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Engine room resource management

Concepts of Contingency Management Understanding the reaction of human beings to emergencies. Case Studies on Emergencies in the engine room and their management.

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FOUNDERING

Erika Sank off Brittany December 1999

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CAPSIZING

Super Ferry 14 Fire off Philippines February 2004

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COLLISION

Gas Roman & Springbok Collision off Singapore February 2003

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CONTACT DAMAGE

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FIRE AND BLOW OUT


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GROUNDING

7 Bunga Teratai Satu Grounded on Great Barrier Reef - November 2000

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FIRE

Mega Borg Pumproom fire & explosion off Galveston June 19908

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EXPLOSION

Cape Horn Methanol Cargo - Explosion off Livorno March 2003

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POLLUTION

Sea Empress Grounded entering Milford Haven February 1996

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HUAL EUROPE

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HUAL EUROPE

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Main cause value


$2,616m
Other 16% Crew error 15%

Human factor 62%

Structural failure 7%

Mechanical failure 6% Deck officer error 30% Equipment failure 9%

Shore person error 7%

Pilot error 8%

Eng officer error 2%

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MEANS OF ACCESS
WELL LIT AND UNOBSTRUCTED WARNING SIGN FIXTURES AND FITTINGS - WHERE SEAMEN MAY TRIP OR PROJECTING OVERHEAD - CAUSING POTENTIAL HAZARD SUITABLY PAINTED OR MARKED GEAR STOWED WITHIN AREA - SECURED GUARD-RAILS SECURE OPENINGS SUITABLY FENCED PORTABLE LADDERS - SECURED

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WORKING ENVIRONMENT
SAFE TO ENTER LIGHTING ADEQUATE VENTILATION ADEQUATE PROTECTION FROM NOISE DANGEROUS GOODS/SUBSTANCES UNNECESSARILY STORED IN THE AREA OR IN A DANGEROUS MANNER LOOSE TOOLS, STORES LYING AROUND UNNECESSARILY

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WORKING CONDITIONS
MACHINERY GUARDED SAFE OPERATING INSTRUCTIONS DISPLAYED SAFETY SIGNS DISPLAYED PERMIT TO WORK NECESSARY PROTECTIVE CLOTHING AND EQUIPMENT CLOTHING AND EQUIPMENT IN GOOD CONDITION AND CORRECTLY USED EVIDENCE OF DEFECTIVE EQUIPMENT LEVEL OF SUPERVISION

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PERSONAL PROTECTIVE EQUIPMENT


HEAD PROTECTION -- HELMETS HEARING PROTECTION -- EAR MUFFS EAR PLUGS FACE AND EYE PROTECTION -- GOGGLES AND SPECTACLES RESPIRATORY PROTECTIVE EQUIPMENT -- DUST MASKS, RESPIRATORS, BREATHING APPARATUS HAND AND FOOT PROTECTION -- GLOVES SAFETY BOOTS AND SHOES BODY PROTECTION -- SAFETY SUITS, SAFETY BELTS, HARNESSES,APRONS,HIGH VISIBILITY CLOTHING PROTECTION AGAINST DROWNING -- LIFEJACKETS, LIFE-BUOYS PROTECTION AGAINST HYPOTHERMIA -- IMMERSION SUITS

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WORK EQUIPMENT
MACHINERY SAFELY GUARDED HATCHES - COVERING REMOVED OR PROPERLY SECURED LIFTING GEAR- PROPERLY INSTALLED, ASSEMBLED AND MAINTAINED TRAINED AND COMPETENT PERSONS TO OPERATE TESTING AND EXAMINATION MARKING OF LIFTING EQUIPMENT

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FIRE PRECAUTIONS
SMOKING ELECTRICAL FITTINGS - MAKESHIFT PLUGS, FLEXIBLE LEADS FIXED HEATERS AND PORTABLE HEATERS SPONTANEOUS COMBUSTION - DRY WASTE, RAGS, SAW DUST, MATERIALS IN STORES MACHINERY SPACES - METAL CONTAINERS FOR WASTE, WOOD/PAINT/SPIRITS IN BOILER ROOMS/STRG.GEAR GALLEYS - OVERHEATING, SPILLING OF OIL/FAT, PLATES SHUT OFF WHEN COOKING IS FINISHED, MEANS TO SMOTHER AND REMOTE CUT-OFFS MARKED AND KNOWN TO GALLEY STAFF

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SECURITY
TERRORISM STOWAWAYS PIRACY AND ARMED ROBBERY

PRECAUTIONS
VIGILANCE SECURITY WATCH / EFFICIENT NIGHT WATCH SEAL OFF ACCESS TO SHIP ESTABLISH CONTACT- EMERGENCY SIGNALS
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MOORING OPERATIONS
RESPONSIBLE PERSON INCHARGE COMMUNICATION WITH BRIDGE HEAVING LINES - NO ADDED WEIGHTS WORK AREA CLUTTER FREE AND WELL LIT EQUIPMENT INSPECTED FOR DEFECTS - OIL LEAKS FROM WINCHES, ROLLERS AND FAIRLEADS MOVING FREELY ROPES WIRES AND STOPPERS - SPLICES ROPES WIRES FLAKED OUT BEFORE USE LAYOUT OF MOORINGS- USE APPROPRIATE LEADS - AVOID SHARP ANGLES
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FIRE DRILL
REPORT TO STATIONS FIRE PUMP - JETS OF WATER FIREMANS OUTFIT AND RESCUE EQUIPMENT COMMUNICATION EQUIPMENT W/T DOORS, FIRE DOORS, DAMPERS ARRANGEMENTS FOR SUBSEQUENT ABANDONSHIP

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LIFEBOAT DRILL
MUSTER STATIONS - UNDERSTANDING OF ABANDONSHIP ORDER DUTIES DRESS LIFEJACKETS LOWERING OF LIFEBOAT LIFEBOAT ENGINE OPERATION OF DAVITS USED FOR LIFERAFT

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MAINTENANCE
SUPPLY TO FIRE MAIN ALARMS AND ISOLATION OF ALARM ACCESS TO FFA ESCAPE ROUTES MACHINERY - SAFETY GUARDS FLOOR PLATES ELECTRICAL SUPPLY STEAM OPERATED MACHINERY PRESSURE RELEASE DEVICES

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MAINTENANCE
BOILERS ENGINES REFRIGERATED COMPARTMENT

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"If you fail to plan, then you plan to fail


Contingency plan on ships Communications Contingency plan ashore Large theater costal state Response Media response

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Contingency response
The clock is ticking Damage control Loss mitigation Operational recovery media handling

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SHIPBOARD EMERGENCY PROCEDURES


Responsibilities
The Master The Chief Engineer The Chief Officer General Responsibilities

Onboard Emergency Response Plan


Emergency Alarms Implementation of the Emergency Response Plan Emergency Response Plan Summary of Elements Salvage Operations General Average USCG D&A Testing Requirements Incident in US Water/Jurisdiction

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Emergency Response Checklists


Oil Pollution Oil Pollution due to Tank Overflow, Pipe Leak, Hose Rupture, or Connection Leak Oil Pollution Due to Hull Leakage Collision Grounding / Stranding Flooding Fire in Port Fire and Explosion (Engine or Pump Room) Fire in Accommodation Cargo Fire on Deck Fire in Cargo Hold Emergency Towing/Salvage Enclosed Space Rescue Preparing of Abandon Vessel Man Overboard Serious Injury, Illness or Death Hull Failure, Flooding and Excessive List

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Cargo Shifting Cargo Jettisoning Uncontrolled Venting or Cargo Jettisoning on Gas Tankers Toxic Release on Gas Tankers Cargo Containment System Failure Toxic Liquid Release at Sea or at Anchorage (Tankers) Toxic Liquid Release at Sea or at Terminals (Tankers) Loss of Stability during Cargo Operations Accidents involving Dangerous Goods Breakaway from Jetty whilst loading/discharging. Heavy weather damage Main Engine Failure Steering Failure Power Failure - Blackout Helicopter Operations Epidemics
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Emergency Response Checklists

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SHIPBOARD EMERGENCY PROCEDURES


Emergency Communication
Initial Notification to shore office Emergency Report Data Sheet General Guidelines on the Emergency Initial and Supplementary Report Emergency Report Format Example of an Emergency Report Contact and Co-operation with other Agencies Statements by Personnel Communication with the Media

Evidence
Evidence Collection Vessel Data Recovery (VDR) Record Keeping

Planning, Preparedness and Training


Familiarization Drills and Exercises

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COMPANY (SHORE) EMERGENCY PROCEDURES


Emergency Response Team
Functions of the Emergency Response Team Team Composition and Main Function Backup Arrangements Responsibility of Emergency Response Team Members During Office Hours After Office Hours Security Related Emergency Situations Company Emergency Response Plan

Activation of Emergency Response Plan

Control Room Facility and Preparation Emergency Management Process


The Emergency Initial Notification Briefing and Action Planning Information Gathering and Assessment Notifications/Reporting
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Dealing with the Media


Dealing with the Media On Site Team Recording Information Notifying Next of Kin Legal Representation Emergency Response to Security Threats
General Emergency Response Actions

Termination of the Emergency Response Plan Planning, Preparedness and Training


Familiarization with the Emergency Response Plan Drills and Exercises

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Companies Commitment for Support in Emergency Situations


The Company understands the seriousness and urgency when a vessel is involved in an accident, whereby the safety of lives on board are at stake and that the accident if not tended to immediately could develop into a major casualty and threaten to pollute the environment. The Company acknowledges that the Master of a vessel has the over riding authority to attend to all matters of safety and pollution in case of an accident.
He is required to direct his ships crew to attend to the accident in the best possible manner and call for outside assistance as necessary. He is also required to contact the shore based management to assist in dealing with the accident to prevent same from becoming a major casualty.

The Company commits to provide full and prompt support in all such situations described above
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Definition of an Emergency
Emergency is defined as any continuing situation or occurrence which:
Puts the lives of persons onboard the vessel in danger Puts the lives of persons in the immediate vicinity of the vessel in danger Puts the safety of the vessel and/or its cargo in danger or at risk Puts the safety of another ship in the immediate vicinity of a vessel ship in danger Causes the vessel to pollute or threaten to pollute the environment.

In any emergency the priorities are the safety of life, the safety of the ship, followed equally by the protection of the environment and the cargo. All other considerations are secondary to these.
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Types of Emergencies

It is not possible to set out detailed procedures for dealing with every conceivable form of emergency Some of the common form of emergencies are: Oil Pollution Due to Overflow or hose burst. Hull leakage Collision Grounding/Stranding Flooding Cargo and Machinery Spaces Fire in Port Fire and Explosion (Engine or Pump Room) Fire in Accommodation Cargo Fire on Deck Fire in Cargo Hold

Emergency Towing/Salvage Enclosed Space Rescue Abandon Ship Man Overboard Serious Injury or Illness/Death Hull Failure, Flooding and Excessive List Cargo Shifting Cargo Jettisoning Uncontrolled venting or Cargo Jettisoning on Gas Tankers Toxic Release on Gas Tankers Cargo Containment System Failure Toxic Liquid release at Sear or Anchorages (Tankers) Toxic Liquid release at Terminal (Tankers) Loss of Stability during Cargo Operations Accidents involving Dangerous Goods Breakaway from Jetty whilst loading/discharging Heavy weather damage Main Engine Failure Steering Failure Power Failure Helicopter Operations Epidemics 43 Operational Level - Performance Enhancement Course 43

Onboard Emergency Response Plan


Emergency Alarms
THE SIGNAL FOR GENERAL EMERGENCY ALARM IS SEVEN OR MORE SHORT BLASTS FOLLOWED BY A LONG BLAST ON THE SHIPS WHISTLE AND ON THE SHIPS GENERAL ALARM.

THE SIGNAL FOR FIRE ALARMS IS INTREMITTENT/CONTINUOUS RINGING ON THE ALARM BELLS (AS PROGRAMMED ON VESSEL) All persons onboard are to Muster at their Emergency Muster stations, they will then be advised of the nature of the Emergency i.e. Fire, Man Overboard, Boat Stations etc. All alarms when sounded on the Automatic Fire Detection System are to be treated as the Fire Alarm and all crew are to proceed to their Emergency Muster Station. Piracy Alarm should be clearly distinctive from any other Alarm
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Implementation of the Onboard Emergency Response Plan


In the event of an emergency on board, the Onboard Emergency Response Plan shall be implemented as follows: The person discovering the emergency shall activate the Local Emergency Alarm and inform the Bridge giving details of the nature and location of the emergency. In port the Local Fire Service or appropriate authorities shall be informed as early as possible. The Emergency Response Checklist for various emergencies is to be used as guidance for dealing with the emergency. Initial Notification/Report to the DPA/Company and communication with external agencies and media shall be as per Emergency Communication guideline. Preserve evidence and maintain accurate records The emergency response shall be as guided by the specific Emergency Response Plan
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Masters Overriding Authority


The Master has the right and the duty to deviate from this Procedure(s) if he, in his own judgment, feels that it will be necessary. International Law and the ISM Code give the Master the overriding authority and responsibility to make decisions with respect to safety and pollution prevention. Therefore the Master may have to make the decision himself to engage a tug. The Master has the authority to sign a salvage agreement without special authority from the owner who is bound by the actions of the master. Informing the Company It is imperative that the Master informs the Company as soon as possible about the occurrences. Should he personally not be able to do so (e.g. because he is concentrating all his efforts on solving the situation on hand) than he should delegate this duty to any available officer. Utmost importance should be given to obtain guidance and assistance from the Company as soon as possible.

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USCG D&A Testing Requirements Incident in US Water/Jurisdiction


The new amendment to U.S. COFR 46 Part 4 states that after an incident all persons involved (Captain and crew) must be tested for alcohol within 2 hours and tested for drugs within 32 hours. If a vessel is involved in an incident and the testing Company cannot physically reach the vessel within 2 hours the Master (or whoever is designated in the chain of custody) may test the crew. The Coast Guard will act as a witness to the testing. If for some reason the Coast Guard cannot be on the vessel (e.g. offshore incident) within 2 hours then it is recommended that the testing be conducted without the Coast Guard acting as a witness as this would be the only option. The Coast Guard will then decide if they want to accept the samples taken, or not use any Alcohol or Drug samples in their investigation
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INCIDENT INCLUDING OIL SPILLS


[PROPBABLE OR ACTUAL]

ASSESSMENT OF NATURE OF INCIDENT


ACTION REQUIRED *** ALERT CREW MEMBERS *** *** IDENTIFY SOURCE OF INCIDENT *** *** ASSESS INCIDENT CHARACTERSTICS*** ACTIONS TO CONTROL INCIDENT

REPORTING
By Master or Other Designated Person When to Report When Incident Occurs Including All Probable & Actual Oil Spills How to Report By quickest means to Coastal State Authority or Ship Movement Reporting Station or Rescue Coordination Centre [at sea] By quickest means to Local Authorities [in Port] By telephone / quickest means to DPA/Company. Who To Contact Nearest Coastal State Harbour & Terminal Operators [in port] The Company Local P&I Representative ( With Companys consent) [in port] Ships Agent [in port] Q.I. [tanker in U.S. waters] What to Report Initial Report IMO Resolution 648[16]

Measures To Minimise Incident / Escape of oil /Threats to Safety/ Environment

NAVIGATIONAL * Alter course / Position / Speed * Change of List or Trim

SEAMANSHIP * Safety Assessment & Precautions * Decide Priority Counter &

Preventative Measures
* Anchoring * Damage Stability & Stress Calculations * Setting Aground or beaching Requirement * Assess Safe Haven Requirement * Prepare for Towage * Ballast /Deballast / Fuel Transfer Operations * Ballast / Deballast / Fuel Transfer Operations * Organise Shipboard Response Activities: * Weather/Tide/Swell Forecast - Fore / Damage Control * Record Events / - Seal Leakage Points etc.

Follow-Up Reports
Damage Sustained & Cause

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Emergency Communication
Initial Notification to Shore Office
In any ship emergency it is essential that the Master notifies the Shore office of the emergency as soon as possible. This initial notification need not wait until all relevant details of the emergency are established i.e. should not be unduly delayed. If in doubt that an emergency exists, the shore office must be alerted. However, this requirement must not be confused with the Master's responsibility to broadcast an international SAFETY, URGENCY OR DISTRESS signal as considered necessary and this SOLAS requirement takes precedence to the Shore office requirement. The initial contact should be by telephone to the Designated Person Ashore or any other Superintendent who the Master is able to contact.

The Companys 24 hrs Emergency Contact number, normal and after office hours telephone numbers of shore based Emergency Response Team members are given in the Annexure to this manual. Masters are reminded that telexes or faxes arriving outside office hours will not be read by anyone till the morning of the next working day.
Verbal communication shall be supplemented by e-mail, fax or telex as soon as possible in the emergency report format which is consistent with the General Principles for Ship Reporting Systems and Ship Reporting Requirements, adopted as Resolution A.648[16] by the IMO. The Initial report should be telexed/faxed/e-mailed to the Company/other parties as soon as possible with whatever information available at that point of time The remaining information can be added and the report re-transmitted as further required information becomes available.
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Own Vessel Name Type of Incident Date & Time of Incident Location of Incident Number of Crew Missing Collision/Fire etc. Local Time Lat/Long or Brg. Dist. or Port/Berth

Injured
Remaining On Board

Emergency Report Data Sheet

Abandoned Ship Time of Abandonment/Evacuation No. of Lifeboats/Life rafts Launched Distress Message Sent/Coastguard Informed Other parties Contacted Weather and Sea Conditions Wind-Speed & Direction, Sea, Swell, Visibility, Temperature, Current/Tide Rate & Direction Immediate Navigation Hazards Shallows, Shallows, Installations etc Installations etc. Other Vessels Name & Type [collision] Location & Description of Damage Pumps Status [Bilge/Ballast/Fuel/Cargo] Power Available Propulsion & Steering Systems Status Fire Fighting Systems Status Type & Extent of Pollution Cargo Type - Especially Dangerous Goods Salvage Services Accepted Type of Service Accepted Eg. No Cure No Pay (LOF 2000) Flooded Spaces Structural/Fire/Cargo Damage Local Time

Salvage Company Name


Action by Port/State Authorities Next Intended Action Assistance Required Next Contact Performance Enhancement Course Operational Level -Time

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additional information for report


The following additional information should be sent to the Company either at the same time as the initial report or as soon as possible thereafter:
Further details of damage to ship and equipment. Whether damage is still being sustained.

Assessment of fire risk and precautions taken. Disposition of cargo on board and quantities involved. Number of casualties. Damage to other ships or property. Name of salvor and type of salvage equipment. Whether further assistance is required. Priority requirements for spare parts and other materials. Details of outside parties advised or aware of the incident. Any other important information. Time [UTC] assistance was requested and time [UTC] assistance expected to arrive at the scene.

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Notification
Reports are to be transmitted by the quickest available means to the responsible authorities of the nearest coastal state or the Rescue Co-ordination Centre [RCC] via the appropriate shore radio station. If the ship is within or near to an area for which a ship reporting system has been established, reports should be transmitted to the designated shore station of that system. After transmission of the information in an initial report, as much as possible of the information essential for the safeguarding of life and the protection of the ship and the marine environment is to be reported in a supplementary report to the coastal state and the Company, in order to keep them informed of the situation as the incident develops
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Main ENGINE FAILURE


Call Master to bridge. Note vessels time and position. Post extra Lookouts/Switch on both the RADARS Exhibit NUC Lights/Signals and appropriate sound signals. Check for other vessels and/or navigational hazards in the vicinity. Broadcast Urgency message to Ships in Vicinity, if applicable. Take action to Manoeuvre ship away from danger. Prepare for Anchoring if in shallow waters. Asses the sea swell, winds and currents, determine the set and drift of vessel. Modify AIS status message to communicate relevant Information. Broadcast Urgency message to ships in the vicinity. Inform VTS or port authority if in controlled or similarly monitored waters. Monitor vessels position continuously. Inform BSM office/DPA Establish if repairs possible by vessels staff and time required for repairs. Repair fault and proceed on passage Periodically update Office with status of M/E. Enter continuously all action taken in the vessels logbook. If ME fault can not be repaired in time to avoid danger:
Inform Company Establish if towage resources are available & time to reach Vessel.

prepare for Towing Operation


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STEERING FAILURE
Call Master to bridge. Engage emergency steering. Inform Engine room, prepare engines for Manoeuvring. Note vessels time and position. Post extra Lookouts/Switch on both the RADARS. Exhibit NUC Lights/Signals and appropriate sound signals. Check for other vessels and/or navigational hazards in the vicinity. Broadcast Urgency message to ships in vicinity if appropriate. Manoeuvre the vessel to an open area, away from danger. Prepare for Anchoring if in shallow waters. Take all way off the ship.(Stop the vessel) Asses the sea swell, winds and currents, determine the set and drift of vessel. Modify AIS status message to communicate relevant Information. Inform VTS or port authority if in controlled or similarly monitored waters. Monitor vessels position continuously. Inform BSM office/DPA Establish if repairs possible by vessels staff and time required for repairs. Repair fault and proceed on passage. Enter continuously all action taken in the vessels logbook. Towage resource avail & time to reach Vessel. Prepare for Towing Operation (refer Emergency Towing Check list no. 2.03.010) Periodically update Office with status
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STEERING FAILURE
Trouble shooting with problem definition and Component identification If fault can not be repaired in time to avoid danger :
Inform Company Establish if towage resources are available & time to reach Vessel.

prepare for Towing Operation


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POWER FAILURE BLACK OUT


AT SEA or Anchorage: The vessel has been designed in such a way that in case of power failure the standby Auxiliary Engine will start automatically in the previously pre-defined sequence (priority). In case none of the Auxiliary Engines takes over, then the Emergency Generator will start automatically. In case none of the generators start automatically, the engineers should check the reason for start failure and attempt manual start and connection to switch board. Therefore it is of the utmost importance: To always maintain the Emergency Generator in fully functional condition. That each crewmember is familiar locally with the Emergency Generator starting procedure and of a second means of starting e.g. hydraulic starter. In the event of a full Black Out (loss of all electrical power and propulsion) the following procedure is to be adopted; If the Black Out Occurs Whilst Underway Switch to the Emergency Steering. Refer to Steering Procedures. Consider Using the Hand Operated Emergency Steering System Providing the Situation Permits Steer Away From the Coast Or From Other Vessels Or Navigational Dangers Such As Oil Rigs, Fishing Vessels, Shoals Etc. Call the Master by Telephone Or Via the General Alarm. Display the Appropriate Daytime Or Night Time Signals. Broadcast A Securite Message to Other Vessels in the Vicinity and Request Other Vessels Give You A Wide Berth. In the Event of A Black Out Whilst in A River, Canal Or Other Similar Confined Or Shallow Waters Prepare Both Anchors As Soon As Possible. The Engine Room Must Keep the Bridge Fully Informed As to the Situation. When Power is Restored Cancel the Securite Message. Continue in Hand Steering Until is Has Been Confirmed That the Gyro Compass is Reliable.

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POWER FAILURE BLACK OUT


Note: The Emergency Generator Supplies Power For:
* Pilot House Lighting * Engine Control Room Lighting * Lifeboat Embarkation Lights * Basic Navigation Equipment * The Emergency Batteries Supply Power to the Radio Room Including the Radio Room VHF.

The Chief Engineer is entirely responsible for preparing a Blackout contingency (recovery) plan specific to the vessel. The Engineer Officers are required to know the procedures at all time. In addition to above, while in port In case of black-out during cargo operations, terminal should be advised and operations suspended. Resumption of operations should be done only after recovering from black out, investigating and rectifying cause for the incident. All systems should be brought on line in a gradual manner and according to their function and importance.

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Communication with the Media


In the unfortunate event of a fleet vessel being involved in a major incident the actions of the Master, Officers and Crew - in terms of responding to enquiries from the media can influence the prestige of personnel and the Company, either negatively or positively. More importantly it can affect the liabilities that may be imposed upon both individuals and the Company. All employees are to refer any requests for information from the media [TV, Radio, Press] to the Company Emergency Response Team and / or refer all calls to the nearest Maritime Technical International (MTI) Office, where subscribed. Refer to Appendix for further information on MTI Services. It is possible that ships staff may be mobbed by a group of journalists, possibly with tape recorders and TV cameras. It is highly important not to loose your temper, do not make any body gestures. It will all be recorded and invariably comes out as negative publicity. Any representative of the vessel being photographed should be presentable in their appearance and dress in keeping with and to project profile of a high quality, responsible ship management Company vessel.
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GENERAL MEDIAS IMPRESSION


SHIPPING IS NOT INTERESTING FOR DAILY NEWS. BBC HAS A SPACE CORRESPONDENT BUT NO SHIPPING CORRESPONDENT. SHIPPING COMPANIES ARE SECRETIVE.
Shipping ?

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A MAJOR PROBLEM WITH THE SHIPPING INDUSTRY IS ITS PATHOLOGICAL SECRECY, ITS REFUSAL TO OWN UP TO ANYTHING AND ITS FEAR OF PUBLICITY
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SHIPPING INDUSTRYS IMPRESSION


MEDIA DOES NOT UNDERSTAND SHIPPING.
MEDIA EXAGGERATES EVERYTHING. MEDIA IS INTERESTED IN SHIPPING ONLY IN CASE OF DISASTERS.
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BOTH
ARE

TRUE

BOTH ARE TRUE


IT IS ALSO TRUE
THAT BOTH, THE

INDUSTRY AND
THE MEDIA NEED EACH OTHER.

WHAT DOES MEDIA WANT?


CRISES SCANDALS

HUMAN INTEREST STORIES

ENVIRONMENT

WHAT MAKES NEWS ?


CONTROVERSY & CONFLICT ANIMALS GOOD HEAVENS !

GOOD PHOTO
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IN A CRISES SITUATION IMPORTANCE OF MEDIA MUST NEVER BE UNDER -ESTIMATED.


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PUBLIC OPINION IS FORMED ON THE BASIS OF MEDIA REPORTS (EVEN IF INFORMATION IS NOT ACCURATE).

MISC BUNGA TERATAI SATU WAS DESCRIBED BY CNN AS A TANKER.


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TELEVISION PICTURES OF DEAD PEOPLE, FLAMES, BLACK SMOKE, DEAD FISH, OILED BIRDS, DIRTY BEACHES CREATE PUBLIC OUTRAGE AGAINST THE SHIPPING INDUSTRY.
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PERCEPTION OF THE MARINE DEPARTMENT /


MINISTRY AND ITS WORK GETS AFFECTED BY THE

MEDIA STORIES.
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UNFAVORABLE PRESS CAN


LEAD TO DIRECT ACTION BY THE GOVERNMENT SUPERVISORY BODIES.
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IN CASE OF AN ACCIDENT,

ESPECIALLY IF IT IS
AFFECTING GENERAL POPULATION .

THE COMMUNITY HAS THE


RIGHT TO KNOW.
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MEDIA HANDLING

UNDERSTANDING THE NEEDS & WORKING OF THE MEDIA BEING PREPARED QUESTIONS FOR THE

LIKELY

PROVIDING CORRECT AND FACTUAL INFORMATION TO AVOID MEDIA RUNNING STORIES BASED ON RELIABLE SOURCES
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UNDERSTANDING THE NEEDS


MEDIA COVERAGE IN DEVELOPED NATIONS IS EXTREMELY RAPID MEDIA COVERAGE IN COUNTRIES WITH LESSER COMMUNICATIONS ALLOWS MORE TIME TO REACT

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UNDERSTANDING MEDIA NEEDS JOURNALISTS IN

DEVELOPED NATIONS
ARE MORE AGGRESSIVE IN

GETTING THE STORY

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UNDERSTANDING MEDIA NEEDS


IN A MAJOR CASUALTY IN SAY USA,

NORTH EUROPE, ETC THE TIME FRAME


TO INITIALLY REACT TO MEDIA MAY BE ONLY 1 OR 2 HOURS AS MEDIA MONITORS COMMUNICATIONS OF THE COAST GUARD, PORT TRAFFIC ETC.

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UNDERSTANDING MEDIA NEEDS


T 0 HR CASUALTY
T + 1 HR INITIAL INFORMATION TO MEDIA

T + 2 HR SET UP INFORMATION OFFICE TO RESPOND TO MEDIA.


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WHAT DOES MEDIA WANT TO FIND OUT?


WHAT HAPPENED?
WHEN DID IT HAPPEN?

WHERE?
WHO ARE THE SHIPS / FACILITIES INVOLVED?

WHAT IS BEING DONE?


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WHAT DOES MEDIA WANT TO FIND OUT?


ANY INJURIES / FATALITIES?

ANY POLLUTION?

ANY DANGER TO LOCAL POPULATION? WHY DID IT HAPPEN?


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OVERALL AIMS OF MEDIA RESPONSE FOR INVESTIGATOR


CONFIRM TO THE MEDIA THAT DEPARTMENT / GOVERNMENT IS AWARE OF INCIDENT AND A SERIOUS RESPONSE TO THE CASUALTY HAS BEEN INITIATED.

I.E. DEPARTMENT / GOVERNMENT IS IN FULL CONTROL.


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AIMS OF MEDIA RESPONSE

CONFIRM SERIOUS INVESTIGATION IS ALREADY STARTED AND

NECESSARY RESOURCES FOR THE

INVESTIGATION ARE IN PLACE.

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Media Response By Shipboard Staff


If contacted by the media, the Master, Officers and Crew shall not discuss details of any incident and shall refer all enquiries to the AESM Office handling the emergency. If an incident has occurred do not deny that it has happened but do not give details. A suitable response could be: I can confirm that an incident has occurred involving this ship. As we are busy with the incident, please contact company Office in [place] for further details. I appreciate your interest but I must ask you to keep the line clear as you are preventing urgent calls coming through. Thank you

Operational Level - Performance Enhancement Course

81

On Site Team
The decision will be taken by the ERT Overall Head and the Corporate DPA, whether to appoint one or more members of the Emergency Response Team to form the On Site Team, to be present at the site of the incident. This will depend on the seriousness of the incident. It is recommended that the person/s from the Emergency Response Team appointed to represent office on site is one with the most practical experience in Emergency and Salvage Operations. Once appointed, the Technical Officer / Assistant will be responsible to arrange all logistics for the travel/accommodation reservations of the On Site Team. The tasks of the On Site Team shall be to:
Advise Overall ERT Head of status of Emergency, repair facilities, Contractors etc. Assist Master and the crew in conjunction with all other members representatives Identify and liaise with all other representatives in attendance (surveyors, P&I/H&M correspondents, lawyers etc.) Co-ordinate on site activities of the above as per instructions from the Emergency Response Team. Establish a local base Establish and maintain contact with the authorities (emergency / rescue/services, environmental / pollution agencies (Qualified Individual in USA), national government agencies etc.) Liaise with salvors, clean up contractors or repair technicians. Liaise with local agents. Be available to meet casualties, claimants and their representatives Take details of claims Collect evidence Take photos, video Identify and report on any additional assistance required Maintain a logbook with chronological details of all events
Operational Level - Performance Enhancement Course

82 82

Legal Representation
Whilst the P&I Club will surely appoint their representative, it must be considered that they are acting on behalf of the Owner. Consequently, consideration must be given to the need to appoint separate legal representation for the Master, Officers and crew as well as the Company.

Operational Level - Performance Enhancement Course

83 83

Contingency preparation
Exercises will involve one or more of the following elements;
INITIAL NOTIFICATION ACTIONS RESPONSE TEAM ASSEMBLY INITIAL EMERGENCY QUESTIONNAIRE COMPILING SPECIFIC EMERGENCY QUESTIONNAIRE COMPILING THIRD PARTY CONTACTING SPECIALIST ASSISTANCE MEDIA RESPONSE SUPPORT INFORMATION TO VESSEL RECORD KEEPING CALLING OFF DRILL AND REVIEWS/FEEDBACKS ,CIRCULATION OF SAME.
Operational Level - Performance Enhancement Course

84 84

Session Overview
Large theatre contingency operation Contingency Planning Reference Information General Guidance

Operational Level - Performance Enhancement Course

85 85

Counter Pollution & Salvage Response Philosophy


1. Search And Rescue Search And Rescue - SAR 2. Dealing with the casualty Salvage Control Unit - SCU 3. Counter pollution at sea Marine Response Centre - MRC 4. Counter pollution on shore Shoreline Response Centre - SRC
Operational Level - Performance Enhancement Course

86 National Contingency Plan Environment Group Training

Six Main Response Options


1. Dispersant Spraying 2. Contain and Recover 3. Cargo Transfer 4. Protection 5. Beach Cleaning 6. Leave it! ( Monitor and evaluate )

Operational Level - Performance Enhancement Course

87 National Contingency Plan Environment Group Training

MRC Structure
Chair- MCA or Harbour Master if incident within Port limits
Environment Group
Membership may include: MCA CPSO MCA Logistics Officer Harbour representative, if a harbour is involved Officer from fisheries department Local Authority Officer to liaise with the SRC Environmental Liaison Officer MCA Public Relations Officer

Operational Level - Performance Enhancement Course

88 National Contingency Plan Environment Group Training

Marine Response Centre Venue & Priorities


Venue - Determined by Chair of MRC (Likely to be at MCA or Port Authority premises)
Priorities:
Assess and monitor the situation at sea Initiate and control dispersant-spraying operations on spilled oil at sea Initiate and control mechanical recovery options at sea

Operational Level - Performance Enhancement Course

89 National Contingency Plan Environment Group Training

Monitor and Evaluate


If oil is moving away from the shore there may be no need to respond - small oil slicks are eventually broken up by the effects of wind and currents Informs other response cells Aerial and satellite surveillance is used to identify oil slicks or illegal oil discharges from ships

Operational Level - Performance Enhancement Course

90 National Contingency Plan Environment Group Training

The purpose of using dispersants


Oil spill dispersants are used to rapidly disperse the spilled oil into the sea before it gets into shallow water or hits the shoreline where most damage occurs Dispersants have limits: They will not work in some cases, They are not an appropriate oil spill response method in other cases
Operational Level - Performance Enhancement Course

91 National Contingency Plan Environment Group Training

Contain and recover at sea


Dedicated recovery vessels Booms can be used to contain oil around source Booms can be towed by ships in various configurations to concentrate the spilled oil into smaller area Skimmers can then be used to collect the oil

Operational Level - Performance Enhancement Course

92 National Contingency Plan Environment Group Training

Role of Environment Liaison Officer (ELO)


Take advice from EG and convey it accurately and cohesively to the MRC To receive information and questions from the MRC and communicate these accurately and cohesively back to the EG Provide an environmental perspective to any statements to the media produced by the MRC
Operational Level - Performance Enhancement Course

93 National Contingency Plan Environment Group Training

Whats The Worst That Could Happen?


Earth
Wind Fire Water Humans

Operational Level - Performance Enhancement Course

94 94

"If you fail to plan, then you plan to fail"


Evacuation Plan
When to close, when to evacuate? Whos in charge? Who stays, who goes? Where to go and how? When to return? What can you take in 15 minutes and how?

Operational Level - Performance Enhancement Course

95 95

"If you fail to plan, then you plan to fail (continued)


Security/Safety
Public Data

Communications

Operational Level - Performance Enhancement Course

96 96

What We Learned
Know the likely hazards you face and plan accordingly Back up your data off-site Identify building and floor wardens Have personal emergency kits at the ready Training, training, training

People care. Let them help.

Operational Level - Performance Enhancement Course

97 97

What Are the Different Types of Emergency Plans


Occupant Emergency Plan
Ensures Safety of Occupants of a Building
Evacuation Shelter in Place (SIP)

Operational Level - Performance Enhancement Course

98 98

What Are the Different Types of Emergency Plans (continued)


Disaster Recovery Plan
Ensures the Recovery of IT Systems Contingency
Plan

Ensures the Continuation of Essential Functions Across a Wide Range of Potential Emergencies to Provide For:
Business Process Continuity Organizational Continuity IT Continuity
Operational Level - Performance Enhancement Course

99 99

Why Develop a Contingency Plan?


Ensure the Safety of Students, Faculty, Staff, and Visitors Prepare Staff and Students for Any Emergency Ensure the Continuation of Essential Functions During an Emergency

Operational Level - Performance Enhancement Course

100 100

Why Develop a Contingency Plan?


(continued)

Minimize Damage and Losses Resulting From an Inability to Perform Essential Functions Facilitate Decision Making During an Emergency Achieve a Timely and Orderly Recovery From a Disruption of Services Caused by an Emergency
Operational Level - Performance Enhancement Course

101 101

How to Develop a Contingency Plan A Five Point Plan


Contingency Plan Development Team
Resources Roles and Responsibilities

Business Impact Analysis


Requirements, Processes, and Interdependencies for Contingency Planning
Operational Level - Performance Enhancement Course

102 102

How to Develop a Contingency Plan A Five Point Plan (continued)


Continuity Strategies
Cost, System Sensitivity, and Recovery Time Objectives

Plan testing, training, and exercise Plan maintenance

Operational Level - Performance Enhancement Course

103 103

Important Components of a Contingency Plan


Response Team Roles:
Senior Management Team Damage Assessment Team Continuity Activities - Lead and Team Members Resumption Activities - Lead and Team Members
Operational Level - Performance Enhancement Course

104 104

Important Components of a Contingency Plan (continued)


Training Testing Alternate Facilities
Location Equipment

Operational Level - Performance Enhancement Course

105 105

Important Components of a Contingency Plan (continued)


Notification/Activation Procedures
Notification of Senior Management Team Performing Damage Assessment Procedures Essential Functions, Their Priority Order for Recovery, and When They Need to Be Functioning

Operational Level - Performance Enhancement Course

106 106

Important Components of a Contingency Plan (continued)


Continuity Activities
Activities to Perform to Keep Essential Functions Working

Resumption of Normal Activities Procedures


Activities to Return the Institution to Normal Operating Procedures and Processing Capabilities
Operational Level - Performance Enhancement Course

107 107

Important Components of a Contingency Plan (continued)


Communication Plan
Internal Procedures and Templates External Procedures and Templates Accounting for Faculty, Staff, and Students Procedures Contact information for faculty, staff, students/parents, and internal and external dependencies
Operational Level - Performance Enhancement Course

108 108

Important Components of a Contingency Plan (continued)


Vital Records
Location Media Access

Operational Level - Performance Enhancement Course

109 109

Important Components of a Contingency Plan


Data Backup and Off Site Storage Awareness and Education Activities Flyaway Kits
Cell Phones and Chargers BlackBerries and Chargers Identification Contingency Plan Occupant Emergency Plan Disaster Recovery Plan Vital Records
110 110

Operational Level - Performance Enhancement Course

Lessons Learned Contingency Planning


People Are the First Priority Practice Practice Practice Practice Real Scenarios Assume No Essential Services Make Common Sense Decisions Be Prepared to Make Decisions Outside of Rules Involve Local Authorities
Operational Level - Performance Enhancement Course

111 111

Lessons Learned Contingency Planning (continued)


KISS Principle A Contingency Plan Is a Living Document Keep Plan Current Confirm Communications Are Received Backup Essential Data Response Team Phone Tree Callers

Pre-Position Vital Records at Alternate Site


Operational Level - Performance Enhancement Course

112 112

Lessons Learned - Occupancy Emergency Planning


Establish Building Captains

Establish Floor Captains and Teams Emergency Supplies


Operational Level - Performance Enhancement Course

113 113

Search and Rescue

Operational Level - Performance Enhancement Course

114

Salvage

Operational Level - Performance Enhancement Course

115

At Sea Response

Operational Level - Performance Enhancement Course

116

Shoreline Clean - Up
Operational Level - Performance Enhancement Course

117

Who is involved and who does what ?


HMCG - Her Majestys Coastguard CPSO - Counter Pollution & Salvage Officer SOSREP Secretary of States Representative SCU Salvage Control Unit MRC Marine Response Centre SRC Shoreline Response Centre EG Environment Group
Operational Level - Performance Enhancement Course

118

Who calls who?


First call usually to HMCG Then CPSO Then scientist who will contact
Local Authorities Environment Group

Operational Level - Performance Enhancement Course

119

All depends on incident type and magnitude


Minor incident info only Minor with potential - ? Major?
Examples

Operational Level - Performance Enhancement Course

120

Command and Control


Secretary of State Chief Executive MCA Director of Operations MCA

SOSREP SCU Salvage operations

HMCG Search and Rescue

MRC At-sea response operations MCA

SRC Shoreline cleanup LA + MCA

Environment Group Environmental advice


Operational Level - Performance Enhancement Course

121

UK Maritime incident response


Each unit has a specific role Some units make decisions and initiate actions Some units have statutory powers, some do not Some provide advice to other units Prime objective of all involved to minimise the potential effects of the pollution

Operational Level - Performance Enhancement Course

123

CPR Branch
Head of CPR Toby Stone Counter Pollution & Salvage Officers Operational Support Logistics & Cost Recovery Gail Robertson Technical & Scientific Kevin Colcomb Kelly Reynolds

SCOTNI Jim Dickson

Logistics & Finance

WESTERN Donald McDonald

Admin Support

EASTERN Ian Jackson

Operational Level - Performance Enhancement Course

124

HMCG
HMCG is most often the first organisation notified of an oil spill at sea SAR Search and Rescue In support of oil spill response:
Provide communications, marine safety information broadcasts, Assists with deployment of ETVs and helicopters, MCA Boats Mobilise personnel to key locations Provide local knowledge of area
Operational Level - Performance Enhancement Course

125

Duty CPSO
Make assessment of incident and assume responsibility for CP & S implications of incident
arrange to deploy assets liaise with owners / operators Inform relevant authorities / organisations activate Marine Emergency Information Room (MEIR), if appropriate contact CP Scientist who will discuss with LAs and carry out any oil spill modeling notify the MCA Media Team
Operational Level - Performance Enhancement Course

126

Duty CPSO
Establishment of contacts during incidents:
MCA CPR Aircraft Response Tug Companies & Brokers Ports & Harbours Environment Protection Agencies MRCCs

SOSREP P&I Clubs


Ship Owners

DEFRA Pollution Contractors

CPSO

Ship Agents MCA MO & MCOs

DTI Salvors

DNSARO

Oil & Gas Operators

MCA Press

Operational Level - Performance Enhancement Course

127

SOSREP
SOSREP
SOSREP has ultimate powers to intervene on behalf of Secretary of State for Transport in any salvage situation or situation where there is a threat of significant pollution

Powers to Intervene and issue Directions Powers to require ships to be moved or not to be moved from a specific area or locality within UK Waters. Powers to establish Temporary Exclusion Zone (TEZ)
Operational Level - Performance Enhancement Course

128

Salvage Control Unit (SCU)


Purpose of SCU is to support SOSREP by:
Considering information on progress of salvage Evaluating all possible options Interacting with on board Salvage Team Providing feedback with other units such as MRC, MEIR, Environment Group Facilitating the mobilisation of resources

Prime objective of all action is to minimise the risk of environmental pollution

Operational Level - Performance Enhancement Course

129

SCU

Membership:
SOSREP, Independent SOSREP Salvage Adviser CPSO, Salvage Master, Harbour Master, Ship owner/insurer representative, EG Liaison Officer, Specialist Scientific Advisor, Health/Safety Adviser

SCU is NOT a decision making body; decisions remain the responsibility of SOSREP
Operational Level - Performance Enhancement Course

130

Marine Response Centre (MRC)


Purpose of MRC is to: Assess and monitor the situation at sea Initiate and control dispersant-spraying operations on spilled oil at sea Initiate and control mechanical recovery options at sea.
Operational Level - Performance Enhancement Course

131

MRC
Members:
CPSO MCA Logistics Officer Harbour representative, if a harbour is involved Officer from relevant fisheries department Local Authority Officer to liaise with the SRC Environmental Liaison Officer MCA Public Relations Officer

Operational Level - Performance Enhancement Course

132

Shoreline Response Centre (SRC)


Purpose of SRC is to co-ordinate and lead the on-shore response
Determine the extent of the problem Agree a strategy and priorities Initiate response Obtain and allocate resources Determine methods of waste disposal Monitor progress Brief elected members, Ministers, VIPs, media
Operational Level - Performance Enhancement Course

133

SRC
Local Authority personnel will be mainly concerned with shoreline clean-up
EA / SEPA Natural England / SNH DEFRA / SEERAD MFA / FRS Contractors ITOPF
GNN Red Cross St Johns Ambulance Oil Company HMCG / CPB Police

Operational Level - Performance Enhancement Course

134

Where the Environment Group sits


Secretary of State Chief Executive MCA Director of Operations MCA

SOSREP SCU Salvage operations

HMCG Search and Rescue

MRC At-sea response operations MCA

SRC Shoreline cleanup LA + MCA

Environment Group Environmental advice


Operational Level - Performance Enhancement Course

135

Environment Group (EG)


Function
To provide advice and guidance on environmental matters to SCU, MRC & SRC

Role is purely advisory


EG has no formal powers (although members may have)

MCA initiates then contacts:


Statutory Nature Conservation Body Environmental Regulator

Fisheries Department
Operational Level - Performance Enhancement Course

136

Environment Group
CORE MEMBERSHIP
Environmental Regulator Statutory Nature Conservation Body Fisheries Department Public Health Officer

Not just for the big incidents Dependant upon location, nature and scale of the incident Other organisations may be invited to join EG at the discretion of the chair

Operational Level - Performance Enhancement Course

137

Environment Group
The core membership may choose to invite:
Sea Fisheries Committee National Park Authorities Local Health Authority HSE Health Protection Agency Animal Welfare bodies - RSPCA, SSPCA Bird casualty record collation - RSPB NGOs Local Wildlife Trusts Local Animal Welfare Trusts
Operational Level - Performance Enhancement Course

138

WHAT IS SAFETY

?
139

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

SAFETY IS
CONTROL OF ACCIDENTAL LOSS

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

140

SAFETY IS
CONTROL OF ANY ACCIDENTAL LOSS AND NOT JUST ABOUT

LSA, FFA AND DRILLS!

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

141

REMEMBER THIS!
WHAT IS SAFETY?
SAFETY IS
CONTROL OF ACCIDENTAL LOSS

WHAT IS LOSS?
LOSS IS
AVOIDABLE WASTE OF ANY RESOURCE
Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

142

Loss is often associated with substantial damage : However, Small damages Small hull repairs Small machinery breakdowns Container damages Cargo damages Personal injuries Small oil spills

Counts for more than the substantial damages THE DAY TO DAY LOSSES CAN VERY OFTEN BE AVOIDED
Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

143

IN TIMES OF KEEN COMPETITION AND LOW PROFIT MARGINS, LOSS CONTROL MAY CONTRIBUTE MORE TO PROFITS THAN AN ORGANIZATIONS BEST SALESMEN. The amount of sales required to pay for losses will vary with the profit margin.
YEARLY INCIDENT COSTS $1,000 5,000 10,000 25,000 50,000 100,000 150,000 200,000 PROFIT MARGIN 1% 100,000 500,000 1,000,000 2,500,000 5,000,000 10,000,000 15,000,000 20,000,000 2% 50,000 250,000 500,000 1,250,000 2,500,000 5,000,000 7,500,000 10,000,000 3% 33,000 167,000 333,000 833,000 1,667,000 3,333,000 5,000,000 6,666,000 4% 25,000 125,000 250,000 625,000 1,250,000 2,500,000 3,750,000 5,000,000 5% 20,000 100,000 200,000 500,000 1,000,000 2,000,000 3,000,000 4,000,000

SALES REQUIRED TO COVER LOSSES This table shows the dollars of sales required to pay for different amounts of costs for accident losses, i.e., if an organizations profit margin is 5%, it would have to make sales of $500,000 to pay for $25,000 worth of losses. With a 1% margin, $10,000,000 of sales would be necessary to pay for $100,000 of the costs involved with accidents.
Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

144

The most valuable fringe benefit of considering safety an operational strategy has been the general improvement in line managements ability to manage all aspects of their total jobs. Believe me, this is not just mere rhetoric It is a proven fact. Lester A. Hudson, President Dan River, Inc

Minimizing loss is as much improvement as maximization of profit. Louis Allen


Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

145

The first duty of business is to survive and the guiding principle of business economics is not the maximization of profit - it is the avoidance of loss. Peter Drucker

LOSS CONTROL MANAGEMENT


I - Identify all loss exposures. E - Evaluate the risk in each exposure.

D - Develop a plan.
I - Implement the plan. M - Monitor
Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

146

ACCIDENT
AN UNDESIRED EVENT THAT CAUSES:
HARM TO PEOPLE DAMAGE TO PROPERTY LOSS TO PROCESS(WORK) Harm to Planet

IT MUST BE A RESULT OF A CONTACT WITH ENERGY OR SUBSTANCE ABOVE THE THRESHOLD LIMIT
Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

147

NEAR MISS
(INCIDENT) AN UNDESIRED EVENT WHICH UNDER SLIGHTLY DIFFERENT

CIRCUMSTANCES COULD HAVE RESULTED IN HARM TO PEOPLE,


DAMAGE TO PROPERTY OR LOSS TO PROCESS.

INCIDENT
NO PAIN

ACCIDENT
PAIN
THRESHOLD LIMIT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

148

FOR EXAMPLE: People


IF A PERSON FALLS AND AFTER GETTING UP DOES NOT HAVE ANY WOUND OR PAIN IN ANY PART OF HIS BODY THEN IT WOULD BE CLASSIFIED AS A NEAR MISS. THE THRESHOLD LIMIT OF HIS BODY HAS NOT BEEN EXCEEDED.

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

149

FOR EXAMPLE - Property


SIMILARLY, IF NO DEFORMATION / DENT / DAMAGE HAS TAKEN PLACE, TO ANY EQUIPMENT OR STRUCTURE, IT WOULD BE CALLED A NEAR MISS.

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

150

HAZARD
A CONDITION OR PRACTICE WITH POTENTIAL FOR ACCIDENTAL LOSS

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

151

INCIDENT

NO LOSS

NEAR MISS

LOSS
ACCIDENT

ACCIDENT RATIO STUDY


SERIOUS OR MAJOR INJURY
Includes disabling and serious injuries. (ANSI-Z 16.1, 1967 Revised. Ratio of 1.15)

MINOR INJURY Any reported injury less than serious.


PROPERTY DAMAGE ACCIDENTS All types INCIDENTS WITH NO VISIBLE INJURY OR DAMAGE (Near-Accidents or close calls)
Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

152

North of England P&I Club Model

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

153

LOSS CONTROL
ANYTHING DONE TO REDUCE LOSS ?

LOSS CONTROL MANAGEMENT:

APPLICATION OF PROFESSIONAL MANAGEMENT SKILLS TO THE CONTROL OF LOSS


Operational Level - Performance Enhancement Course

Anglo Eastern Maritime Training Centre

154

LOSS IS THE CONSEQUENCE OF AN ACCIDENT. LET US STUDY WHY THE LOSS IS CAUSED.

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

155

LOSS CAUSATION MODEL


THIS WILL BE EXPLAINED IN NEXT FEW SLIDES..

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES

INCIDENT CONTACT

SUBSTANDARD ACTS AND CONDITIONS

WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANT PROFIT

PRE-CONTACT OR PRE ACCIDENT


Anglo Eastern Maritime Training Centre

CONTACT

POST-CONTACT

Operational Level - Performance Enhancement Course

156

LOSES CAN BE CAUSED TO:


LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT
LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS BASIC CAUSES PERSONAL FACTORS JOB FACTORS IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS INCIDENT CONTACT WITH ENERGY OR SUBSTANCE LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

W H Y ?

PRE-CONTACT

CONTACT

POST-CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

157

FOR A LOSS TO OCCUR A CONTACT


MUST TAKE PLACE - THIS IS CALLED THE

INCIDENT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

158

E.G.. STRUCK BY... CAUGHT BETWEEN... CAUGHT IN...

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

159

E.G.. STRUCK BY... CAUGHT BETWEEN... CAUGHT IN...

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

160

COMMON TYPES OF ENERGY TRANSFER


(Listed by American Standard Accident Classification Code)
Struck against (running or bumping into) Struck by (Hit by moving objects) Fall to lower level (Either the body falls or the object

falls and hits the body)


Fall on same level (slip and fall, tip over)

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

161

COMMON TYPES OF ENERGY TRANSFER


Caught in (pinch and nip points) Caught on (snagged, hung) Caught between (crushed or amputated) Contact with (electricity, heat, cold, radiation, caustics,

toxics, noise)
Over stress / over exertion / over load

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

162

FOR AN INCIDENT TO OCCUR THERE MUST BE AN IMMEDIATE CAUSE

ASK WHY TO GET TO BASIC CAUSE!


Anglo Eastern Maritime Training Centre

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

Operational Level - Performance Enhancement Course

163

E.G.. (1) FAILURE TO USE PROTECTIVE CLOTHING (2) GREASY SLIPPERY DECKS

IMMEDIATE CAUSES SUBSTANDARD ACTS AND SUBSTANDARD CONDITIONS SYMPTOMS

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

164

SUBSTANDARD PRACTICES
Failure to follow rules and regulations Operating equipment without authority Failure to warn Failure to secure Operating at improper speed Making safety devices inoperable

Removing safety devices


Using defective equipment
Operational Level - Performance Enhancement Course

Anglo Eastern Maritime Training Centre

165

SUBSTANDARD PRACTICES
Using equipment improperly Failing to use personal protective equipment properly

Improper loading
Improper placement Improper lifting

Improper position for task


Servicing equipment in operation Horseplay

Under influence of alcohol and/or other drugs


Suicide or homicide
Operational Level - Performance Enhancement Course

Anglo Eastern Maritime Training Centre

166

SUBSTANDARD CONDITIONS
Inadequate guard or barriers

Inadequate or improper protective equipment


Defective tools, equipment or materials Congestion or restricted action

Inadequate warning systems


Fire and explosion hazards Poor housekeeping; disorderly workplace
Prescription without diagnosis is malpractice, whether it be in medicine or management. Karl Albercht, Organization Development
Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

167

SUBSTANDARD CONDITIONS
Hazardous environmental conditions; gases, dusts,

smokes, fumes, vapours


Noise exposures Radiation exposures

High or low temperature exposures


Inadequate or excessive illusion Inadequate ventilation

Inadequate port and berthing facilities


Congestion or restricted action
Anglo Eastern Maritime Training Centre
Operational Level - Performance Enhancement Course

168

IMMEDIATE CAUSES ARE ONLY THE SYMPTOM. THERE IS ALWAYS A MORE FUNDAMENTAL OR BASIC CAUSE FOR AN ACCIDENT TO OCCUR

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST -CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

169

E.G.. INADEQUATE TRAINING INADEQUATE SPECIFICATIONS ON REQUISITION

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST -CONTACT

Anglo Eastern Maritime Training Centre

Operational Level - Performance Enhancement Course

170

E.G.. (1) FAILURE TO USE PROTECTIVE CLOTHING (2) GREASY SLIPPERY DECKS

IMMEDIATE CAUSES SUBSTANDARD ACTS AND SUBSTANDARD CONDITIONS SYMPTOMS

ASK WHY AGAIN AND AGAIN TO GET TO THE BASIC CAUSE!


Anglo Eastern Maritime Training Centre

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

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171

BASIC
E.G.. INADEQUATE TRAINING INADEQUATE SPECIFICATIONS ON REQUISITION CAUSES PERSONAL FACTORS JOB FACTORS

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST -CONTACT

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THE BASIC CAUSE WOULD NOT HAVE OCCURRED IF THERE WAS PROPER CONTROL TO PREVENT ACCIDENTS. THE LACK OF CONTROL IS THE ROOT OF THE ACCIDENT

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

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E.G.. NO SYSTEM OF EMERGENCY DRILLS VESSEL MUST BE NAVIGATED SAFELY AT ALL TIMES?? STEERING TEST NOT DONE

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS


COMPLIANCE TO STANDARDS

LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS

BASIC CAUSES PERSONAL FACTORS JOB FACTORS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

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TYPES OF LACK OF CONTROL


E.G.. NO SYSTEM OF EMERGENCY DRILLS VESSEL MUST BE NAVIGATED SAFELY AT ALL TIMES?? (VAGUE) STEERING TEST NOT DONE
LACK OF CONTROL INADEQUATE PROGRAM PROGRAM STANDARDS COMPLIANCE TO STANDARDS BASIC CAUSES PERSONAL FACTORS JOB FACTORS

INADEQUATE PROGRAM INADEQUATE PROGRAM STANDARDS NON COMPLIANCE TO STANDARDS

W H Y ?

IMMEDIATE CAUSES SUBSTANDARD ACTS AND CONDITIONS

INCIDENT CONTACT WITH ENERGY OR SUBSTANCE

LOSS PEOPLE PROPERTY PROCESS PLANET PROFIT

PRE-CONTACT

CONTACT

POST-CONTACT

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PERSONAL FACTORS
Inadequate Physical / Physiological Capability

Physical / Physiological stress


Mental / Psychological Stress Lack of Knowledge Lack of Skill Improper Motivation
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JOB FACTORS
Inadequate leadership and supervision

Inadequate Engineering Inadequate purchasing Inadequate maintenance Inadequate tools & equipment Inadequate work standards Wear and tear Abuse or misuse
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STAGES OF CONTROL
THRESHOLD LIMIT

PRE-CONTACT CONTROL CONTROL CAUSES

CONTACT CONTROL

POST - CONTACT CONTROL CONSEQUENCES

POTENTIAL LOSS AUDIT Anglo Eastern Maritime Training Centre INSPECTIONS INCIDENT REPORTING

ACTUAL LOSS ACCIDENT REPORTING 178

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Theories of Accident Causation and Investigation Method(s) Based Thereon

1. 2. 3. 4. 5.

Single Event Theory Domino Theory Fault Tree Theory Process Theory (Event Charting) Human Error Theory

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The Single Event Theory


The theory is based on the assumption that an accident consists of a single event that has a cause. Find the cause and phenomenon can be explained. The investigative task is easy; find the cause and correct it, and accidents can be prevented. Investigators look for data in accidents that will support the idea that conditions such as attitudes, attentiveness etc. cause accidents. Focus on the cause can result into scapegoat and the theory may encourage an incomplete examination of the accident phenomenon. Not applied anymore

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180 OISD

180

The Domino Theory


Herbert William (Bill) Heinrich in 1930s. Five metaphorical dominoes labeled with accident.

Premise of the theory is that if a set of unsafe conditions (hazards) set up a row of these vulnerable dominos, an unsafe act would start toppling them.
The accident is avoided by removing one of the dominoes, normally the middle one or unsafe act.
The sequence is: Injury, caused by an; Accident, due to an; Unsafe act and/or mechanical or physical hazard, due to the; Fault of the Person, caused by their; Ancestry and Social Environment.
181 OISD 181

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ILCI Model

First update of the Domino Theory presented by Bird & Loftus in1976. This revised model introduced two new concepts: The influence of management and managerial error Loss, as the result of an accident could be production losses, property damage or wastage of other assets, as well as injuries. The re-labelled dominoes are: Management - Loss of Control / Lack of Control Origins - Basic Causes / Basic Concepts, Symptoms - Immediate Causes, Contact Incident /accident, Loss - People / Property.
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182 OISD

182

Investigation Method Based on Domino Theory: Systematic Cause Analysis Technique (SCAT)

SCAT originally developed by the International Loss Control Institute (ILCI); is currently a proprietary method of Det Norske Veritas.

Method based on ILCI Loss Causation Model. Immediate causes of an accident - circumstances that immediately precede the contact.

Basic causes (diseases or real causes) behind the symptoms the reasons why the substandard acts and conditions occurred.
Three reasons for lack of control: Inadequate program Inadequate program standards and Inadequate compliance with standards

Elements that should be in place in a safety program

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183

SCAT has five blocks approach to ensure all aspects of an incident are looked into. First block- contains description of the incident. Second block - lists the most common categories of contact that could have led to the incident under investigation.

Third block- lists the most common causes.

immediate

Fourth block- lists common basic causes.

Fifth block- lists activities generally accepted as important for a successful loss control program.

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184 OISD

184

Advantages and Pitfalls of Domino Theory and Methods Based on This


Popularity of Domino theory is due to: Its simple, Its an easy fix It places blame It makes users look good The major criticism of the theory Its potential for introducing bias into the investigation procedure.

Investigator must identify one or more unsafe acts and / or conditions as causes.

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185 OISD

185

Process Theory (Event Charting)


To identify, order, and display the explanation of the relevant factors in the accident. Premise - an accident is not a single event; it is a segment of a continuum of activities; in the process an activity is interrupted with accompanying unintentional harm. The objective of the investigation should be to isolate this process and prepare a description of the entire process for the activity. First step is to define the end of the incident sequence. The diagram starts from the end point, working backward - most immediate contributing event is identified. Events must describe an occurrence, breaking down the sequence into discrete events.

Methods based on event charting are Multilinear Events Sequencing, Sequentially Timed Events Plotting Procedure (STEP), Human, Technology and Organisation (MTO).

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186 OISD

186

Fault Tree Theory


Top Event Undesired state of a system. Analysis of environment and operation to find all credible ways (faults) in which the undesired event can occur. Graphical presentation of various parallel and sequential combinations of faults leading to undesired event. Logical interrelationship of basic events. Includes those faults which contribute to the top event. Gates Methods based on event tree are Causal Tree Method, Management Oversight and Risk Tree (MORT) and TapRoot.

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187 OISD

187

Human Error theory


Accident is attributed to the failure of the system through human error. Three broad factors leading to human error are: Overload, inappropriate response and inappropriate activities Overload A syndrome where the individuals natural capacity is overwhelmed. Factors causing overload can be natural ability, training, state of mind (personal problems, emotional stress, worry) design of the workplace (noise, climate, lighting, distractions), fatigue level and unclear instructions.

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188 OISD

188

Human Error Theory Contd.


Inappropriate Response Persons response in a given situation can be the determining factor whether an accident could be prevented or could lead to the cause of one. Examples are ignoring a suspected hazard, willingly disregard to a safety procedure, circumventing safety locks on equipment. Inappropriate Activities Examples are undertaking a task without the requisite training, being unfamiliar with equipment and procedures, misjudging the degree of risk associated with the task. The human factors analysis and classification system (HFACS) is a method based on human error theory

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189 OISD

189

Reasons Swiss Cheese Model of Human Error


Latent failure Latent failure Latent failure

Active failure

Organisation

Unsafe supervision
Preconditions for unsafe acts Unsafe acts

Any incident is preceded by: An unsafe act an error or violation, which is encouraged by Preconditions for unsafe acts substandard conditions or substandard practices. These in turn are not prevented or corrected due to Unsafe supervision planned (but) inappropriate operations; failure to correct known problems; supervisory violations; and underlying all of this are Organisational influences - poor resource management; organisational climate; organisational processes.

Incident investigation method TRIPOD-Delta is Reasons theory


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based on

OISD

190 190

Control Strategies for Different Kinds of Accidents

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191 OISD

191

Increased risk

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192

OSVs: Crew and Safe Operations


Late 90s Considerable increase of accidents, mostly in the North Sea:
- Supply vessels - Anchor handling vessels - Rescue vessels
14 12 10 8 6 4

Last days/hours of rotation/watch

2 0 1995 1996 1997 1998 1999 2000

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Sleep problems for OSV crews


What are the causes of your sleep problems at sea?
Noise Vibration in cabin Cabin temperature/humidity Wakened by alarms or other loud noises Bad mattress/pillow/duvet Need to get up to urinate Bothered by shift-working Conflicts/worries at home Other (write): Conflicts/worries at work Feel that something on board is not safe Physical problems (write): Snoring

51
32

29 28
22 18

15
12 11 8

6
4 3 0 10 20 30 Percentage 40 50 60

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Reprinted with permission from Sintef

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Effects of human fatigue


Fatigue drastically reduces human alertness levels and negatively affects job performance. Although fatigue is difficult to define, it can be generalized as "impaired alertness. Fatigue affects humans in different ways, although most people suffer from: decreased problem solving ability increased risk taking delayed reaction time moodiness inability to concentrate, and inattentiveness. Logical reasoning and decision-making are affected by fatigue and it impairs human physical abilities such as strength, speed, coordination, and balance

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CAUSES OF FATIGUE
Fatigue may result from: poor sleep quality sleep deprivation physical/mental exertion emotional stress disruption of circadian rhythms poor physical condition, drug/alcohol use. Everyone has felt the effects of fatigue. It is usually described as an uncontrollable urge to sleep or rest. It has also been described as a "fog" that comes over the brain at certain times of the day. Of importance is that fatigue lowers alertness levels and impairs performance.

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FACTORS AFFECTING SLEEP

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RESTORATIVE SLEEP ENVIRONMENT


The sleeping environment determines a persons ability to get three of the four factors of restorative sleep, namely quality, continuity, and quantity. Quantity and time of day are impacted by work schedules and operational commitments. The design factors that create a good sleeping environment also impact the watch station, working, and recreational environments.
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SLEEP DEPRIVATION & ALTERNESS


Effects of Reduced Sleep on Alertness Levels Effect of Successive Days of Reduced Sleep on Alertness Levels

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DESIGN FACTORS AFFECTING SLEEPING ENVIRONMENT


The foundation of the diagram is the six design factors, all of which naval architects and marine engineers can directly control. These factors determine how comfortable the working and sleeping environments are aboard a ship: lighting noise vibrations ventilation temperature, and ship motions These all can be incorporated through the preliminary design of a vessel and maintained throughout ships post-production life

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Heinrich Triangle
Single fatality Permanent total disabilities Permanent partial disabilities Lost work cases Restricted work cases Medical treatment cases First aid cases Dangerous occurrences/Near misses Unsafe acts/Unsafe conditions

More information at the bottom = More to learn from the bottom


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Crystal Ball for L.P.


ACCIDENT 1 DEBILITATING INJURY, AN OIL SPILL, OR CASUALTY LOSS TIME, ACCIDENTS, MINOR CARGO CLAIMS, ETC UNEXPECTED REPAIRS, HULL DAMAGE, WHARF DAMAGE ETC.

MINOR ACCIDENT PROPERTY LOSS

10

30

EVENTS

600

1 Accident is preceded by 10 Minor Accidents is preceded by 30 Property Loss is preceded by 600 Events

Source: Prevention through People

Leadership Development Seminar, Mumbai Eurasia International (China)


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Bow Tie Diagram


Threat 1 Consequence 1

HAZARD

Threat 2

Initiating Event

Consequence 2

Threat 3

Threat barriers Saf.Crit. Saf.Crit.

Recovery measures Saf.Crit.

Consequence 3

Saf.Crit.
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ManagementPerformance Enhancement Coursetasks Operational Level - activities and

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ACCIDENT INVESTIGATION Reactive


What happened ? Where did it happen ?

RISK ASSESSMENT Proactive


Before each task do JHA
What can go wrong ? What could cause it to go wrong? What could be done to prevent it going wrong?

When did it happen ?


How did it happen ? Why did it happen ? Who were involved ?

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Performance Management
Management = getting work done through others Managers performance is only as good as his/her employees performance Managers job = performance management of others

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Performance Management
An iterative process of goal-setting, communication, observation and evaluation to support, retain and develop exceptional employees for organizational success.

Set Goals

Communicate

Evaluate

Observe

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Why Manage Performance?

To reach organizational mission and goals

Encourage and reward behaviors aligned with organizational mission and goals Curb or redirect non-productive activities

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What do Employees Expect?


Clear expectations
Positive/constructive feedback on a regular basis Involvement in goal setting

Be treated fairly and consistently


Sharing of information and resources Job/career enrichment opportunities
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Performance Management
Organizational system Focusing on employee performance Consistently applied throughout organization With a supporting structure

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Names of Systems
Performance Management Performance Appraisals

Evaluation Systems
Job Review Systems Feedback Systems
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PROBLEM SOLVING

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OVERALL PROCESS
I. II. III. IV. V. VI. Overall Process Defining the Problem Formulating the Hypothesis Collecting the Facts Conducting the Analysis Developing the Solution

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Analytical Thinking follows the scientific approach to problem solving

Problem

Solution

Hypothesis

Analysis

Facts

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Problem

Defining the Problem

Solution

Hypothesis

Analysis

Facts

Definition: A problem is a situation that is judged as something that needs to be corrected implies that a state of "wholeness" does not exist Importance: It is our job to make sure were solving the right problem it may not be the one presented to us by the client. What do we really need to solve? Basic Concepts: Most of the problems are initially identified by our clients Defining the problem clearly improves focus it drives the analytical process Getting to a clearly defined problem is often discovery driven Start with a conceptual definition and through analysis (root cause, impact analysis, etc.) you shape and redefine the problem in terms of issues
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Problem

Formulating the Hypotheses

Solution

Hypothesis

Analysis

Facts

Definition: Hypothesis is a tentative explanation for an observation that can be tested (i.e. proved or disproved) by further investigation Importance: Start at the end - Figuring out the solution to the problem, i.e. "hypothesizing", before you start will help build a roadmap for approaching the problem Basic Concepts: Hypotheses can be expressed as possible root causes of the problem Breaking down the problem into key drivers (root causes) can help formulate hypotheses
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Problem

Collecting the Facts

Solution

Hypothesis

Analysis

Facts

Definition: Meaningful information (has merit not false) that is qualitative (expert opinions) or quantitative (measurable performance) to your decisions Importance: Gathering relevant data and information is a critical step in supporting the analyses required for proving or disproving the hypotheses Basic Concepts: Know where to dig Know how to filter through information Know how to verify Has happened in the past Know how to apply Relates to what you are trying to solve

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Problem

Conducting the Analysis

Solution

Hypothesis

Analysis

Facts

Definition: The deliberate process of breaking a problem down through the application of knowledge and various analytical techniques Importance: Analysis of the facts is required to prove or disprove the hypotheses Analysis provides an understanding of issues and drivers behind the problem Basic Concepts: It is generally better to spend more time analyzing the data and information as opposed to collecting them. The goal is to find the golden nuggets that quickly confirm or deny a hypothesis Root cause analysis, storyboarding, and force field analysis are some of many analytical techniques that can applied

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Problem

Developing the Solution

Solution

Hypothesis

Analysis

Facts

Definition: Solutions are the final recommendations presented to our clients based on the outcomes of the hypothesis testing Importance: Solutions are what our clients pay us for Basic Concepts: It is important to ensure the solution fits the client solutions are useless if they cannot be implemented Running an actual example through the solution is an effective way of testing the effectiveness and viability of the solution

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TOOLS AND TECHNIQUES FOR "DEFINING THE PROBLEM"

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Problem Identification
A problem becomes known when a person observes a discrepancy between the way things are and the way things ought to be. Problems can be identified through: Comparative/benchmarking studies Performance reporting - assessment of current performance against goals and objectives SWOT Analysis assessment of strengths, weaknesses, opportunities, and threats Complaints Surveys Etc.

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Getting to the "Root" of the Problem


Sometimes the thing we think is a problem is not the real problem, so to get at the real problem, probing is necessary Root Cause Analysis is an effective method of probing it helps identify what, how, and why something happened Definition of root cause:
Specific underlying cause Those that can reasonably be identified Those that management has control to fix
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Root Cause Analysis Technique Five Whys


Five Why's refers to the practice of asking, five times, why the problem exists in order to get to the root cause of the problem
Employee turnover rate has been increasing

Why?

Why?

Why?

Why?

Why?

Employees are leaving for other jobs


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Employees are not satisfied

Employees feel that they are underpaid

Other employers are paying higher salaries

Demand for such employees has increased in the market


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Root Cause Analysis Technique Fishbone Diagram


Fishbone Diagram (a.k.a. Cause and Effect Diagram) is an analysis tool that provides a systematic way of looking at effects and the causes that create or contribute to those effects.
Cause Detail Result (Problem) Cause Detail

Detail Cause Cause

Detail

The value of the Fishbone Diagram is that it provides a method for categorizing the many potential causes of problems or issues in an orderly way and in identifying root causes 223 of 58
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Other Root Cause Analysis Techniques


Force Field Analysis Visually show forces that impact your problem or issue Scatter Diagrams Graphs the relationship of two variables quantifies the correlation, showing how one variable influences another Process Mapping Maps the as is flow of activities that make up a process look for excessive handoffs, redundancies, and other root causes of inefficiencies Benchmarking Compares existing performance to another internal or external source, identifies issues not otherwise revealed through other techniques
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Basic Questions to Ask in Defining the Problem (regardless of the technique used)
Who
Who is causing the problem? Who says this is a problem? Who are impacted by this problem? Etc.

What
What will happen if this problem is not solved? What are the symptoms? What are the impacts? Etc.

Where
Where does this problem occur? Where does this problem have an impact? Etc.

When
When does this problem occur? When did this problem first start occurring? Etc.

Why
Why is this problem occurring? Why? Why? Etc.

How
How should the process or system work? How are people currently handling the problem? Etc.

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225

TOOLS AND TECHNIQUES FOR " FORMULATING THE HYPOTHESES"

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Issue Diagram is an effective method for breaking down problems and formulating hypotheses
Hypothesis #1A
Hypothesis #1B Issue #1 Hypothesis #1C Key Questions #1C-c Hypothesis #1D Problem Issue #2 Key Questions #1C-d Key Questions #1C-a Key Questions #1C-b

Issue #3
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Key Components of Issue Diagram

Issues

Questions which need to be answered or topics which need to be explored in order to solve a problem Speculative answers for issues that are phrased as questions and/or areas of exploration for issue phrased as topics Questions that probe hypotheses and drive the primary research required to solve the problem

Hypotheses

Key Questions

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Identifying the Issues


What key topics should we explore to help the client solve this problem?
Client wants to decide whether they should divest their widget X manufacturing business

Issue #1

Is there a market for divesting this business?

Problem

Issue #2

Is this a cost effective solution for the client?

Issue #3
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What impacts will there be for the displaced employees?


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Key to Identifying Issues


1. Develop a comprehensive list of all possible issues related to the problem 2. Reduce the comprehensive list by eliminating duplicates and combining overlapping issues 3. Using consensus building, get down to a major issues list (usually two to five issues)

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Formulating the Hypotheses


Market Interest? Issue #1

Hypothesis #1A
Hypothesis #1B Etc.

The market is large.

Divest Widget X Business?


Problem

Cost Effectiveness? Issue #2

Hypothesis #2A Hypothesis #2B Etc.

What are some possible answers to the issues?

Impacts on Employees? Issue #3


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Hypothesis #3A Hypothesis #3B

Large percentage of employees will likely retire in two years.

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Etc.

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Framing the Key Questions


The market is large. Market Interest?

Key Question #1A-a Key Question #1A-b Key Question #1A-c

How many players are there in the market? How many are large enough to take on the client's business?

Hypothesis #1A Hypothesis #1B

Issue #1

Divest Widget X Business?

Cost Effectiveness?

Hypothesis #2A Issue #2 Hypothesis #2B


Large percentage of employees will likely retire in two years.

Problem

What questions need to be answered to prove/disprove the hypothesis? Key Question #3A-a Key Question #3A-b Key Question #3A-c How many employees are 50 years old or older and interested in retiring?
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Impacts on Employees?

Hypothesis #3A Hypothesis #3B

Issue #3
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Common Pitfalls in Creating Issue Diagram


Issues
Issues which are: Too broad, which expand beyond the objectives Too narrow Too many to be easily remembered Of uneven weight Not sequenced effectively Hypotheses which are: Too few to cover the issue Too many to be easily remembered Not supportable by data Not directly relevant to the issue Key questions which are: Too few to test the hypotheses Too many to be easily remembered Irrelevant to the hypotheses Not answerable with data
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Hypotheses

Key Questions
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Key Messages
Issue diagrams provide a framework for brainstorming and documenting the issues driving the problem and identifying the facts (i.e. data) required to support conclusions and recommended solutions Hypotheses and the key questions will help shape data collection requirements and ensure that only relevant data is collected Formulation of hypotheses and key questions is an evolving process they will need to be revised as new insights and discoveries are made

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Brainstorming is useful when there is a wide range of possible issues and solutions Brainstorming is not appropriate for testing an idea; it is used to generate ideas There are numerous brainstorming techniques, which include group brainstorming, individual brainstorming, and storyboarding Individual brainstorming is usually not recommended unless time is too tight, participants are rarely available, group is too large, etc. Brainstorming can be useful for Force Field Analysis identifying all forces impacting the problem
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Brainstorming A Method for Identifying Issues and Formulating Hypotheses

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Tips for Brainstorming


1. State the purpose and objective of the brainstorming session from the onset 2. Set ground rules for participants 3. Give everyone an opportunity to participate 4. Solicit all ideas and opinions nothing is rejected until consensus building takes place 5. After exhausting all ideas, eliminate certain ideas, e.g. not relevant, duplicative, etc. 6. Finalize outcome of the brainstorming process through consensus: Highest Priority, Assigning Points, etc.

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TOOLS AND TECHNIQUES FOR "COLLECTING THE FACTS"

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Getting to the Facts


In order to answer the key questions and validate the hypotheses (presented in the earlier steps), collection of factual information is necessary First critical steps are to identify what information, i.e. data elements, is required and develop a data collection approach/technique Depending on the type of problem being solved, different data-collection techniques may be used Combining a number of different techniques allows looking at problems from different perspectives Data collection is a critical stage in problem solving - if it is superficial, biased or incomplete, data analysis will be difficult

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Using the Issue Diagram to identify data and information needs


Number of companies in the industry Revenues for the last 5 years Etc.

Key Question #1A-a


Hypothesis #1A Issue #1 Hypothesis #1B

Key Question #1A-b


Key Question #1A-c Key Question #3A-a Key Question #3A-b Key Question #3A-c

How many are large enough to take on the client's business? What information or data needs to be collected to answer these questions? How many employees are 50 years old or older and interested in retiring?

Hypothesis #2A Problem Issue #2 Hypothesis #2B

Hypothesis #3A Issue #3 Hypothesis #3B

Ages of the employees Employee interest level Etc.

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Data Collection Techniques


Technique
Using Available Information Observing Interviewing Administering Written Questionnaires Conducting Focus Groups
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Description
Using data that has already been collected by others Systematically selecting, watching and recording behavior and characteristics of people, objects or events Oral questioning of respondents, either individually or as a group Collecting data based on answers provided by respondents in written form Facilitating free discussions on specific topics with selected group of participants

Tools
Checklist Data compilation forms Eyes and ears Data compilation forms Interview guide Data compilation forms Survey Questionnaire Flip charts
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Importance of Combining Different Data Collection Techniques


Qualitative Techniques (Flexible)
Produce qualitative data that is often recorded in narrative form Useful in answering the "why", "what", and "how" questions Typically includes: Loosely structured interviews using open-ended questions Focus group discussions Observations

VS.

Quantitative Techniques (Less Flexible)


Structured questionnaires designed to quantify pre- or post-categorized answers to questions Useful in answering the "how many", "how often", "how significant", etc. questions Answers to questions can be counted and expressed numerically

A skillful use of a combination of qualitative and quantitative techniques will give a more comprehensive understanding of the 241 of 58 Operational Level - Performance Enhancement Course 241

TOOLS AND TECHNIQUES FOR "CONDUCTING THE ANALYSIS"

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Conducting the Analysis


The next step in problem solving is to "make sense" of the information collected in the previous step There is an abundance of analytical techniques that can be applied for understanding:
What are the most important issues? What performance areas are weak? What are the core competencies of the client? What forces can influence the problem?
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Pareto Analysis Benchmarking SWOT Force Field Analysis


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Specific Sequential Steps that lead up to the Analysis


1 2
Make sure you know what you are trying to solve Clearly defined issues or questions drive the analysis!

Match up the clearly defined question or issue with the appropriate analytical tool(s)

Once youve matched up the analytical tools against the question or issue, then go out and collect the facts

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Apply analytical tools and move back upstream


1. Start with clearly defined issues or questions
How many are large enough to take on the client's business?
Key Question #1A-a Hypothesis #1A Issue #1 Hypothesis #1B Key Question #1A-c Key Question #1A-b

2. Select the Analytical Tool


# of companies in industry Revenues for last 5 years

Benchmarking

Hypothesis #2A Problem Issue #2 Hypothesis #2B

What analysis needs to be done to answer this question?


Key Question #3A-a Key Question #3A-b Key Question #3A-c

Hypothesis #3A Issue #3 Hypothesis #3B

Age of employees Employee interest level in retiring

3. Collect required information per the Analytical Tool selected

How many employees are 50 years old or older and interested in retiring?

4. Once you complete your analysis, move back upstream to answer the key question you started with
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Analytical Techniques
Benchmarking Compare and measure a process or activity against an internal or external source SWOT Analysis Assessment of strengths, weaknesses, opportunities, and threats Force Field Analysis Overall environmental landscape and how it impacts the subject Cost Benefit Analysis Compare total equivalent costs (all the minuses) against equivalent value in benefits (all the pluses) Impact Analysis What if type analysis to assess the impact of change on an agency Pareto Chart Bar Chart for categorizing issues or other attributes in terms of importance
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Benchmarking
Measures and compares your performance against other similar activities or processes internally or externally Differences indicate possible performance issues May be difficult to collect comparable measurement data Comparing best in class performance is better than comparing average performance Best sources of data are in the private sector -Hays Benchmarking, Benchmarking Exchange, The Benchmarking Exchange, etc.
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Benchmarking Example
Average Days for Source Selection
Air Force . . . . . . . . . . . 75 Days Army . . . . . . . . . . . . . . . 96 Days Navy . . . . . . . . . . . . . . . 116 Days Canadian Army . . . . . . 145 Days
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SWOT Strengths Weaknesses Opportunities Threats


Identifies Strengths, Weaknesses, Opportunities, and Threats by asking: What things are we good at, what things are we not good at, what things might we do, and what things should we not do? Probably the most common analytical tool for strategic planning Somewhat subjective Easy to understand and follow Very useful for identifying the core competencies of any organization
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SWOT Example
Internal Assessment of the organization, its people, services, competencies, etc. Strengths
Client has a global infrastructure to service all types of customers Services are in high demand in most parts of the world

Weaknesses
Client has limited resources for expanding its global reach Key processes are not very cost competitive when compared to other service providers

External Assessment of direct and indirect forces, social, economic, political, etc. Opportunities
Untapped demand exists in almost half of the World New Technologies make it possible to expand service reach
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Threats
Other clients are investing in newer technologies Some clients are entering into strategic partnerships to expand their global footprint
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Force Field
Visually shows significant forces that impact the problem Forces tend to be those factors that promote or hinder a solution to a problem Prioritize forces between direct (more important) and indirect (less important) May need to brainstorm to generate ideas to list all forces
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Force Field Example


Problem: Agency is not strategically focused
Positive Forces Promotes the Solution Defense Department is promoting the Balanced Scorecard Federal Public Sector has mandates such as GPRA Lower level agencies have balanced scorecards in place Strategic planning is growing in importance within the entire public sector Negative Forces Inhibits the Solution Public Sector mandates lack enforcement teeth no major urgency to become strategically focused. Agency is not resourced to develop strategic plans and execute on nonstrategic issues Agency has too many other change initiatives going on

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Direct More Important

Indirect Less Important


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Cost Benefit
Identify all expected costs and benefits to make sure the decision has economic merit. Costs includes all tangible outlays (time, money, etc.) and intangible /qualitative factors where you can assign some value Compare using a set of decision criteria oranges to oranges, apples to apples, etc. Look at the net changes between making the decision vs. not making the decision Office of Management and Budget Circular A-94 provides guidelines on how to do cost benefit analysis in the Federal Public Sector.
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Cost Benefit Example


Choice A: Proposed Solution - Design and develop an on-line database system The Costs (minuses)
Software License Fees

The Benefits (pluses) Consistent Reporting Reduced Data Entry Much faster turnarounds when updating master records Improved accuracy in reporting

Upgrade network capacity Database development time Training of end-users Requires regular maintenance Choice B: Do Nothing Status Quo
Software License Fees

Maintenance Costs Planned Upgrades


254 ofChange in Costs Choice A B = 58

Net Benefit = $ 250,000

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$ 700,000

Change in Benefits Choice A B = $ 950,000


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Impact Analysis
Identifies broad and diverse effects or outcomes associated with a problem and/or the proposed solution Answers certain questions: How will this change impact our agency? What are the consequences of not acting on the problem? Objective is to minimize adverse or negative impacts going forward Very useful in assessing risk of different proposed solutions helps you reach the right solution Numerous tools can be used to assess impacts

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Impact Analysis Tools


Scenario Playing Storyboarding out how the future will unfold between alternatives: Do Nothing vs. Solution Cost Benefit Analysis - Used to quantify impacts Decision Tree Analysis Build a tree and assign probabilities to each alternative to arrive at the most likely solution Simulation Modeling a process and seeing how it changes when one or more variables change Prototype Model Build and test the solution on a small scale before implementation to flush out lessons learned
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Pareto Analysis
Quantifies what is most important on a graph 80 / 20 Rule Puts focus on the significant problems or issues Must group problems or issues based on a common and measurable attribute (such as reworks, errors, downtime, hours, etc.) = Left Vertical Axis of Bar Chart Must categorize problems or issues what type is it? (poor quality, long wait times, etc.) = Right Horizontal Axis of Bar Chart Plot the data and rank according to frequency descending order from left to right
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Pareto Chart

Downtime, Errors, # of Employees, etc.

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Categories

Causes, Products, Mfg. Lines, Operators Machines, Defect Types, etc. Operational Level - Performance Enhancement Course

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Key Messages
Dont rush out and collect information until you know what analytical tools you need to use each tool has its own information needs Use a combination of tools to cover all the bases All decisions involve some assumptions so you will never have all the facts Analysis is a discover driven process, it moves incrementally in baby steps you learn, adjust and go through numerous iterations until you have insights; i.e. you can now take action on the issue or problem
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TOOLS AND TECHNIQUES FOR "DEVELOPING THE SOLUTION"

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Basic Concepts
Select and plan the solution that has the greatest impact on solving the problem Use a solutions rating matrix to weigh different solutions based on selection criteria (costs, probability of success, ease of implementation) Solutions should have support from your previous analysis that you can clearly communicate to the client Test your solutions as much as you can use some of the Impact Analysis Tools
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Key Messages
100% out-of-the box solutions dont exist No solution is a guarantee be flexible with implementation and be willing to revisit your requirements Solutions rarely work unless you get buy-in and commitment from the client if the client refuses to accept the solution, it will not work! Be prepared to back up your solution with an implementation plan, complete with milestones to measure performance
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Common Land Mines that Blow Analytical Thinking Apart


Once a problem is defined, Professional Consultants must have some ability to develop a possible solution. If the Consultant has no control to make recommendations for a problem, then the problem has been defined outside the scope of the project. The clients definition of the problem may not be correct. The client may lack the knowledge and experience that Professional Consultants have. Since most problems are not unique, Professional Consultants may be able to validate the problem and possible solutions against other sources (past projects, other experts, etc.). The best solutions to a problem are often too difficult for the client to implement. So be careful about recommending the optimal solution to a problem. Most solutions require some degree of compromise for implementation.

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Summary
Analytical Thinking follows the Scientific Approach Five Step Process for Consultants: - Define the Problem - Test in the form of Hypothesis - Focus on Facts - Analysis (Various Analytical Tools) - Recommend a Solution
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ALL OPERATIONS ARE TRANSFORMATION PROCESSES

TRANSFORMED RESOURCES MATERIALS INFORMATION CUSTOMERS

ENVIRONMENT

INPUT
FACILITIES STAFF

TRANSFORMATION PROCESS

GOODS AND OUTPUT SERVICES

TRANSFORMING RESOURCES

ENVIRONMENT
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VALUE-ADDED SERVICE CATEGORIES

Problem Solving

Information

Operations Management

Sales Support

Field Support

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OPERATIONS MANAGEMENT BASIC PRINCIPLES

Materials Information Customers

Operations management is concerned with producing and delivering products and services

Products and services

All types of enterprise have an operations function, even if it isnt called operations. Most operations produce both products and services.

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Operations Activities as Feedback Loops


Design activities set the basic configuration
Planning & control activities guide short/medium term changes

Improvement activities guide longer term changes

Design

Planning & Control

Improvement
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Contingency Planning: How to Keep Operating During Any Type of Disaster

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Not Just Back, Better


Taking care of faculty and staff Immediate relief for students Putting the pieces back together; recovering information It will be better

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Then is this Risk?..

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What is Risk?

Definitions

Simply Risk is The Chance of an adverse event

It is also the possibility of a loss for a gain!


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The Risk Management Process Definitions Major Accidents Risk Management Philosophy
Hazard Identification Risk analysis Risk Assessment Risk Management Options

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Basic Definitions
Hazard
A physical situation with the potential to cause harm (eg storage of flammable/explosive materials). A hazard with the potential to course significant harm eg multiple fatalities.

Major Hazard

Risk

The likelihood of a specified level of harm eg likelihood of a fatality.

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Risk Assessment Process


Formal Risk Assessment (FSA) Process (based on IMO guidelines) Identification of hazards Risk Assessment Risk control options Cost benefit assessments Recommendations for decision making Note: a similar but simpler process is adopted for shipboard level
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Risk Management Philosophy


Dont wait for a major accident to identify need to improve major hazard management. Need to learn lessons from accidents (Hindsight) but dont rely on this approach Manage risks via Foresight rather than Hindsight ie be proactive rather than reactive.

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Risk Management Philosophy


Aim is not to try to totally eliminate risk (all pursuit of opportunity carries risk). Risk Management is not about:
Being risk averse Being reckless

Risk management is about:


Being risk aware Timely, systematic, transparent decision-making.
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Risk Management Process


What are we trying to achieve? (Design Intent) What could go wrong? (Hazard Identification) How likely and how big an impact? (Risk Analysis) How significant is this estimated risk and do we need to reduce this risk? (Risk Assessment) If so, what is the most cost-effective control/mitigation option? (Risk Management)
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Risk Analysis
Likelihood of Harm?
Frequency of similar scenarios
Company Sector All Sectors Qualitative estimates eg from rare to likely.

Failure rate data


Component Equipment System Quantitative estimates eg X failures year (mean/range)
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Risk Analysis
Impact/consequences? Impact of similar scenarios
Physical damage (people/plant/environment) Financial damage Qualitative estimates eg minor to catastrophic

Consequence Modelling
Explosion overpressure Overpressure consequences Damage thresholds (plant); dose response (people) Probability of death.
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Risk Analysis
Risk = likelihood x consequences eg frequency event = 0.002 per year
probability of fatality = 0.4 per event

Risk of death
= 0.002 events x 0.4 fatalities year event = 0.0008 = 8 x 10-4 fatalities Year
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Risk Assessment
Is the risk significant? Is the risk tolerable/acceptable?

Need to compare output from risk analysis to pre-determined risk criteria. These risk criteria reflect the risk appetite of society and the organisation.
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Risk Assessment - Qualitative Risk Matrix

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Risk Assessment
Is Risk tolerable/ acceptable? Red = unacceptable; RM action Must be taken. Broadly acceptable tolerable if risk is ALARP
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Green Amber

= =

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ALARP = As Low As Reasonably Practicable


ALARP implies use of cost-Benefit Analysis

Costs of safeguard

Benefits of safeguard

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ALARP
To satisfy ALARP requirement (UK Law) must provide a safeguard unless the cost is grossly disproportionate to the benefits (eg costs outweigh benefits; costs = 10 x benefits)

Benefits Costs

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Quantitative Criteria
10-3

Risk is Intolerable Risk is broadly acceptable - Risk is tolerable if ALARP = tolerable if ALARP
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10-6

Between 10-3 & 10-6

Earlier example ( 8 x 10-4)

Operational Level - Performance Enhancement Course

INTOLERABLE Risk levels cannot be accepted at any cost TOLERABLE Risk levels may be tolerated if demonstrated to be ALARP

> 10-3 / y (10-4 / y for new facilities)

> 10-6 / y
BROADLY ACCEPTABLE Risk levels broadly acceptable No further explicit demonstration of risk reduction required

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Cost Benefit Analysis


Need some metric to compare costs and benefits.

Costs expressed in monetary terms (eg )


Benefits are statistical fatalities averted (lives saved)

Benefits require value of an averted fatality (ie value of a life).


Very emotive subject (after an event) Risk Management is predictive (before an event).
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Risk Assessment
For CBA typical values (UK) 1.5m. If safeguard costs 200,000.
Plant life = 30 years Reduces risk from 8 x 10-4 to 10-4
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Cost Benefit Analysis


7 x 10-4 averted
x

30 years = 0.021 fatalities

Costs per fatality averted = 9.5 m. 8 x 10-4 is Upper ALARP region; Gross Disproportion Factor = 10. Therefore, safeguard is required under ALARP principle (9.5m v 15m)
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Risk Management
Hazard Identification Risk Analysis Risk Assessment Risk Management Options

Technical Avoid
Control/Mitigate

Financial

Absorb

Transfer

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Risk & Regulation


1. Prescriptive Regulations
Specify detailed requirements Straight forward design processes Relatively easy assurance processes Regulations need to keep pace with technological change Pressure on regulatory processes. Onus is on regulators

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Risk & Regulation


2. Changes following Major Accidents
Seveso Flixborough Piper Alpha EC Directive on Major Hazards COMAH Regulations New offshore safety regime

From Prescriptive to Goal-based Regulations

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What can go wrong - Hazard Identification

How bad will it be Consequence analysis


How often estimation Frequency or likelyhood of

So what? -

Risk Assessment

What can I do about it Risk Management


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a structured and systematics methodology, aimed at enhancing maritime safety & security including:
Protection of life, Health, Marine environment and property, By using risk and cost / benefit assessments.

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RISK ASSESSMENT
Hazard Identification Risk Assessment
Decision Making Recommendation

Risk control options

Cost benefit Assessment

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IDENTIFY

Determine the condition that potentially result in a hazard


Qualitatively determines and prioritize the effects of the hazard Identify the means to prevent or mitigate the hazard

EVALUATE

CONTROL

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E1

E2

E3

E4

E5

Elements of the system

Effects

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Risk Assessment Process


1. 2. 3. 4. 5. 6. Inventory of operations Identify hazards Identify existing safeguards Determine risk Implement more risk controls Review Assessments

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Chances of occurrence of loss Estimate this from 0 (low risk) to 100% (high risk). Value of likely loss Estimate this into Low & High. (These are arbitrary & relative).

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Value of loss

High

Calculated Risk

Unacceptable Risk

Acceptable Risk

Calculated Risk

Low 0%

Chances of occurrence

100%
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Take steps to reduce the chances of occurrence Training & Teamwork; Processes & Practices. Take steps to reduce the value of possible loss Delegate & Distribute; Safe & Sure. If necessary, change the process to achieve the same goal.

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Engineered System
HAZI D

Benefits Qualitative Analysis


BALANCE

Decisions 1.---------2.---------3.----------4.----------

Quantitative Analysis

ALARP Costs

5.----------

RISK ANALYSIS RISK ASSESSMENT RISK MANAGEMENT


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Quantitative and Qualitative Risk Assessment


Quantitative Explicit evaluation of a risk i.e.

Qualitaitive
Banded approach to evaluating risk i.e. risk of major spill from a vessel going aground is

Likelyhood of death from road accidents is 1.0 E-4 1 in 10,000 people will die from road accidents in a year

Once in a ship life

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Effective Risk Management requires effective Risk Assessment Minimization of Risk improves Operational Performance Budgets are limited so need to know where to spend money to improve safety through effective Cost Benefit Analysis (CBA)
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Am I ready to take the risk!


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Material Requirement Planning (MRP)

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What is MRP?
Computerized Inventory Control Production Planning System Management Information System Manufacturing Control System

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What can MRP do?


Reduce Inventory Levels Reduce Component Shortages Improve Shipping Performance Improve Customer Service Improve Productivity Simplified and Accurate Scheduling Reduce Purchasing Cost Improve Production Schedules Reduce Manufacturing Cost Reduce Lead Times Less Scrap and Rework Higher Production Quality
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What can MRP do?


Improve Communication Improve Plant Efficiency Reduce Freight Cost Reduction in Excess Inventory Reduce Overtime Improve Supply Schedules Improve Calculation of Material Requirements Improve Competitive Position

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Three Basic Steps of MRP


Identifying Requirements Running MRP Creating the Suggestions Firming the Suggestions

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Quantity on Hand Quantity on Open Purchase Order Quantity in/or Planned for Manufacturing Quantity Committed to Existing Orders Quantity Forecasted

Step 1: Identifying the Requirements

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Step 1: Important Information MRP is..


Company Sensitive Location Sensitive Date Sensitive

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What to Stock What items need to be maintained on-site? What items are readily available or can be provided via alternative vendor managed inventory solutions? How much to stock - Establishing initial min/max inventory levels, adjusting inventory levels, EOQs, reorder points, safety stock, etc. Inventory Turnover What are the companys goals with respect to working capital investment in inventory; What is the desired turnover ratio; How can the inventory turnover ratio be improved without impacting Maintenance and Operations? Capital Spares How many spares should be maintained; How are they tracked and managed; Can they be used as common spares for more than one facility; What alternatives exist today; How large is the investment in capital spares and how is it managed?
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Critical Spares How are critical spares identified; What is the process to stock and maintain these items; What alternatives exist; Are they repairable; Are they used on multiple pieces of equipment; What is the mean/average time between failures? Process for placing new items into stock Who recommends and approves additions to stock; What are the controls and requirements? How old items are removed from stock - Who recommends and approves deletions from stock; What are the controls and requirements; How are assets disposed of and what monetary recovery is obtainable? Asset management How are capital assets managed, tracked, maintained and identified; How are maintenance material and labor costs associated with these assets tracked and maintained? Maintenance strategy What is the current maintenance strategy with respect to response time; return to service time; cost vs. benefit; preventative maintenance; service levels, predictive maintenance vs. corrective/unplanned maintenance?
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Maintenance planning and scheduling Who is responsible for this function; Is it formalized and followed; How are major repairs and shutdowns planned for, materials staged, equipment ordered/rented? Resource management What resources currently manage MRO and asset management; How many FTEs are involved in ordering, managing, receiving, stocking, issuing and tracking of MRO and capital assets; Are there resource constraints in the organization? Performance measurement How are suppliers measured today with respect to performance, repairs, returns, stock levels, etc.; How are maintenance, operations, and materials management measured with respect to performance?
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Step 2: Running MRP Creating the Suggestions


Critical Items Expedite Items Delay Items

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Step 3: Firming the Suggestions


Manufacturing Orders Purchasing Orders Various Reports

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Overview of the MRP System


Product Structure File Master Production Schedule Inventory Master File

Material Requirements Planning

Manufacturing Orders

Purchase Orders

Various Reports

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MRP Inputs
Product Structure File Master Production Schedule Inventory Master File

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Product Structure File


Bill of Materials

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Master Production Schedule


Schedule of Finished Products Represents Production, not Demand Combination of Customer Orders and Demand Forecasts What Needs to be Produced

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Inventory Master File


On-Hand Quantities On-Order Quantities Lot Sizes Safety Stock Lead Time Past-Usage Figures
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MRP Process
Schedules the Production of all items using an MRP Matrix
MRP Matrix
Item: Lot Size: Low-Level Code: Lead Time:

PD 1

2 3 4 5

Gross Requirements Scheduled Receipts Projected on Hand

Net Requirements
Planned Order Receipts Planned Order Releases
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Terms Defined
Item name or number for the item being scheduled Low-Level Code the lowest level of the item on the product structure file Lot Size order multiples of quantity Lead Time the time from when an order is placed to when it is received PD Past Due Time Bucket, orders behind schedule
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Terms Defined
Gross Requirements demand for an item by time period Scheduled Receipts material already ordered Projected on Hand expected ending inventory Net Requirements number of items to be provided and when Planned Order Receipts net requirements adjusted for lot size Planned Order Releases planned order receipts offset for lead times
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Example of the MRP Process


Item: A Lot Size: 25 Low-Level Code: 1 Lead Time: 1

PD

1 10

Gross Requirements Scheduled Receipts Projected on Hand

15 25 25 30 25

20

Net Requirements
Planned Order Receipts Planned Order Releases
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Example of the MRP Process


Item: A Low-Level Code: 1 Lot Size: 25 min Lead Time: 1

PD

1 10

Gross Requirements Scheduled Receipts Projected on Hand

15 25 25 30 25

20

10

20 20 20 15

Net Requirements
Planned Order Receipts Planned Order Releases

10

25 25 25 25 25 25 30 25
329

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MRP Outputs
Manufacturing Orders Purchasing Orders Various Reports

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330

Module 9 Incident Resources Management


Subjects covered in this module include:
Principles of resource management Incident resource management

Establishing resource needs


Resource ordering Resource check-in process Utilizing resources - staging areas

Resource demobilization
Resource management considerations

09-01-I300-SL
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Module 9 Objectives:
1. Identify and describe the four basic principles of resource management.
2. Identify the basic steps involved in managing incident resources. 3. Know the contents of, and how the Operational Planning Worksheet (ICS 215) is used. 4. Identify the organizational elements at the incident that can order resources.
09-02-I300-SL (1 of 2)
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Module 9 Objectives: (cont.)


5. Describe the differences between single and multipoint resource ordering and the reasons for each. 6. Describe why and how resources are assigned to staging areas, camps, and direct tactical assignments. 7. Describe the purpose and importance of planning for resource demobilization. 8. Identify five key considerations associated with resource management and the reasons for each.
09-02-I300-SL (2 of 2)
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Principles of Resource Management


Plannin g Organizing

Controlling

Directing

09-03-I300-SL
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Resources Direction Involves:


Motivation

Providing leadership
Delegation of

authority

09-04-I300-SL
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In ICS Direction is Accomplished by Assigning Responsibility and Authority Throughout the Organization:
Uses other peoples knowledge and skills Completes task without unnecessary delay Enhances training and personnel

development environment

Provides a more meaningful work


09-05-I300-SL
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336

Incident Resource Management Process:


Establishing resource needs Resource ordering Check-in process Resource use

Resource demobilization
09-06-I300-SL
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337

Planning Meeting Activity Checklist


No. 1 2

Activity
Give situation and resources briefing State Incident objectives and policy issues State primary and alternative strategies Designate Branch, Division, Group boundaries and functions as appropriate Describe tactical operations and tactics

Primary Responsibility
Planning Section Chief Incident Commander Operations Section Chief Operations Section Chief

3
4 5 6 7 8 9 10

Operations Section Chief


Operations, with support of Planning, and Logistics Section Chiefs Operations and Logistics Section Chiefs

Make tactical resource assignments


Determine Operations facilities and reporting locations Develop the resources, support and overhead order Develop Communications, Medical, and Traffic supporting plans Approve and implement the plan

Planning and Logistics Section chiefs


Planning and Logistics Sections Incident Commander approves and General Staff implements

09-07-I300-SL

Operational Planning Worksheet


Can be Used as a Display at the Planning meeting
Operational Planning Worksheet ICS 215

09-08-I300-SL

The ICS 215 Form is a Basic Planning Tool


It provides information on:
Incident work location Work assignments Kind and type of resources needed Current availability of incident resources Reporting location Requested arrival time for additional resources
09-09-I300-SL

Incident Resources:
Personnel resources
are assigned to functional areas within ICS sections based on experience, training, and past performance.

Equipment resources
consist of both the equipment and the personnel to operate the equipment. This includes aviation resources.
09-10-I300-SL

Placing Resource Orders from the Incident


Incident Commander must approve all resource orders.
Authorized to Place Resource Orders

Incident Commander Logistics Section Chief Supply Unit

09-11-I300-SL

Essential Elements of Information for any Resource Order:


Incident Name Order and/or request number Date and time of order Quantity, kind, type of resources Reporting location Requested arrival time Radio frequency Person/title placing request Callback Number or Radio designation

for clarification
09-12-I300-SL

Send Resource Orders by:


Radio Terminal

FAX

Phone

09-13-I300-SL
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Single vs. Point Ordering of Resources from an Incident


Single Point Ordering

Agency Dispatch

Incident 09-14-I300-SL

Be Sure You Understand the Ordering Process!!!


Single Point Ordering Preferred Method

Multi-Point Ordering Done When:


Multi-agency involvement requires it The kind of resource requires special handling Required by agency policy

Agency overload Agency policy Complex order

09-15-I300-SL

Multipoint Resource Ordering from an Incident


Medical
Fire Police

09-16-I300-SL

Resource Check-in Locations at an Incident Incident Base


Camp
Staging Area Resource Unit at the Incident Command

Post
Helibase
09-17-I300-SL

On an Incident Resources are Initially Assigned to:


Base or Camps

Division s or Groups

Staging Areas

09-18-I300-SL

Incoming Resources are assigned to Staging Areas Because:


Resources will be assigned during the

current operational period.


Resources are needed to provide a

reserve force for contingencies.


Resources are to be formed into Task

Forces and/or Strike Teams.


09-19-I300-SL

Staging Area Managers Must be Briefed


Briefing

Number and kind of resources Communications Minimum resource levels How to obtain resources Expected duration Logistics support

09-20-I300-SL

Task Forces and Strike Teams:


Can be formed on the incident.

When formed on the incident they

must be disassembled prior to release from the incident.


09-21-I300-SL

Demobilization
Planning - begin early!

Set up a Demobilization unit for larger

incidents.
Operations Section will set continuing

tactical resource needs.

09-22-I300-SL

Demobilization Plan
General information

Responsibilities
Release priorities Release procedures

Home

Directory
09-23-I300-SL

Key Resource Management Considerations


Safety
Personnel

accountability
Managerial control
Adequate reserves
09-24-I300-SL

Cost

INVENTORY MANAGEMENT SYSTEM

Types of inventory What types of inventory should be maintained; Expense vs. Capital? Functions of inventory What is the function of inventory today? Reasons for holding inventory Why is inventory maintained on-site today; Why is inventory owned vs. utilizing a third party consignment program? Safety stock How is safety stock determined; Who determines what levels of safety stock should be maintained; How often are these items and associated inventory reviewed? Inventory counting What inventory counting methods are currently utilized; How often is inventory performed; Who performs inventory; What is the accuracy rate; Are the results published; Is there a corrective action program to correct deficiencies? P-card purchases and receipts How are P-card purchases and receipts tracked with respect to usage, repair and purchase of MRO and capital assets; Are they entered into any CMMS program? Open vs. Closed storerooms Are stocking locations open or closed; If open why; Current problems with open storerooms today?
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Operational Level - Performance Enhancement Course

INVENTORY MANAGEMENT SYSTEM

Bar Coding of parts Are capital assets and MRO materials bar coded today; Are they integrated into a CMMS or ERP program? Repairable items returned to stock, issued for repair How are repaired items tracked going into and out of stock; How are repair costs tracked and maintained; What cost is assigned to repairable items for inventory valuation? Gas cylinders, bulk gas, chemical and lubricant delivery, inventory mgt EOQs; Inventory levels and measurement; Third party management; SLAs and KPIs required; Quality and Compliance TCO for inventory and asset management/maintenance Develop, update and maintain the TCO for all maintenance of assets; Develop TCO for all costs associated with MRO activities in order to determine the best solution Standard naming conventions for multiple locations Develop and implement standard naming conventions and formatting of descriptions, etc. for all MRO materials and capital assets; Apply standards across company lines and locations; Reduce inventory based upon redundancy of items Compliance - Measure compliance monthly with all programs to ensure cost savings and process improvements are obtained; Establish timeframe to achieve compliance goals

Operational Level - Performance Enhancement Course

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INVENTORY MANAGEMENT SYSTEM


Change management Develop and implement comprehensive change management program to reduce time required to successfully implement all changes to the Materials Management and Maintenance departments Inventory reduction strategies Utilize cross-functional teams with key stakeholders to develop and implement inventory reduction strategies that focus on inventory dollars. Common methodologies include periodic reviews of usage and lead times, reducing/eliminating safety stock, ABC inventory analysis, improving integrity of CMMS databases, revising MRO ordering guidelines, and re-structuring supplier relationships Inventory investment recovery strategies Develop and implement inventory and asset investment recovery programs for obsolete assets and MRO materials Vendor Managed Inventory Programs Analyze cost vs. benefit of Vendor Managed Inventory Programs whenever possible in order to lower the TCO Standardization (equipment and spare parts) Develop and implement MRO material and equipment standards whenever possible working with key internal stakeholders
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Operational Level - Performance Enhancement Course

INVENTORY MANAGEMENT SYSTEM


Tracking Delivery metrics for MRO The ability to track and measure the velocity for all inbound and outbound MRO materials and capital assets has a significant impact on the confidence of the Maintenance and Operations business units with respect to Materials Management managing the MRO materials and asset management programs. Utilizing bar codes, these metrics and subsequent reports are important tools. Reporting Developing and generating timely, accurate and targeted reports that detail cost, efficiency and overall effectiveness of all purchases and utilization of MRO materials and capital asset
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Maintenance Management System (MMS)

Operational Level - Performance Enhancement Course

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Maintenance Management System (MMS)


Maintenance management is a method of utilizing resources to accomplish a predetermined level of service for critical assets. Formal maintenance management includes the primary management functions of planning, organizing, directing and controlling. A maintenance management system (MMS) can be described as a systematic process to manage a maintenance program.
Operational Level - Performance Enhancement Course

386 386

ELEMENTS OF MMS
Planning maintenance activities based upon the road features to be maintained, the resources (labor, equipment & materials) needed to provide maintenance and the level of service to be provided by the maintenance. This includes preparing budgets based upon maintenance performance standards to define the specific types and amounts of maintenance work. Organizing the labor, equipment and material resources to ensure that planned maintenance activities can be accomplished with the budget available. Directing maintenance operations by authorizing, scheduling and supervising maintenance activities and preparing the annual, seasonal and short-term schedules needed for guidance. Controlling maintenance operations by monitoring work accomplishment and expenditures to ensure that planned work programs are actually achieved within available resource levels.

Operational Level - Performance Enhancement Course

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INFORMATION FLOW IN MMS

Operational Level - Performance Enhancement Course

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MMS IMPLEMENTATION
The basic components of maintenance management systems developed and generally accepted maintenance organizations include: The development of performance standards for principal maintenance activities describing the procedures to be followed, the labor, equipment and materials to be used and the rate of production to be achieved. The determination of workloads through the measurement of quantities of the various elements of the road system (system inventory) and the evaluation of external influences (such as weather and traffic) acting upon these elements which create a need for maintenance. The budgeting (dollars) of resources (labor, equipment, materials) to meet the predicted workload in terms of specific programs (activities, quantities, locations) to be achieved. The scheduling of activities within the budgeted program to utilize resources in the most efficient manner, to reduce fluctuations in manpower and equipment requirements, and to keep the roadway system operating in a safe, convenient manner. The establishment of a management information system which provides the basic knowledge required by operating managers for routine decisions and the special reports required by management for control and improvement of the program

Operational Level - Performance Enhancement Course

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