JAPAN P& I CLUBVol.51 June 2021

P&I Loss Prevention Bulletin
The Japan Ship Owners'Mutual Protection & Indemnity Association Loss Prevention and Ship Inspection Department

Risk Assessmentin PracticeContents§1 Introduction ……………………………………………………………………………………… 2§2 Risk Management
2-1
What is risk? …………………………………………………………………………………… 6
2-2
Risk management ……………………………………………………………………………… 7
2-2-1 The need for risk management ………………………………………………………………… 8
2-2-2 What is risk management? …………………………………………………………………… 8§3 Risk Assessment
3-1
Fundamentals of risk assessment ………………………………………………………………10
3-2
Why risk assessment is necessary ………………………………………………………………11
3-3
Effectiveness of risk assessment ………………………………………………………………14
3-4
Risk assessment structure ………………………………………………………………………15
3-4-1 Identifying hazards ……………………………………………………………………………15
3-4-2 Risk analysis ……………………………………………………………………………………19
3-5
Why is risk assessment not effectively utilized on a vessel and/or by ship management companies?
= Problem areas = ……………………………………………………………………………36
3-5-1 The difficulty of incorporating risk assessment on board a vessel …………………………………36
3-5-2 Psychological factors ……………………………………………………………………………38
3-5-3 The blurring line between safety and danger ……………………………………………………40
3-5-4 An absence of human resource development to identify risks ……………………………………41§4 How to Handle Risk Assessment
4-1
Fundamental countermeasures …………………………………………………………………42
4-1-1 On the vessel …………………………………………………………………………………42
4-1-2 Management at shore catering department: shipowner and ship management company …………43
4-2
Risk assessment in practice ……………………………………………………………………45
4-2-1 Practice ………………………………………………………………………………………45
4-2-2 Functional sustainability…………………………………………………………………………45
4-3
Risk assessment procedures ……………………………………………………………………46
4-3-1 From the perspective of frequency, likelihood (probability) and severity ……………………………46
4-3-2 Procedure (Example) (Fig. 23,24 Attachments 4 and 5) …………………………………………48
4-3-3 Risk assessment example = rough weather preparation = ………………………………………50
4-4
How to handle risk assessment: summary ………………………………………………………64§5 Case Study Analysis of an Accident
5-1Date and time of occurrence and vessel particulars ………………………………………………66
5-2
Timeline of events leading up to the accident ……………………………………………………71
5-3
Determination of accident cause by the Japan Transport Safety Board and Japan Marine Accident
Tribunal ………………………………………………………………………………………76
5-4
Countermeasures to prevent recurrence by shipowners and the Japan Transport Safety Board ……77
5-5
4M5E analysis …………………………………………………………………………………77
5-6
Accident cause from the perspective of human error ……………………………………………84
5-7
Risk assessment (Fig. 54, see Attachment 22) ……………………………………………………87

5-7-1 Physical countermeasures ………………………………………………………………………88
5-7-2 Administrative countermeasures（How to break the chain of human error）………………………90§6 Conclusion …………………………………………………………………………………………92
References …………………………………………………………………………………………93= Attachments =Attachment 1 Quantified risk assessment index guidelines (criteria) : Severity …………………………94
Attachment 2 Quantified risk assessment index guidelines (criteria) : Frequency of occurrence …………94
Attachment 3 Risk assessment index guidelines (criteria): Risk severity assessment and classification …95
Attachment 4 How to fill in the Pre-work risk assessment table ………………………………………96
Attachment 5 How to fill in the Risk assessment table …………………………………………………97
Attachment 6 Risk assessment examples Pre-work assessment table: Preparation of Deck 1 for rough weather … 98
Attachment 7 Risk assessment examples Pre-work assessment table: Preparation of Deck 2 for rough weather … 99
Attachment 8 Risk assessment examples Pre-work assessment table:
Preparation of Deck for rough weather ………………………………………………………100
Attachment 9 Risk assessment examples Pre-work risk assessment table:
Preparation of Engine 1 for rough weather …………………………………………… 101
Attachment 10 Risk assessment examples Pre-work risk assessment table:
Preparation of Engine 2 for rough weather …………………………………………… 102
Attachment 11 Risk assessment examples Risk assessment form :Preparation of Engine for rough weather …………………………………………… 103
Attachment 12 Risk assessment examples Pre-work risk assessment table:
Preparation of catering department 1 for rough weather ……………………………… 104
Attachment 13 Risk assessment examples Pre-work risk assessment table:
Preparation of catering department 2 for rough weather ……………………………… 105
Attachment 14 Risk assessment examples Risk assessment form:
Preparation of catering department for rough weather ……………………………… 106
Attachment 15 Vessel A Quay collision accident Accident timeline …………………………………… 107
Attachment 16 Vessel A Quay collision accident Maritime Accident Summary of Related Facts ……… 108
Attachment 17 Maritime Accident Accident Cause (Unsafe behaviour): Vessel A Quay collision accident … 109
Attachment 18 Maritime Accident Accident Cause (Unsafe conditions): Vessel A Quay collision accident … 110
Attachment 19 Maritime Accident Analysis using 4M5E and Countermeasure List (Unsafe behaviour):
Vessel A Quay collision accident …………………………………………………… 111
Attachment 20 Maritime Accident Analysis using 4M5E and Countermeasure List (Unsafe conditions):
Vessel A Quay collision accident …………………………………………………… 112
Attachment 21 Human characteristics, Human error and Psychology :Vessel A Quay collision accident … 113
Attachment 22 Pre-work risk assessment table: Vessel A Quay collision accident …………………… 114

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P&I Loss Prevention Bulletin§1

Introduction

In the seminars that we conducted and in the Loss Prevention Bulletins, we have statedthat “the root cause behind marine casualties is approximately 90% the result of a chainof human errors.” However, unfortunately, it is not possible to eliminate the occurrenceof human error, thus in order to prevent maritime accidents, it is important to “break the
chain of sequential errors”.
When considering measures to prevent maritime accidents, we have shown that thesecan be chiefly classified into three specific methods (shown in Fig. 1) that are aneﬀective means of preventing further accidents.

① Eﬀective practice of BRM/ERM

How to break the chain of human error
in actual ship operation and work scenarios②４M５E analysis

Countermeasures to prevent
recurrence based on analysis
of past accidents and trouble③ Risk assessment

The meeting of all parties involved todetermine countermeasures that prevent
accidents and problems before they occur

Fig. 1 Three maritime accident prevention measures

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JAPAN P& I CLUB
① Effective implementation of BRM/ERM (Bridge/Engine RoomResource Management)This is a method that breaks the chain of human errors on the spot. Even experienced
Masters and Chief Engineers (C/E) can make mistakes because they are human beings.
Thus, BRM/ERM is a system that supports the duties of those involved in a cohesive
manner so that one person’s mistake does not cause a dangerous situation whereby teammembers and resources around him/her can quickly recognize and correct the mistake intime.
“Communication between each resource” serves as the basis of this and is illustrated in
the M-SHELL Model (Fig. 2) below.

〈 M-SHELL Model 〉
      

S
H
E

M


M

Management（managing and utilizing SHELL)

Fig. 2

L

BRM・ERM
M-SHELL Model② Planning of measures that prevent maritime accidents through
4M5E analysis
In the event of a maritime accident occurring, in addition to the analysis from a physicall
point of view, there is a method of developing countermeasures to prevent the same
type of accident from occurring again by (1) identifying the event from the point ofview of the “4Ms” of failures, i.e. Man, Machine, Media (working environment) and3

P&I Loss Prevention Bulletin
Management, (2) analysing the result of (1) in terms of why the “Unsafe conditions”
and “Unsafe behaviour” (Fig. 3) occurred, and (3), based on the results of (2) analysis,
formulating countermeasures for each of the “5Es”, i.e. Education, Engineering,
Enforcement, Example and Environment. This method has been developed and adopted
by NASA (National Aeronautics and Space Administration) for accident investigation.
Although this method has been commonly used in the manufacturing industry, it is notwidely spread in the marine industry: because it is originally less familiar, and, unlikein the manufacturing industry, accident causes are to be often found in human nature
following a deeper analysis, which is where problems arise. For more details, pleaserefer to the Loss Prevention Bulletin Vol.50.

    
   ：         

            

Fig. 3      
     !      

Unsafe conditions and Unsafe behaviour

Source: Japan Industrial Safety & Health Association,“Seminar on Case
Studies:Accident Analysis and Countermeasures”

4JAPAN P& I CLUB
③ Devise countermeasures that prevent maritime accidents throughrisk assessment
Risk assessment is the method designed for crew to examine the risks involved in theirduties on board the vessel, especially when carrying out irregular work, and to develop
countermeasures in advance. The idea is to share this information with all parties
involved, including other management personnel at the shore catering department suchas the shipowner, ship management company, charterer and so on in order to prevent
accidents before they occur.
In 1999, in the manufacturing industry on land, Guidelines on Occupational Safety and
Health Management Systems (Note 1) was introduced along with the Industrial Safety
and Health Act (Act No. 57, 1972) and Risk management legislation.
However, later during 2010, the International Maritime Organization (IMO) createdthe ISM Code (International Management Code for the Safe Operation of Ships
and Pollution Prevention). When this Code was revised, many companies wererecommended to introduce a Risk management approach and incorporate it into their
Safety Management System (SMS) and Safety Management Code, however, these are
yet to be implemented successfully.
Note 1: OSHMS stands for Occupational Safety Health Management System.
(Ministry of Labour Notification No. 53, April 30, 1999 (Guidelines on Occupational
Safety and Health Management Systems)

In terms of ship operations, based on a full understanding of the above proposed
approach to prevent disasters (accidents) “ ② 4M5E analysis” and “ ③ Risk
assessment”, it is a requirement that related parties be aware of “ ① BRM/ERM” while
putting these into practice in the field. This time, the author will describe what is entailedin Risk Assessment.

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P&I Loss Prevention Bulletin§2 Risk Management

2-1 What is risk?
According to “Risk management principles and guidelines” of JIS Q 31000, risk isdefined as follows:

Definition of risk: the effect of uncertainty on objectives
On the other hand, the International Safety Standards ISO/IEC Guide 51 defines “risk”
as a “combination of the probability of occurrence of harm and the severity of that harm”
and that “the probability of occurrence includes the exposure to a hazardous situation,
the occurrence of a hazardous event and the possibility to avoid or limit the harm.” Also,in IMO, risk is defined as the combination of the frequency and the severity in MSCMEPC.2/Circ.12/Rev.2 (Annex, page 4).
In accordance with Japan’s Industrial Safety and Health Act, the Ministry of Health,Labour and Welfare (MHLW) has established “Guidelines on Occupational Safety and
Health Management Systems” (Ministry of Labour Notification No. 53, April 30, 1999),
which was partially amended by the Ministry of Health, Labour and Welfare Notification
No. 54 on July 1, 2019. In section 3 (implementation details), risks are defined asfollows:

Risk:

6

Severity of the injury or illness that may result from the danger (hazard)or harm and the degree of likelihood or possibility of its occurrence.
(Provisional translation)

JAPAN P& I CLUBIt is necessary to understand that “crisis” means an intense difficult and dangerous
situation that has already occurred, and that risk is not the same thing.

“RISK” ≠ “hazard” or “crisis”
As mentioned above, “risk” is considered to be “something uncertain that has not yet
occurred” and can be expressed as a function of the degree and probability (frequency)of adverse effects resulting from the presence of a “hazard” lurking in the course ofcarrying out work on board: dangers that are not present now, but which can be foreseen
to occur in the future.

“Risk” = “degree of impact” × “frequency”
This will be further described in chapter 3.

2-2 Risk management
The ISM Code contains the following provisions relating to risk management: Quoted
from ClassNK’s amendments to the International Safety Management (ISM) Code. (Theamendments entered into force on 1 January 2015.)
1.2 Objectives
1.2.2 Safety-management objectives of the Company should, inter alia:.1 provide for safe practices in ship operation and a safe working
environment;.2 assess all identified risks to its ships, personnel and the environment
and establish appropriate safeguards; and.3 continuously improve safety-management skills of personnel ashore
and aboard ships including preparing for emergencies related both tosafety and environmental protection

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P&I Loss Prevention Bulletin
The ISM Code refers to risk as: “We do not prescribe any particular method of risk
management and it is for the company to choose the appropriate method for its
organisation, its vessels possessed and its routes.” (Provisional translation). Let us
examine this in detail.

2-2-1 The need for risk management
With the collaboration of the shipowner, ship management company and crew,by specifying the series of processes of the PDCA cycle: (P: Plan）→(D: Do）→(C: Check)→（A: Action）and by promoting continuously and proactively safety
management activities, the aim of risk management is to reduce the potential hazards
that can cause accidents and disasters and create a comfortable working environment onboard, at the same time.
The absolute number of accidents has decreased since the ISM Code and the Safety
Management Code was introduced, however recently that rate of decrease has slowed
down. There is a decrease in the number of experienced crew who have accumulated
safety management know-how. Also, because it is common to have mixed boarding of
foreign crew on ocean going vessels, there is a diﬀerences in culture and customs foreach country. As a result, safety management know-how on board is not sufficiently
passed on, leading to the fear that this may not be passed on to the next generation,
which could cause further accidents.
Under these circumstances, without leaving operational safety measures to thevessel only, it is required that the shipowner and the ship management company also
be responsible for establishing a system of safety management to be implemented“systematically” and “continuously”, and for it to be planned and used in an integrated
and appropriate manner.

2-2-2 What is risk management?
As mentioned above, risk management is the process of systematically managing risks

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JAPAN P& I CLUBto avoid or mitigate losses.
In addition, a risk management structure mainly consists of “risk assessment” and “riskmanagement (risk response)”. Moreover, it consists of “risk identification” and “riskanalysis”, and “risk analysis” consists of “risk evaluation”, “risk management” and“communicathion”.
Risk management has been introduced as a business management technique toeﬀectively deal with unforeseen losses caused by various hazards at minimum cost. The
background to this is that, with the enforcement of the Companies Act in 2006, it became
necessary for joint-stock companies to establish a “system for the management of therisk of loss”. In addition, the Japanese version of Sarbanes-Oxley (SOX) Act (Financial
Instruments and Exchange Act) came into force in 2008, requiring the development of a“financial risk management system”.
As a result, it has been said that we have moved from an era of compliance to an eraof risk management, and in recent years, risk management has been in the spotlight inbusiness management, also.
Until now, it seems that risk management was implicit in the decision-making processof any company, but with the introduction of new legislation and increased awarenessof risk management, risk management has moved from being implicit to being explicit(visible).

Risk management
Risk assessment
Risk
identiﬁcation

Risk analysis

Evaluation
Management
Communication

Risk response
Continuous improvement (Kaizen) through PDCA
Fig. 4

Risk management conceptual diagram

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P&I Loss Prevention Bulletin§3

Risk Assessment

3-1 Fundamentals of risk assessment
Risk assessment is to ensure the safety of the vessel and crew’s good health, and suchdays when people used to say, “We simply need to comply with the law,” are gone. Now,
the shipowner and ship management company are also expected to take all possible
measures to ensure the safety of the ship and the well-being of the crew and not leave
the burden of safe operation at sea entirely to the vessel.
Therefore, shipowners and ship management companies need to ensure that their ship
management incorporates “methods that maximise health and safety standards wherever
possible”, and one of the most eﬀective ways to achieve this is through risk assessment.
In recent years, many shipping companies have developed and set up their own crisis
management and specialised risk management departments. Meanwhile, internal audits,potential accident reports and risk prediction (KY: Kiken Yochi) activities have beencommonly used to identify the risks existing on board and to establish safety measuresin advance.
In a broad sense, these activities are part of risk assessment. However, risk assessment
is, in addition to these empirical activities, characterised by a systematic and logicalapproach to the development of safety measures.

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JAPAN P& I CLUB

3-2 Why risk assessment is necessary
In the past, the basic approach to prevent a disaster (accident) on board was toinvestigate the cause of an accident, formulate measures to prevent recurrence of similar
accidents, and ensure that all ships were aware of these countermeasures. This was a socalled “responsible pursuit type” measure or a “grave-post type” measure in which theperson involved in the accident was punished, the relevant parties briefed on the accident
and then the case closed.（For details, please see “Thinking Safety”, Loss Prevention
Bulletin Vol. 35）.
However, it has been recognised that learning from past disasters (accidents) is notenough when it comes to formulating recurrence preventive countermeasures.
When a crew member, who is a professional operator of the vessel, causes an accident
despite being aware of the potential danger, the preventive measure is to ask “Why
did the crew member behave in such an “unsafe” way? Based on the fact that 90% of
the root causes of marine accidents are a chain of human errors, we have “identified
technicians’ common characteristics”, “human characteristics”, “psychological factors”
and “human brain capacity” that may cause human errors. Therefore, it has become
necessary to analyse the causes of accidents in terms of such factors which cause humanerrors, and carry out “preventive countermeasures” to find out what can be done to avoid
such situations. Thus, the need for “preventive countermeasures” has increased.
It is therefore necessary to introduce a risk assessment approach that pays attention topotential hazards and one that takes proactive countermeasures, in order to eliminate or
reduce the risks that exist on board, and to further promote fundamental safety on board,
thereby improving safety standards. Figure 5 illustrates this.

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P&I Loss Prevention Bulletin

Follow-up
approach
Health and safety
management thatlearns from past
accidents

Front-end approach
Eliminate or reduce risk＋
Follow-up approach
Health and safety
management that learns
from past accidents

Fig. 5 From Follow-up approach to Front-end approach Source: Risk Assessment Training
Materials by Japan Industrial Safety and Health Association (JISHA)

In addition, in Article 5 of the Labour Contracts Act (Consideration to the Safety of aWorker), the duty of care for safety is set out in the following.

＝ The Labour Contracts Act (Article 5) ＝In association with a labour contract, an Employer is to give the necessary
consideration to allow a Worker to work while ensuring the employee’s physicalsafety.

That is to say that, as mentioned above, in recent years we have moved from an era of“compliance” to an era of “risk management”. Figure 6 illustrates this.

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JAPAN P& I CLUBScope of statutory
requirements
Scope of obligation
for industrial accident
compensation

Laws and regulations(instructions)

Criminal responsibility
Obligation effort
Public notices, guidelines and notices

Administrative
responsibility
Company regulations
and operation standards

Civil liability“Foreseeable”and“avoidable” danger
Worker's gross negligence or force majeure

Social responsibility
Scope of obligation
for industrial accident
compensation

Fig. 6

Worker’s intentions

Source: Scope of the duty of care for safety from “Practice of duty of care forsafety from court cases” (Provisional translation). From the Japan Industrial Safety and
Health Association (JISHA), ed.

In other words, the following two duties are needed in order to fulfil the duty of care to
maintain safety:
1 Duty to warn Worker of any danger
To foresee hazards on board, especially potential hazards around the crew.

2 Duty to avoid foreseeable consequences
Risks to be eliminated or isolated/mitigated. Or, for residual risks thatstill remain, the crew needs be aware of their existence in order to takecountermeasures in daily shipboard health and safety to prevent accidents
from occurring.

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P&I Loss Prevention Bulletin

3-3 Effectiveness of risk assessment
By carrying out a risk assessment, we can expect the following benefits:1

Not only crew but also shipowner and ship managementcompany can share their perception of risk
By carrying out a risk assessment on board and reporting it to the shipowneror ship management company, there is a common understanding of the risks
existing on board.

2

Increased sensitivity to risksThis increases the sensitivity of everyone involved to better understandrisk, and enables them to deal with risks that might otherwise have been
overlooked.

3

Enable physical countermeasures to be taken with a focus on
fundamental safety
By sharing safety measures that were previously left to the vessel or onboard, it will be possible to establish safety measures in advance that
correspond to the risk level. In particular, it will enable the promotion ofphysical countermeasures that focus on fundamental safety (see below ⑤ ).

4

Reasonable prioritisation of safety measures
Countermeasures taken to eliminate, reduce or isolate risks to below an
acceptable level of risk, and the results of the risk assessment etc. canalso determine the order of priority.

5

Reasonable countermeasures taken in terms of cost-eﬀectivenessIn the event of ③ taking any physical countermeasures as in the above
cases, costs will also be incurred. By speciﬁcally considering the urgency
and funding of each risk countermeasure, it will also be possible to selectthose that are reasonable from a cost-beneﬁt perspective.

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JAPAN P& I CLUB6

The reasons from a management approach: what to follow,
etc. are clear for residual risks
Residual risk inevitably remains, even after elimination, reduction or
isolation. In such cases, the response must be left to the ship's crew, with
the necessary management measures put in place. If the crew is involved
from the beginning, as they will understand the reasons, such as why they
have to work with care, what needs to be followed will be observed.

3-4 Risk assessment structure
Risk assessment starts with identifying hazards (harmful events) and then analysing therisks identified. The analysis is then assessed, the frequency of occurrence (probability)
and the impact of risks (severity), and measures (controls) are then put in place
according to the required level of risk, which is the product of frequency of occurrence
and impact. It is a series of processes comprising of the effective communication ofthese measures to relevant parties. (See Fig. 7）

Risk Analysis

Risk

Risk

Identiﬁed

Evaluation

Risk

Management(Response)

Risk

Communication

Fig. 7 Risk assessment process

3-4-1

Identifying hazards

The first step in risk assessment is to identify the hazard and the source of the hazard of
the machinery, equipment, work activities and environment in question (work activities,
work location, etc.) This is the most important task in carrying out a risk assessment.

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P&I Loss Prevention Bulletin

Knowing the diﬀerences between hazards and risks
It is important to distinguish the diﬀerence between hazards and risks. A “hazard” can be
defined as “anything that has the potential to cause injury or trouble”. This includes
not only the ship’s equipment and machinery, but also environmental and human factors.
However, no matter how many of these hazards exist on board the vessel, no injury
or trouble should occur. It is only when the crew are exposed to these hazards that thepossibility of trouble or an accident involving people arises. This “combination of theseverity of an accident caused by the hazard and the likelihood of it occurring” is called
the “risk”. Therefore, even if the hazard exists, if the crew or operator is not present, or
if the crew or operator is not involved in the operation, then the risk does not exist.

Process leading to personal injury or trouble
The process leading to personal injury or trouble is shown in the Figure 8. Personal
injury or trouble occurs when the Hazard and Man or Machinery (the vessel’s equipmentetc.) meet. This type of thinking is also used in risk prediction (KY) activities to assess
the current situation.
A “dangerous situation” occurs when a person or piece of equipment is exposed to(or approaches) a hazard, and a hazardous event occurs when safety measures are
insufficient/inappropriate/faulty. And, when hazardous events occur and “avoidance”
fails, trouble or an accident involving people occurs. As you can see from this process,there are four possible ways to prevent trouble and accidents involving people. For
details, please see P.24 3-4-2 (2) Risk management (response), to be described later.

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JAPAN P& I CLUBEliminate the hazard
Ensure that man and machinery (ship's equipment) are not exposed to (orapproach) the hazard
Have appropriate and suﬃcient safety measures in placeThat the hazardous event is successfully avoided when it occurs



    Contact
!    Are the safetymeasures sufficient?

Adequate/appropriate     

Insufficient/inappropriate/faulty 

  

Can it be avoided(mitigated)?

Successful avoidance

Avoidance failure         

Fig. 8 Process leading to personal injury or trouble

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P&I Loss Prevention Bulletin

Some remarks when identifying hazards on a vessel
Risk assessment begins with identifying the hazard. The following points should betaken into account when identifying hazards on the vessel.

Hazards are to be identiﬁed among all related persons
The more familiar experienced operators are with their duties, the more difficult
it is to identify hazards. It is also necessary to involve the senior officers (Master/Chief Engineer and Chief Oﬃcer/First Engineer) and the crew who will be doing thework, rather than having only the crew, who will be doing the work, perform hazard
identification.
In addition, the identification of hazards from the point of view of inexperienced crew
members is often a blind spot for experienced personnel. It is therefore also important tocheck the work site with all concerned before starting the risk assessment meeting.

Collecting information
Wherever possible, reference information should be obtained from the ship managementcompany or other sources, such as risk assessment reports, accident reports and potential
accidents on other ships.

Review of legislation and company rules
Grasp the relevant laws and regulations, safety management codes and SMS manuals
etc., and start work on the basis of them until covering all manner of work, even if there
are no procedures available (inc. irregular work).

Prioritisation
Where there is more than one task or process, the plan should be developed sequentially,
starting with those that are considered to pose the greatest risk.
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JAPAN P& I CLUB
Although collecting information is an important part of the above work, it should
be noted that the crew changes every few months. Therefore, it is imperative that
information gets passed on, since risk assessment tends to be based on the discretion andknowledge/experience of individual crew members, and becomes ad hoc.
It is necessary not to collect information only when the risk assessment is conducted, but
to organize it on a daily basis, considering it to be useful as a material for conducting
risk assessment, and to prepare a list of materials so that appropriate information can beprovided promptly when the risk assessment is actually conducted. It is also necessary
to prepare a list of materials so that appropriate information can be provided promptly
at the stage of risk assessment and handed over to the successor. For example, one
way to sharpen keen insight and observation will be through daily near misses. The
ship management company is also expected to compile information on each vessel andprovide it to the vessel on a regular basis.

3-4-2 Risk analysis
A “risk analysis” related to safety on a vessel is a framework for preventing theoccurrence or minimising the risk of an accident occurring, rather than cleaning up after
the accident, where the ship’s operations or crew may be adversely aﬀected by a “hazard”
on board or during operations.
This means that all crew members involved in the various operations to be carried out onboard the vessel will hold a briefing before starting work to identify the hazards that canbe expected during the operation, and the kinds of accidents involving people or troublethat may occur.
Risk analysis consists of three elements: Risk evaluation, Risk management (response),and Risk communication, which interact to improve the results of risk analysis.
Remarks: website of the Ministry of Health, Labour and Welfare.

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P&I Loss Prevention Bulletin

1 Risk assessment
The risk assessment assesses the impact of risk posed by a potential hazard on board or
at work, in terms of what type of personal injury or trouble is likely to occur and at what
rate (likelihood or degree of likelihood), and if they do occur, how serious are they likely
to be (severity or degree of seriousness). Then, based on the magnitude of the assessedrisk, determine the priority of reducing the risk and take measures to eliminate or reduce
the risk according to that priority.
Risk is a combination of the probability and severity of a hazard causing personal injury
or trouble. Then, in order to effectively utilize a risk assessment for it to lead to theelimination of risks and reduction measures, it is necessary to determine the criteria forthe “degree of likelihood” and “impact of severity” of risks in the assessment, which arethen divided into several levels.
Moreover, depending on the extent of the likelihood and severity categories obtained
from the risk assessment, the impact of the risk (risk level) posed by the hazard isdetermined. The higher the likelihood and the greater the severity, the higher the risk
level. We then set “priorities for reducing the risk”, starting with those with the highest
level of risk.

Risk assessment setting methods
For classifying the elements of risk, there are largely two main methods in order toassess risk and set priorities: the non-quantified method and the quantified method.

1）Non-quantified method
This is a matrix of severity and probability, and is widely used as an evaluation method
when establishing prevention countermeasures against accidents involving people in the
manufacturing industry on land. Examples are shown in Tables 9-1 and 9-2.

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JAPAN P& I CLUB
Non-quantified assessment and priority setting criteria
Severity

SignificanceSeverely injured

Minor injury

Highly likely

Ⅳ

Ⅲ

Ⅱ

LikelyⅣ

Ⅲ

Ⅰ

Not very likely

Ⅲ

Ⅱ

Ⅰ

Likelihood

Table 9-1

Example of non-quantiﬁed assessment and priority setting criteria

Non-quantified risk level and how to proceed with countermeasures
Risk level

Risk

Approach for risk mitigation

Ⅳ

There is a serious health andsafety issue

Immediate risk reduction measures
Stop work until action is taken (Note 1)

Ⅲ

There is a health and safety issue

Prompt risk reduction measures

Ⅱ

There are some health andsafety issues

Systematic risk reduction measures

Ⅰ

There are only a few health andsafety issues

Risk reduction measures where
necessary (Note 2)(Note 1) Risk level IV is a risk level that is unacceptable for the workplace(Note 2) Risk level I is a level that is broadly acceptable for the workplace
Table 9-2

Non-quantiﬁed risk level and how to proceed with countermeasures

Extract from the Japan Industrial Safety and Health Association (JISHA)

2）Quantified method（Attachments 1, 2 and 3）
This method of numerically assessing risk in terms of two factors, “likelihood/frequencyof occurrence” and “severity”, has been widely adopted in safety management codes and
SMS manuals in the shipping industry.
The likelihood and frequency of occurrence are taken into account comprehensively
and are often classified into three to five levels. The severity of the hazard is usuallycategorized into one to four levels in order to understand the severity (impact) of thepersonal injury or trouble that is expected to occur as a result of the hazard.
A risk assessment is made by multiplying the values obtained from the “Probability and
Frequency of occurrence” and “Severity” assessments. The risk level is then assessed21

P&I Loss Prevention Bulletin
on a scale of 5 levels: LL（very low risk）〜 HH（very high risk）, and each onboard
operation is identified as belonging to one of the risk categories. Finally, the assessment
as to whether or not work can be carried out is based on a comparison of the risk level
reduction between “Before” and “After” measures are implemented. Examples areshown in Tables 10-1, 10-2 and 10-3.

Quantified risk assessment index guidelines (criteria)【Frequency of occurrence evaluation criteria】

Attachment 1

Frequency ofoccurrence

Nominal frequency of occurrence

Probability ofoccurrence5

Level of repeated encounters in a lifetime (occurringin less than 3 to 6 months)

3/10

4

A level that has more than one encounter in a lifetime(occurring about once every six months to a year)

3/100

3

A level that has several encounters in a lifetime（occurring in less than 3 to 5 years)

3/1,000

2

A level that has very few encounters in a lifetime(occurring about once every 5-20 years)

3/10,000

1

A level that is close to zero encounters in a lifetime(occurring once in more than 20 years)

3/100,000

Table 10-1 Example of criteria for setting a quantiﬁed assessment (frequency of occurrence)

Quantified risk assessment index guidelines (criteria)【Severity evaluation criteria】
Level

Health andsafetyPublicconcern

Environment
impactEconomic loss

Management
system4

Death/public
impactWorldwide
media
coverage

Large-scale andlong-term pollution

100 mm yen
above

Completeshutdown

3

Serious injury orillness, limited
public impact

National
press
coverage

Serious pollution

10 - 100 mm
yenPossible
shutdown

2

Minor injury,
small impact
on public

Reported inlocal press

Medium-sized pollutionof medium duration in alimited area

5 mm - 10 mm
yen

Affected1

Minor injury/
no public
impactRarelybroadcasted

Minor pollution or
no pollution

Less than 5
mm yenNo impact

Table 10-2

22

Attachment 2

Example of criteria for setting a quantiﬁed assessment (severity)

JAPAN P& I CLUBRisk assessment Risk index (criteria)【Risk severity assessment classification】
Risk severity
assessment

Level

Region

LL

Very low risk

[Region ofsafety]L

Low risk

Attachment 3
Assessment as to whether or notwork can be carried out

1
2
3
4
5
6
7

M

Medium risk

8

[Region of
uncertainty](Permissible and
ALARP region)[Work possible]
Ensure that risk mitigation
measures are implemented andthat work is carried out in linewith this

※

9
10
11
12
13

H

High risk[Hazardous
region](Regionwherebypermission is
not allowed)

14
15
16
17
18
19

HH

Extremely highrisk[Work not possible]
Where it is necessary to carry out
work in order to respond to an
emergency or for other reasons,the work must not be carried out
without the permission of the
manager, notwithstanding thesafety management regulations.

20※ ALARP AREA： As low as Reasonably Practicable
Table 10-3 Example of criteria for setting a quantiﬁed risk level assessment

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P&I Loss Prevention Bulletin

2 Risk management (response)
Following a risk assessment of the work on board, proactive countermeasures are put
in place for each task. There are chiefly five risk countermeasures: Risk Aversion, Risk
Reduction, Risk Sharing, Risk Isolation and Risk Holding and so on.

1

Risk Aversion（Fundamental Safety）
This is a method to avoid the risk itself. It means to eliminate the causesof risks.

2

Risk Reduction (Functional Safety)
This is a method to minimize the frequency of occurrences and the impactof damage.

3

Risk Sharing
Sharing the risk with organisations other than the vessel (e.g. ship
management companies, shipowners, charterers etc.)
Risk transference and dispersion are two methods of sharing risk. It is
important to prepare for compensation of loss, when a risk becomesapparent as this is an eﬀective countermeasure when insuring. In this case,
it is also referred to as the transference of risk to an insurance company.

4

Risk Isolation (Physical Countermeasures)
A method that does nothing about the risk itself, but rather isolates itwith protective measures.

5

Risk Holding
There is no countermeasure against risk.
This can be said to be accepting the risk, and is used for risks that occur
infrequently and causing little damage, but on the vessel, it is necessary
to share risk information among the crew.

Figure 11 illustrates the relationship between these measures. The graph shows theprobability of a risk occurring on the vertical axis and the severity of the risk on the24

JAPAN P& I CLUBhorizontal axis; by placing each measure in the graph it is possible to observe any
response method tendencies.

High

Risk Possibility(Probability)        

  

Low
Small

Large

Size of Damage(Impact) when a risk becomes apparent
Fig. 11 Risk management correlation diagram
Source: Information security management and the PDCA cycle：
Information-technology Promotion Agency, Japan（IPA）

An illustration of the existing risks when carrying out work on board is shown in Figure
12.
In this example, the diagram on the left shows that there are five risks on board. Then, arisk assessment was implemented on board before the start of operation, and as a resultof the above mentioned countermeasure in place, three risks remained on board, as
shown in the below diagram.

25

P&I Loss Prevention Bulletin    
Risk Reduction（Functional Safety）

 









Risk Sharing（Passing on Risk）

Risk Aversion（Fundamentally Safe）

Fig. 12    

Risk Isolation

Risk Holding（Risk Acceptance）

Diagram of risk management

However, the reality is that it is diﬃcult to eliminate or remove risks in actual on board
operations. Therefore, it seems that most of the countermeasures are “managing residualrisk”, such as reduction, and risk holding by sharing information among the crew, or
isolating it by means of shipboard work. However, even with these countermeasures inplace, it is a must to be aware that there is still a potential unknown risk that none of thecrew will be aware of. These countermeasures can be prioritised as shown in Figure 15.

Priorities for mitigation measures
a. Essential measures  

Eliminate risks by discontinuing or changing
dangerous work

b. Physical countermeasures
Improve equipment such as protective fences,interlocks and safety devices

c. Administrative countermeasures
Introduce maintenance of manual, off-limit measures,operation of alarms, two-man operations, training, etc.

d. Use of personal protective equipment      To be Implemented only when risks that cannot be     eliminated or reduced despite measures a, b and c.
   
Fig. 13 Priorities for reduction measures

26

High
Priorities for mitigation measures       
 

Low

JAPAN P& I CLUBIn Figure 13, “a. Essential measures” refers to the measures mentioned in Figure 12,
such as removing or eliminating the risk. If these measures are implemented, the risk
itself will disappear from the vessel and safety will be maintained instead.
In addition, “b. Physical countermeasures”, also shown in Figure 12, is a measure suchas isolation, which can be simply dealt with by shipboard work, but it is often diﬃcult toimplement on board in practice because of the cost.
Therefore, these two countermeasures require a response from the company, with little
or no crew involvement.
On the other hand, countermeasures “c. Administrative countermeasures” and “d. Useof personal protective equipment” refer to the reduction and holding of risks in Figure
14, which shows the above mentioned “managing residual risk”. In “c. Administrative
countermeasures”, these are to be considered by both the ship management company or
shipowner and the crew and, possibly incorporated into the safety management code and
SMS manual. However, these countermeasures do not eliminate the risk from the vessel.
In addition, countermeasure “d. Use of personal protective equipment” is only applicable
if the risk level is low and the risk held is determined as is. This is a reactive measure,which assumes that a disaster will occur and mitigates the damage.
Obviously, the priority is higher for “a. Essential measures”, but from the crew’s point ofview, the idea of diﬀerentiating risk levels in this way has never been applicable before,
and they may not be accustomed to the idea of prioritisation per se either.

Residual risk management
Residual risk is defined in the ISO/IEC Guide 51 as “risk (3.9) remaining after risk
reduction measures (3.13) have been implemented”.
As mentioned above, the limited and special working environment of a ship makes it

27

P&I Loss Prevention Bulletindiﬃcult to take essential and physical countermeasures. For residual risks, the concept of“ALARP” as described below is less familiar to the vessel. However, the vessel and the
shipowner and ship management company must be fully aware of these residual risks.

ALARP
ALARP:As Low As Reasonably PracticableAs explained in 10(2) of the “Guidelines and Commentary on the Investigationof Danger or Hazards, etc.” (provisional translation) by the Safety Division of theIndustrial Safety and Health Department, Ministry of Health, Labour and Welfare(MHLW) in 1999, risk is the “concept of reducing risk appropriately to as low alevel as is reasonably practicable (ALARP) by implementing higher priority risk
reduction measures as far as reasonably practicable.” (Provisional translation)

Risk can be divided into the following three areas:(Figure 14)(a) An area of risk where the risk is too great to be tolerated at all(Intolerable).
(b) An area where the risk is considered to be small or too small. A
generally acceptable risk (Broadly acceptable).
(c) Area between (a) and (b), and it is required to be reduced to a level thatis realistic, taking into account both beneﬁts of accepting that risk level
and the costs of further reducing it (ALARP region).

There are a large number of explanations regarding the ALARP region, but it has not (andcannot) been defined as to what risk level reduction is acceptable, as it varies from caseto case.

28

JAPAN P& I CLUBUnacceptable area（ 

ALARP（ 
        

Broadly acceptable area

Fig. 14 ALARP region

Please note that the acceptable risk level is not future-proof, but constantly changing, as
it is determined by the below factors:
The values of todayʼs society
The search for the best balance between the ideal of absolute safety andwhat can be achieved
Requirements/speciﬁcations that are compatible with the task (system)
Optimality factors for objectives and cost eﬀectiveness

Remarks on risk management(countermeasures for risk reduction)
The following points should be noted when considering and implementing
countermeasures for risk reduction.

When formulatingThis is to be carried out mainly by supervisors such as the Master/Chief
Engineer and Chief Oﬃcer/First Engineer. If necessary, a draft proposal

29

P&I Loss Prevention Bulletin
is drawn up, with advice from the ship management company and otherexperts.
It is important that a broad range of risks is extracted. The ﬁrst step inthis process is to specify the diﬀerences between direct and deliberateactions and reasonably foreseeable misbehaviours or error in operation .
Then, based on the purpose of the work and the environmental
conditions of the workplace, the work process then needs to beclarified. At the same time, naturally assuming that people makemistakes and errors , we need to be able to anticipate the kinds of
mistakes and errors that people will make, to get a full picture of theseand to identify weaknesses in advance.
It is important to check if the draft conforms with the standard of laws
and ordinances, safety management codes and SMS manuals.
In addition, any mitigation measures that have been formulated need to
be checked that they have not created any new risks.
The possibility of transferring the risk through Essential or Physicalcountermeasures is to be also considered.
The mitigation measures (a draft proposal) prepared by the supervisors
such as Master/Chief Engineer or Chief Officer/First Engineer are to
be explained to the crew and all ideas that can be put forward are
discussed and reﬁned. The ﬁnal risk reduction measures are then sharedwith the shipowner and ship management company.
The shipowner and ship management company should re-evaluate therisk reduction measures developed by the vessel and feed back theresults to the vessel.
No mitigation measures should be taken that intentionally (or arbitrarily)
reduce the risk level. Also, verify which risk factors (hazards) are aﬀectedby the mitigation measures to be implemented.
Countermeasures that rely on Man/People (crew here) do not, inprinciple, reduce the risk level.
We have to think more on the safe side, bearing in mind that skill levels
vary from person to person.

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JAPAN P& I CLUBWhile working

A supervisor must be present during the work to oversee its
implementation. A record, including photographs, must be kept. It isalso a recommendable idea to create a format for the report form.
Regarding operations in the context of risk reduction and holding, it
is possible that some of the mitigation measures developed cannot
be implemented immediately, or may not function eﬀectively. In thiscase, either provisional measures (obviously more safety-oriented)
must be implemented on board with the approval of the supervisor,or the work must be terminated. In the event of any provisional
measures taken or work terminated, it is a requirement that it
be reported immediately to the shipowner or ship managementcompany to receive advice as well.

After completing the operation

It is important to have a Review Meeting every time to check that
there was no trouble.
The results should be shared with the crew and a record made andreported to the shipowner and ship management company. The
reports from each ship are accumulated as company know-how andbecome a technical resource for the creation of a strong workplace
on board.
The companyʼs management of the database enables it to provide
information to each ship and workplace on board in a timely manner.

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P&I Loss Prevention Bulletin

3 Risk communication
The definition of risk communication is given in “Efforts for risk communication
concerning food safety” in the Ministry of Health, Labour and Welfare’s homepage.

Deﬁnition of risk communication
Risk communication is the mutual exchange of information and opinions between risk
assessors, risk managers, consumers, operators, researchers and other interested parties
during the entire risk analysis process. It includes an explanation of the results of therisk assessment and of the risk management decisions.
Sense of security , which is present progressive［continuous］in form,
is placed on top of safety , consisting of a sequence of events in thepast (including risks acceptable according to science, technology andtechnicians). (Fig. 15)
Regarding the structure of risk communication, safety is formed byscience, technology and technicians; the next level consists ofassessment and risk managementrisk, then on top of that comes risk

communication supporting the sense of security in the shape of two
wedges which mean trust.
The vessel, the ship management company and the shipowner are
all interchangeable. It is important to reassure clients (owner andcharterer) through risk communication about thesafety measuresthat have been established.
In the case of actual work on board, the crew must be able to carry out
their work with a sense of security .

32

JAPAN P& I CLUBIn other words, it is not possible to maintain safety if the Master/Chief Engineer orChief Officer/First Engineer is left holding on to the prevention countermeasures,
against accidents, that have taken so much eﬀort and time to be established, and it is notpossible for the crew to carry out the work with a sense of security.
Therefore, we must communicate the countermeasures we have developed to all parties
involved, and that the risks which are shared, reassurance, and a sense of security
supported by mutual trust, are firmly established. Risk communication is the method toachieve this.

ASenseASenseof
eof
Securityy
Trust

Trust

Risk Communication
Risk Evaluation and Management

SafetyFig. 15 Risk communication connecting safety and sense of security

Figure 12 on P.26 shows five risk countermeasures on board. Inevitably, with on board
operation, it is diﬃcult to take essential countermeasures that exclude or erase risks; we
can only reduce or hold the residual risks that remain. In addition, there are unknown
risks that no one on board will be aware of, and it is in these fluctuating conditions thatthe safety of the ship is maintained. This means that shipowners, ship managementcompanies and charterers etc. have to be prepared for any possible trouble that may
occur on board at any time.
It is necessary to make these risk measures (reduced or held) visible and to share
information between crew members and between the ship and the shipowner or ship33

P&I Loss Prevention Bulletinmanagement company, in order to support each other through mutual trust via risk
communication.
But is there still a lack of risk communication within the vessel and between the
shipowner and the ship management company?
The approach of increasing the level of safety through risk communication is known as
the Johari Window. By analysing information about the self as seen by the self and theself as seen by others, we can understand the self in the following four ways.

The Johari Window model❶ Personality known by the person as well as by others (Public：
Open window)❷ Personality known about the person by a group that the person
is unaware of (Blind spot window)❸ Personality that a person knows about themselves that is kept
unknown to others (Hidden window)❹ Personality that is unknown by the person about themselvesthat is also unknown by others (Unknown window)

Let us consider how this might apply to risk assessment. When blind spots, hidden, andunknown areas are reduced and risks that are existing are shared via risk communication,
the public (Open window) area is expanded. And by reducing these unknown risks asmuch as possible, the safety level is steadily increased. (See Figure 16)
In other words, the Open area specifies that all members within the range of activity,
including the vessel and its land management department (shipowner and ship
management company), are equally aware of the danger, thus proactive measures can betaken.

34

JAPAN P& I CLUBto Self  

to Others  

  




  

 

              Open Self

Blind Self   

             

Hidden Self            

Unknown Self

to Self 

 

 

to Others 


 



Open Self              Blind Self

  

             

Hidden Self 






           
 

Unknown Self

Fig. 16 Johari Window

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P&I Loss Prevention Bulletin

3-5 Why is risk assessment not eﬀectively utilized
on a vessel and/or by ship management companies?
＝ Problem areas ＝Problem areas

As described above, it is understood that the combination of risk assessment and BRM/
ERM described at the beginning of this guide is an effective means of prevention(through countermeasures) against accidents, especially when carrying out any unusual(unfamiliar) work on board. Therefore, why are we not able to carry it out eﬀectively,
despite the fact that we are aware of this?
Seemingly, there are mainly four reasons why risk assessment is not eﬀectively utilized
on a vessel and/or by ship management companies:
It is not easily incorporated on board
Psychological factors
The ambiguity between safety and danger
Human resource problem: The need to train personnel who canidentify risks

The combined eﬀect of these four factors is that risk communication, which is based ontrust among crew members and between ship and shore, does not work eﬀectively andbecomes more diﬃcult to carry out.

3-5-1

The diﬃculty of incorporating risk assessment on board
a vesselIn the first place, risk assessment is one management tool used in corporate management
such as compliance and fraud prevention.
As shown in Figures 6 (on P.13) and 17, the social context in which companies operate
has since changed dramatically that corporate social responsibility is now no longer just lip
36

JAPAN P& I CLUB
service. Compliance with the law and regulations is of course a given, and even if notlegally punishable, companies with poor awareness of compliance, environment and safety
can be seen by public opinion as “below investment grade” which may seriously damage
the business’ reputation and ability to operate. In fact, this has actually happened in the past.
And since the measures established by risk assessment are costly, they are operated
based on the concept of “visualisation: a numerical understanding” of cost-eﬀectivenessthrough an index of frequency of occurrence.

Compliance
Narrowly deﬁned compliance
Compliance with the law
Company level
SMS Manual,
Safety Management Code (Japan),
Employment Rules etc.
Employee level
Common Knowledge,
Technical Level,
Technical Knowledge etc.

Environment

Safety・Act on Prevention of Marine Pollution
and Maritime Disaster・Ballast Water Management Convention
・Energy Efﬁciency Design Index
Convention
・Act on Liability for Oil Pollution Damage
・Ship Recycling Convention
etc.

・Convention On the International Regulations
for Preventing Collisions at Sea (COLREG)
・SOLAS Convention
・International Safety Management Code (ISM)
・Seaman Law/ILO Maritime Labour
Convention
・STCW Convention
etc.

Fig. 17

Compliance in a broad sense37

P&I Loss Prevention Bulletin

On the other hand, a ship is required to “operate with 100% safety”.
This means that safety measures must be implemented regardlessof the frequency or severity of incident occurrence. In other words,
neglecting a risk that is close to zero in frequency on the vessel would
be unthinkable. There was no idea that the crew, as technicians,
would be expected to accept the aforementioned “risk prioritisation”
and “ALARP region” requirement.

Based on this awareness and concept, the results of the risk assessment practised on
the vessel are reported to the ship management company. However, if the managing
departments (managers) are instructed to “take no positive action despite the highseverity of the index due to the cost involved” and feed this back to the ship, those on
board may find this diﬃcult to accept, which may result in a loss of trust between shipand shore.
In particular, when people in higher positions (such as the management layer of amanagement company or the Master of a ship) are two-faced, it only causes confusion
among their subordinates. As a result, on board the vessel as a workplace, they will only
follow instructions from the company and will not “question” a decision.
This may be one of the reasons why risk assessments are not so familiar on board a ship,owing to the diﬃculty of incorporating risk assessments.

3-5-2

Inability to utilize psychological factors effectively

There are psychological factors that prevent risk assessment from being utilized
effectively. This can make risk communication difficult, which in turn makes risk
assessment diﬃcult to practice. There are two main psychological factors here.

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JAPAN P& I CLUB

Factors making "Risk communication" diﬃcult①

Perception gap
for risksFig. 18

Assumptions
about safety②

Factors that make Risk communication diﬃcult

Perception gap for risks

There is a gap between “actual risk” and “perceived risk”.
Hazard perceived to be greater than the actual riskThis is ampliﬁed when faced with unknown risks, little information, or hazards
that we do not understand well or have no control over.

Hazards perceived to be smaller than the actual risk
We have a tendency to believe that it is smaller because of the clear
convenient or beneﬁcial factors, when we attempt to play the hazard down by
ourselves. This is where Normalcy Bias ( Iʼm special, nothing can hurt me!) or
Conﬁrmation Bias ( Stop exaggerating! ) come to the fore.

Assumptions about safety

If, in the 12 Human characteristics that we all have, “ ⑨ Human beings sometimes makeassumptions” comes to the fore, and Normalcy Bias (this is when people believe, “I’mspecial, nothing can hurt me”) is triggered making us assume that this is correct, it will
be more diﬃcult for us to change this way of thinking.(See figure 52)
For example, when on board, are not the following assumed?
Ships are built to be safe.
In the periodic maintenance of the equipment in the engine room, it is not
yet time for open maintenance, because it is within the manufacturer's

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P&I Loss Prevention Bulletin
recommended operating time.
We pass this sea area all the time and there are not many ﬁshing vessels
today, so it will be safe to leave the bridge watch shift to the duty oﬃcer only.
This is what we have been doing all along, and weʼve never had any
problems before, so thereʼs no risk involved. We really do not need topractice a risk assessment of anything.
And so on...

3-5-3

The blurring line between safety and danger

As explained in 3-5-1, unlike the manufacturing industry on land, the environment onboard a vessel does not have the concept of risk prioritisation or ALARP regions. In
addition, the concept of risk did not exist in the Japanese language, but when the methodof risk assessment was introduced here, it could be said that the crew felt uneasy about
the middle ground between danger and safety (Fig. 19).

High risk

Low risk

Impact of risk

Japanese
expressions

Human sense(feeling)

DangerSafetySafetyAnxiety

Danger(We don't know if it is safe or dangerous)

Fig. 19

The blurring line between safety and danger

It is easy for crew or a technician to distinguish the diﬀerence between risks that are, by
anyone’s reckoning, “major and unacceptable”, and risks that are “minor and generally
40

JAPAN P& I CLUB
acceptable”. However, if we do not properly use risk communication for the risks thatlie in between, and fail to connect safety which is supported by the science, physics,
technology and engineers that we have developed, with the sense of security which
is supported by trust that is built on top of it, the result will be the very opposite of
security. This may be one of the reasons why risk assessment has not been successfully
implemented on board.
This is especially true in the case of vessel operations, where the severity of the risk
may be minor, but if it leads to absence from work, it can have a direct impact onother vessel operations as replacements cannot be arranged immediately. In addition,
when shipowners, ship management companies and other shore based management
departments suggest an “interim response: ALARP”, the common nature of technicians(see Loss Prevention Bulletin Vol.50 for more details) means that they have no choice
but to follow the instructions, despite their opposition, which may make them even moreanxious.

3-5-4

An absence of human resource development to
identify risks

It has only been around a decade since risk assessment was introduced to the maritime
industry, this is partly due to a lack of familiarity with the concept of risk assessment onboard ships and in the land management department, and partly due to a lack of trained
personnel to lead risk assessments. It is quite common in the manufacturing industry on
land, and various training courses are oﬀered, so it is a good idea to participate in themfor our human resource development.

41

P&I Loss Prevention Bulletin§4 How to Handle
Risk Assessment
4-1 Fundamental countermeasures
4-1-1 On the vessel
The purpose of risk assessment is to prevent any accidents occurring by communicating
and sharing information about risks such as blind spots, hidden and unknown areas
among crew members, or between the vessel and management at the shore catering
department such as the shipowner and ship management company, in the event ofcarrying out various risky operations.
It is therefore important that the briefing includes all of those involved in the operationand that the results be announced to the crew and shore management, rather than it being
carried out by the Master/Chief Engineer or Chief Oﬃcer/First Engineer only at a desk.
In order for risk assessments to be eﬀective, the following must be taken into account:
The vessel must also be cost conscious. Please note that our top priorities
are safe operations and safety ﬁrst .
What is important in risk assessment is to clarify 5W1H plus 2F1H (Forwhat, For whom and How much (cost conscious) before starting any
work, and to study countermeasures by identifying

what risks

areinvolved on board from an objective and birdʼs eye view and to consider
countermeasures. In particular, it is strictly forbidden to deliberately
underestimate the assessment of severity .
The Master/Chief Engineer or Chief Oﬃcer/First Engineer should also42

JAPAN P& I CLUB
carefully consider and quantify the Frequency to determine the risk level.
In particular, measures to further reduce the risk level must be considered
for those judged to have a medium, high or very high risk level.
Report to the person in charge of the company once the pre-operationalrisk assessment of the vessel has been completed. In this case, for thosewith a medium, high or very high level of risk, further explanation will need
to be provided as to why the level of risk could not be reduced to low orvery low and the kind of work necessary when planning countermeasures.

4-1-2

Management at the shore catering department：
shipowner and ship management company

Once the results of the pre-operational risk assessment of the vessel have been received,
the ship’s superintendent should not carry out the assessment by him or herself as amanagement representative, but should ensure that the contents of the report from thevessel are reviewed by several parties, including the risk manager. Management at theshore catering department such as the shipowner and ship management company shouldnote the following points when assessing the report from the vessel.
For those with a medium risk level (region of uncertainty) or low risk level (regionof safety), the content should be examined and additional advice given asnecessary.
For high/very high risk levels reported as hazardous areas, measures should
be considered with a view to on shore support.
The results of the evaluation and feasibility of the work determined by the land
management department must be fed back to the vessel prior to the planned
start of operation. This must always include the following information. Without
such an explanation, trust between ship and shore will erode.
Company is to decide on whether or not work can be carried out based on the
results
Additional countermeasures to be taken by the company to reduce the level of risk
Clear instructions on the timing and location (port) of implementation
If not implemented, a reasonable reason for not doing so, is to be provided,

43

P&I Loss Prevention Bulletin
etc.

Close

communication between

ship and shore based on trust
Fig. 20

The importance of mutual trustMore importantly, if top management does not implement
the countermeasures taken both on board and on land, their
existence will quickly become meaningless. It is no exaggeration
to say that “awareness raising” at management level is key to thecontinuation of risk assessment.

If top management does not implement
the countermeasures themselves, their
existence will quickly become

meaninglessFig. 21 Top management practice44

JAPAN P& I CLUB

4-2 Risk assessment in practice4-2-1 Practice
As explained in §3 3-5, Why is risk assessment not effectively utilized on a vessel
and/or by ship management companies? “=Problem areas=”, we understand that risk
assessment is an eﬀective accident prevention measure, but know also that it is not yet
at a practical level to be easily carried out. However, there is no need to dwell on thistoo much, because it will be incorporated more easily if we think of it as simply making
something that has been done implicitly on board the ship “Visualization” by using arisk assessment table.
Unlike land-based industries, including manufacturing, where crews change every few
months and are far removed from management, a risk assessment can increase the levelof safety.
In particular, before carrying out any unusual (unfamiliar) work (e.g. tankinspections, open maintenance or repair of critical equipment, work on
board while in dock)
For routine tasks such as weighing the anchor, entering or leaving port, etc.
when the crew changes

4-2-2 Functional sustainability
In order for risk assessment to be functional, it is necessary to have a predetermined
system of organisation and review procedures. It is therefore essential to regularly
review and improve the organisational systems that enable risk assessment to take place.
The key elements of a risk assessment are:Creating a risk assessment system
By enabling the organisation to be capable of utilizing risk assessmenteﬀectively

45

P&I Loss Prevention Bulletin
Speciﬁc rules are needed such as At what stage, who by, and when is it tobe conducted? and How will the results be utilized?
Regular risk assessment reviews are also important (To be aware of theneed to respond in a timely manner to changes in societyʼs tolerance levels)
Practise as early in the process as possible (phases of design and planning)
Risk assessments should be repeated for designs with changing tasks
or objectives and for new or revised critical processes that have beenplannedPractise from a variety of perspectives, including with multiple personnel
members
Consider all processes in the operation procedure
Information should be collected at the earliest opportunity in order toevaluate, review and take action
The results of the review should be stored in a database and used whenplanning subsequent new work or work that needs to be redone
Human resource development to identify risks
Continue to gather, review, evaluate data and consider public informationin the search for the best solution after the work has been carried out

4-3 Risk assessment procedures

4-3-1

From the perspective of frequency, likelihood(probability) and severity

As we have seen in detail in Chapter 3, if we now summarise the processes leading topersonal injury and trouble in terms of “frequency, likelihood and severity”, we can see
the relevance, as shown in Figure 22.

46

JAPAN P& I CLUB

Frequency

 

! 

"

Contact
#      

Occurrence
probability ofhazardous
event

Probability

Possibility ofrisk avoidance

Are the safetymeasures sufficient?

Adequate/appropriate   

Insufficient/inappropriate/faulty$

 %  

Can it be avoided(mitigated)?

Successful avoidance

Avoidance failure

Severity            

Fig. 22 Process leading to personal injury or trouble and its relationship with frequency /probability/severity

Identify the frequency of dangerous situations, examine the occurrence probability ofhazardous event avoidance, and assess the severity of personal injury and trouble if risk
avoidance fails.

47

P&I Loss Prevention Bulletin

4-3-2

Procedure (Example)(Fig. 23 and 24 Attachments 4 and 5)

Pre-work assessment table (Fig. 23) and Risk assessment table (Fig. 24) are to be usedhere.
On the Vessel

A risk assessment meeting is to be held with the related crew members regarding thework to be carried out.
Identify possible risks and hazards where possible and determine the level of risk
using the Pre-work assessment table.
For each of the risks identified, measures are considered and changes in the risk level
are assessed.

This is then compiled and reported to the management department responsible
such as the shipowner or ship management company on shore.

Management at the shore catering department：
shipowner and ship management company

A risk assessment meeting is to be held with the relevant parties.
For each risk listed in the Pre-work assessment table submitted by the vessel, it is tobe assessed by the managing shore catering department.

In addition, the results are transferred to a risk assessment table and a decision istaken on whether to carry out medium or high level risk work, which is then fed
back to the vessel.

48

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䐡䚷㻭㼟㼟㼑㼟㼟㼙㼑㼚㼠㻌㼛㼒㻌㼒㼞㼑㼝㼡㼑㼚㼏㼥㻌㼍㼚㼐㻌㼟㼑㼢㼑㼞㼕㼠㼥㻌㼛㼒㻌㼛㼏㼏㼡㼞㼞㼑㼚㼏㼑㻌㻌㻌㻌㻌㻌㻌㻌㻌㼍㼒㼠㼑㼞㻌㼕㼙㼜㼘㼑㼙㼑㼚㼠㼍㼠㼕㼛㼚㻌㼛㼒㻌㼙㼑㼍㼟㼡㼞㼑㼟㻌㼍㼚㼐㻌㼍㼏㼠㼕㼛㼚㼟㻸㼍㼟㼠㻌㼞㼑㼏㼛㼞㼐㼑㼐㻌㻿㼑㼘㼑㼏㼠㻌㻭㻌㼠㼛㻌㻱㻌㼣㼕㼠㼔㻌㼞㼑㼒㼑㼞㼑㼚㼏㼑㻌㼠㼛㻌㼠㼔㼑㻌㼒㼞㼑㼝㼡㼑㼚㼏㼥㻌㼛㼒㻌㼞㼕㼟㼗㻌㼕㼚㻌㼀㼍㼎㼘㼑㻌㻝㻌㼒㼞㼑㼝㼡㼑㼚㼏㼥㻌㼛㼒㻌 㼛㼒㻌㼠㼔㼑㻌㼞㼕㼟㼗㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻚㼛㼏㼏㼡㼞㼞㼑㼚㼏㼑

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㼟㼑㼢㼑㼞㼕㼠㼥

㻮㼍㼟㼑㼐㻌㼛㼚㻌㼠㼔㼑㻌㼞㼑㼟㼡㼘㼠㼟㻌㼛㼒㻌䐡㻘㻌㼕㼚㼜㼡㼠㻌㻎㼄䇿㻌㼒㼛㼞㻌㼠㼔㼑㻌㼕㼚㼕㼠㼕㼍㼘㻌㼞㼕㼟㼗㻚㻮㼍㼟㼑㼐㻌㼛㼚㻌㼠㼔㼑㻌㼞㼑㼟㼡㼘㼠㼟㻌㼛㼒㻌䐡㻘㻌㼕㼚㼜㼡㼠㻌㻎㼅䇿㻌㼒㼛㼞㻌㼠㼔㼑㻌㼒㼕㼚㼍㼘㻌㼞㼕㼟㼗㻚㻟㻿㼑㼘㼑㼏㼠㻌㻝㻌㼠㼛㻌㻠㻌㼣㼕㼠㼔㻌㼞㼑㼒㼑㼞㼑㼚㼏㼑㻌㼠㼛㻌㼠㼔㼑㻌㼘㼑㼢㼑㼘㻌㼛㼒㻌㼟㼑㼢㼑㼞㼕㼠㼥㻌㼕㼚㻌㼀㼍㼎㼘㼑㻌㻞㻌㼛㼒㻌㼠㼔㼑㻌㼞㼕㼟㼗㻌㼙㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻚䐟㻌㻵㼙㼜㼍㼏㼠㻌㼛㼚㻌㼔㼑㼍㼘㼠㼔㻌㼍㼚㼐㻌㼟㼍㼒㼑㼠㼥㻲㼞㼑㼝㼡㼑㼚㼏㼥㻌㼛㼒㻌㼛㼏㼏㼡㼞㼞㼑㼚㼏㼑䐠㻌㻱㼚㼢㼕㼞㼛㼚㼙㼑㼚㼠㼍㼘㻌㼕㼙㼜㼍㼏㼠㻡䐡㻌㻹㼑㼐㼕㼍㻌㼕㼙㼜㼍㼏㼠䐢㻌㻲㼕㼚㼍㼚㼏㼕㼍㼘㻌㼕㼙㼜㼍㼏㼠㻝䐣㻌㻵㼙㼜㼍㼏㼠㻌㼛㼚㻌㼠㼔㼑㻌㻿㼍㼒㼑㼠㼥㻌㻹㼍㼚㼍㼓㼑㼙㼑㼚㼠㻌㻿㼥㼟㼠㼑㼙䚷䚷䚷䚷䚷㻭㼟㼟㼑㼟㼟㼙㼑㼚㼠㻌㼍㼢㼑㼞㼍㼓㼑㻌㼛㼒㻌䐟䡚䐣㻝㻿㼑㼢㼑㼞㼕㼠㼥

䐠䚷㻿㼠㼡㼐㼥㻌㼛㼒㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟䚷㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻼㼞㼑㼢㼑㼚㼠㼕㼛㼚㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟%QORCP[CFOKPKUVTCVKQPFGRV UHKPCNFGEKUKQP㻟㻠㻯㼛㼚㼟㼕㼐㼑㼞㼍㼠㼕㼛㼚㻌㼛㼒㻌㼍㼘㼠㼑㼞㼚㼍㼠㼕㼢㼑㻌㼙㼑㼠㼔㼛㼐㼟㻘㻌㼜㼞㼑㼢㼑㼚㼠㼕㼢㼑㻛㼙㼕㼠㼕㼓㼍㼠㼕㼛㼚㻌㼙㼑㼍㼟㼡㼞㼑㼟㻌㼣㼕㼠㼔㻌㼞㼑㼒㼑㼞㼑㼚㼏㼑㻌㼠㼛㻌㼠㼔㼑㻌㼜㼞㼛㼏㼑㼐㼡㼞㼑㻌㼙㼍㼚㼡㼍㼘㻭㼘㼠㼑㼞㼚㼍㼠㼕㼢㼑㻌㼙㼑㼍㼚㼟

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㻾㼕㼟㼗㻦㻌㻴㼕㼓㼔㻌㼘㼑㼢㼑㼘㻾㼕㼟㼗㻦㻌㻹㼑㼐㼕㼡㼙㻌㼘㼑㼢㼑㼘㻾㼕㼟㼗㻦㻌㻸㼛㼣㻌㼘㼑㼢㼑㼘㻵㼚㼕㼠㼕㼍㼘㻌
㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠㻦㻌䇾⁊䇿㻲㼕㼚㼍㼘㻌㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠㻦㻌䇾⁋䇿䐢䚷㼂㼑㼞㼕㼒㼕㼏㼍㼠㼕㼛㼚㻌㼛㼒㻌㼒㼕㼚㼍㼘㻌㼍㼟㼟㼑㼟㼟㼙㼑㼚㼠 㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻭㼞㼑㻌㼠㼔㼑㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼍㼚㼐㻌㼍㼏㼠㼕㼛㼚㼟㻌㼠㼍㼗㼑㼚㻌㼍㼜㼜㼞㼛㼜㼞㼕㼍㼠㼑㻌㼍㼚㼐㻌㼔㼍㼟㻌㼠㼔㼑㻌㼘㼑㼢㼑㼘㻌㼛㼒㻌㼞㼕㼟㼗㻌㼎㼑㼑㼚㻌㼞㼑㼐㼡㼏㼑㼐㻫
㻵㼙㼜㼘㼑㼙㼑㼚㼠㼍㼠㼕㼛㼚㻌㼛㼒㻌㼠㼔㼑㻌㼜㼞㼛㼜㼛㼟㼑㼐㻌㼏㼛㼡㼚㼠㼑㼞㼙㼑㼍㼟㼡㼞㼑㼟㻌㼣㼕㼘㼘㻌㼞㼑㼐㼡㼏㼑㻌㼠㼔㼑㻌㼘㼑㼢㼑㼘㻌㼛㼒㻌㼞㼕㼟㼗㻌㼠㼛㻌㼍㻌㼘㼛㼣㻌㼘㼑㼢㼑㼘㻚㻹㼕㼠㼕㼓㼍㼠㼕㼛㼚㻌㼙㼑㼍㼟㼡㼞㼑㼟㻾㼑㼢㼕㼟㼑㼐㻌㼐㼍㼠㼑㻦㻌㼅㼅㼅㼅㻛㻹㻹㻛㻰㻰㻾㼑㼢㻚㻌㼄㼄

㻺㼛㻚㻌㼛㼒㻌㼥㼑㼍㼞㼟㻌㼠㼛㻌㼎㼑㻌㼒㼕㼘㼑㼐㻌㼒㼛㼞㻦䚷㼄㼄㻌㼥㼑㼍㼞㼟

Fig. 24 Risk assessment table by management department on land49

P&I Loss Prevention Bulletin

4-3-3 Risk assessment example = rough weather preparation =As an example, the risk assessment will cover the Deck department, the Engine
department and the Catering department assuming rough weather preparation for atyphoon forecast from dawn the next day. Please refer to Attachments 6 to 14 for the
Pre-work assessment tables of each department.
①

Deck department (Figs. 25,26,27, and 28 Attachments 6, 7 and 8)

A total of eight risks were identified on the vessel and the results are summarised as
below.
・Mean value in Frequency of occurrence：3

・Mean value in Severity (Personal injury)：4・Mean value in Severity (Non-personal injury)：4・Risk level (Applied both Personal injury andNon-personal injury)：12（H）For the risks identified above, the following countermeasures were established. The risk
level is the product of frequency of occurrence and severity.

・Mean value in Frequency of occurrence：3

・Mean value in Severity (Personal injury)：2・Mean value in Severity (Non-personal injury)：1・Risk level (Personal injury)：6（M）

・Risk level (Non-personal injury)：3（L）

By preparing for rough weather on the deck, Accidents involving people has dropped
from (H) to (M) and Non-personal injury from (H) to (L). Accordingly, in this example,
the higher overall risk level of 6 (M) for personal injury has been adopted.

50