties
The STS
Hose Superintendent should
Improper hose Ensure that bolts are in connection/integrity to
Flanges and quick
confirm correct Stop cargo transfer and Vessel’s crew to coordinate
Damage to adjecent
Correct gasket is being connect/disconnect couplings First Assessment with respect
connection place and tightened be pressure tested at 5 connection at the inform the involved with the Mooring Master prior
Disconnect all hoses Hose string
used should be in good condition to any action to the extend of the damage
evenly bars manifold parties
Hose Breakdown
Notify relevant team to
be ready to transfer
casualty to the ship’s Emergency cast off
Vessel’s crew to coordinate Appropriate PPE to be hospital with Personnel Injury
procedures to be
with the Mooring Master worn appropriate means
Minimum bending initiated
Minimum Bending Radius to be in line Hose to be inspected
Radius is exceeded with industry for kings and crushed
requirements sections
Assessment, Training
and Incident
Investigation Timely inform Reputation damages
procedures to be
Charterers
examined
Establish and maintain
Maximum flow rate not
Transfer rates are assessed proper communication
to exceeded
Transfer rate too high based on vessel data provided between the two
manufacturer's
at the Q88 vessels and the POAC
specifications
Tool-box meeting to be
Crew not familiar with arranged upon Experienced personnel
transfer procedures embarkation of the STS
in overall supervision
Superintendent
Personnel being
transferred to be
equipped with strobe
Ways to evacuate any An emergency response lights in conditions Personnel being transferred to
seriously injured team, including with reduced visibility be dressed appropriately with
personnel to a suitably trained or at night to aid PFDs, together with survival
STS Operations - Emergency means of Rescue boats to be fully recovery in case a
Personnel Transfer to shore-based medical medical support suits where environmental
Suspend any personnel Personnel Injury
Non certified crane for Personnel Transfer recovery to be facility should be members, should be prepared for person falls into the conditions require it
Alternative methods of be conducted through transfer procedures /Fatality
Personnel Transfer by considered designated immediate deployment water
personnel transfer to be the crane which is initiated
Basket discussed certified
Failure or
improper use of
equipment used Alternative methods of
First Assessment with respect
in PTB to the extent of the damage Suspend any personnel Structural Damage
Weather limitations for PTB to be recovered personnel transfer to be
PTB to be established discussed
on the PTB, Crane or Vessel transfer procedures
Adverse metocean
and agreed by the Limit personnel transfers by
conditions involved parties Basket to one, if possible
Efficient
Both Ships Navigation
Suspension criteria communication to be
Minimum visibility Both vessels’ RAM Lights to be in good
should be agreed at established between
Poor Visibility over one Nautical Mile lights to be functional working condition
the JPO ships
External condition of
Fender selection Fender rigging plan the fenders should be
assessment should be should be prepared visually assessed.
Primary fender conducted from both prior to the Latest maintenance
positioning/ Masters and STS commencement of the certificates should be
condition Service Provider STS Vessel’s crew to
provided
coordinate with the Check and replace
Mooring Master prior Request tug assistance damaged equipment,
Suspend/Abort Primary/ Secondary
to any action / Switch in case of primary including any fittings
fender failure
on all available deck fender failure berthing maneuver of both vessels
lights
Back up VHF
Test the
radio/frequencies and
Communications
emergency
means between
communication Vessel’s crew to
vessels before the
means (i.e. whistle) for coordinate with the Sound the fire alarm,
commencement of Emergency Parties to
the entire period of Mooring Master prior Check for Vapor on Inform OOW and
Tool-box meeting to be the operations to provide the bridge
the operation should to any action / Switch Main Deck and initiate advise Engine Room of Fire/ Explosion
arranged upon ensure timely on all available deck with frequent updates the situation
Fail of be agreed with the STS process to stop
embarkation of the STS responses from the lights leakage
Communication Superintendent
Superintendent Master/Vessels
Before
berthing/mooring
operations establish
and agree satisfactory
communications
Fatigue of crew, Stress
between Bridge to
Lack of Planning and and Strain due to Work/ Rest hours to be Bridge /
Teamwork prolonged contracts Forecastle-Bridge /
kept as per SMS
Poop deck
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