Hazard assessment and root

cause analysis
The second step is hazard assessment
and root cause analysis. Here, the
objective is to determine the potential
impact of a hazard and what causes
the hazard. There are two major
considerations on the impact.
     One is probability—how likely the hazard
is to cause loss; the other is severity—how
severe that loss will be. There are also two
considerations in the root-cause. One is
readily apparent and the other is
concealed. We have to be apprehensive of
the latter because this will be known only
after the accident happens and can be
identified by deep, thorough and analytical
process. Normally it involves machineries
that are not in continuous use i.e. lifeboat
motor etc.
 Causal Factors of
Accidents
 In order to identify potential hazards, one
needs to be aware of the main causal factors
that can lead to accidents. This includes the
following:
 • Human Error — An individual action or performance that is
different than what is required.
 • Material Failure/Malfunction—A fault in the equipment,
thereby causing or contributing to an accident
 • Environmental Conditions — Any natural or manmade
surroundings that negatively affect performance.
 The root sources that are responsible for
contributing to human error include:

• Individual Failure—The individual knows and is trained to

standard but elects not to follow the standard.
• Supervisor’s Failure—The supervisor does not enforce
known standards.
• Training Failure—The individual is not trained to known
standard (i.e., insufficient, incorrect, or no training on
the task).
• System Failure—The standards, procedures or work
instructions are not clear, not practical, or does not
exist in the system. It refers to inadequate design or
performance of safety programs that provide training,
resources, enforcement, and supervision.
• Support Failure—Resources such as personnel,
equipment, material, supplies, or facilities are not
provided or are insufficient
Hazardous conditions and unsafe or inappropriate
behaviors you see in the workplace are the
observable symptoms or effects of deeper system root
causes.
 
 Surface symptoms:

  Are unique conditions or individual behaviors (you can

point at a person or object)
 May exist or be performed by anyone, anytime, anywhere
 May directly cause or contribute to an incident or accident
   May be important clues revealing root causes.
 An accident does happen due to Sub-standards
conditions and practices in the work places.
SUB-STANDARD
CONDITIONS
1. Poor housekeeping /
disorderly work places;
2. Insufficient ventilations,
illumination, safety signs;
3. Defective tools / protection
equipment, appliances;
4. Defective / inadequate
equipment, tools,
appliances;
5. Inadequate stowage of
hazardous, dangerous and
explosive materials;
6. Defective and inadequate
spare parts / stores;
7.Inadequate information.
SUB-STANDARD PRACTICES
1. Miss-operation of machinery /
equipment / instrument;
2. Improper handling of
hazardous materials and fire
hazards;
3. Failure to use personal
protective equipment;
4. Using improper equipment /
tools;
5. Working under the influence
of alcohol and/or drugs;
6. Poor information for safe
work;
7. Improper communication;
8. Non observance of rules &
regulations;
9. Improper hand over/report;
The basic causes of sub-standard conditions/practices
are personal factors and job factors. Examples are
as follows:

PERSONAL FACTORS
1.  Lack of knowledge;
2.  Lack of skill;
3.  Inadequate physical capability;
4.  Inadequate mental capability;
5.  Lack of emergency response capability;
6.  Physical stress;
7.  Mental stress;
8.  Improper motivation.
JOB FACTORS
1.  Inadequate leadership / supervision;
2.  Inadequate operation;
3.  Abuse or misuse;
4.  Inadequate work standards;
5.  Inadequate tools and equipment;
6.  Inadequate purchasing;
7.  Inadequate maintenance;
8.   Wear & tear;
9.   Force Majeure;
10. Non-conformity of shore support.
Diagnose and Treat the Underlying
Root Causes!
 
To eliminate the visible surface
symptoms or effects, we need
to accurately diagnose and
treat the underlying root
causes for 95% of all
workplace accidents: the
inadequate design and
performance of the safety
management system.
 System design Weaknesses – Inadequate
planning and development(Failure to plan
the work)
Characteristics:
   Missing or inadequate policies, plans, programs,
processes, procedures
   Missing or inadequate resources - money, time,
people, materials, etc.
   The deep root causes for most accidents
 
Effects:
   Cause system performance failures
 
 System Performance Weaknesses - Failure to
accomplish action plans (Failure to work the
plan).

Characteristics:
   Failure to effectively accomplish safety policies,
plans, processes, procedures or practices
   Failure to provide training, resources, enforcement,
supervision, and leadership
 
Effects:
   Cause common hazardous conditions and/or unsafe
behaviors
 Cause repeated unique hazardous conditions and/or
unsafe behaviors
 Types of Hazard Assessment

Hazard assessment, which involves hazard

identification, is the first step of the hazard
management process. There are basically
three types of hazard assessment that can be
applied in hazard management. Depending on
the time available, complexity of the tasks or
activities and the level of participation, the
following types of hazard assessment should
be adopted.
• Quick hazard assessment—This technique is used
when the task or activity to be performed is simple or
straightforward and there is little time available for
planning. The conduct of Tool Box Meeting (TBM) is
the best example for this assessment.
• Deliberate hazard assessment—This technique is
used for tasks or activities that are moderately
complex or with significant risks. Time is available for
planning and detailed coordination is required to
ensure smooth execution of the tasks/activities. (Ex.
Arrival & Departure Safety Meeting)
• In-depth hazard assessment—This method is used
when the tasks or activities involved are complex,
large scale or high risk. It requires input from experts
and ample time is available for detailed planning and
coordination, which may involve several parties. (Ex.
Voyage Planning)
 Hazard Assessment Process
The objective of the hazard assessment process is to
determine the potential impact of the hazards on the
operation. The process examines each hazard in terms
of probability (how likely it will occur) and severity (how
badly the effect is if a mishap does happen) to determine
the risk level of the incident resulting from exposure to
the hazards. The outcome of hazards assessment is to
determine the level of risk (ranges from extremely high to
low) associated with a particular hazard and to provide
an estimate of the overall risk to the operation caused by
hazards that cannot be eliminated. (i.e. Force Majeure)
 Hazard Probability

Each hazard can be assessed in relation to

the probability of a hazardous incident. The
probability estimate for each hazard may be
based on the task, courses of action (COA)
being developed, or frequency of a similar
event. Assessment should be made on the
impact of each hazard in terms of
probability or how likely it will occur.
 Hazard Severity

The severity of each hazard is

expressed in terms of:
• Degree of injury or illness
• Loss of or damage to equipment or
property
• Environmental damage
• Other impairing factors
The degree of severity estimated for each
hazard may be based on knowledge of the
results of similar past events. The Roman
numerals in italics following each degree (1
through 4) provide symbols for depicting
severity. For example, (4) represents the
catastrophic degree of severity. A summary of
the four degrees of hazard severity are:
Catastrophic
Critical
Marginal
Negligible
 Making Risk Decisions
When making decisions, the control
options selected to eliminate the
hazard or reduce the risks must take
into consideration the task or mission
requirements. The key consideration in
making risk decisions is to determine if
the risk is justified.
 Risk Decision Level
The supervisor directly responsible for the
task should make risk decisions. Risk is
accepted if the potential benefits outweigh
the costs. However, when the risk is high
or extremely high, it should be taken to the
Shore Technical Officer for a decision.