Deliverable D9 - Summary Report

MCA P404 – D9 SUMMARY REPORT
MARITIME AND COASTGUARD AGENCY
MCA RESEARCH PROJECT 404

FSA OF SHIPPING – PHASE 2
TRIAL APPLICATION TO HSC
DELIVERABLE D9 – SUMMARY REPORT
C705\27\001R Rev B August 1998 Page 0.1 of 0.4

CONTENTS
Page No.
GLOSSARY OF TERMS 0.5
1. INTRODUCTION
1.1
1.1 BACKGROUND TO THE FSA APPROACH
1.1
1.2 PROJECT OBJECTIVES 1.3
1.3 SCOPE OF WORK
1.4
2. METHODOLOGY AND METHODOLOGY IMPROVEMENTS

2.1
2.1 INTRODUCTION 2.1
2.2 INFLUENCE DIAGRAM DEVELOPMENTS
2.1
2.3 ELICITATION OF EXPERT JUDGEMENT
2.10
2.4 ALLOWING FOR AVERSION IN COST BENEFIT ASSESSMENT AND
DECISION
MAKING
2.12
3. DATA GATHERING FOR THE TRIAL APPLICATION TO HSC

3.1
3.1 THE GENERIC HSC MODEL
3.1
3.2 RULES AND REGULATIONS
3.1
3.3 HSC STAKEHOLDERS 3.4
3.4 HUMAN FACTORS
3.4
3.5 TECHNICAL AND OPERATIONAL ISSUES 3.7
3.6 HISTORIC INCIDENT DATA
3.11
4. TRIAL APPLICATION TO HSC – FSA STEP 1 – HAZARD IDENTIFICATION

4.1

4.1 TASK 1.1 – PROBLEM DEFINITION

4.1
4.2 TASK 1.2 - HAZARD IDENTIFICATION
4.3
4.3 TASK 1.3 - HAZARD SCREENING 4.5
4.4 STEP 1 CONCLUSIONS
4.10
5. TRIAL APPLICATION TO HSC – FSA STEP 2 – RISK ASSESSMENT

5.1
5.1 TASK 2.1 - IDENTIFICATION OF CAUSES AND CONSEQUENCES
5.1
5.2 TASK 2.2 - STRUCTURING THE RISK CONTRIBUTION TREE
5.3
5.3 TASK 2.3 – QUANTIFICATION OF RISK CONTRIBUTION TREE
5.4
5.4 TASK 2.4 – FN CURVES, PLL AND DISTRIBUTION OF RISK THROUGH
THE RISK CONTRIBUTION TREE
5.10
5.5 TASK 2.5 – STRUCTURING AND QUANTIFICATION OF INFLUENCE
DIAGRAMS 5.12
CONTENTS CONTINUED
Page No.

5.16
6. TRIAL APPLICATION TO HSC - FSA STEP 3 – RISK CONTROL OPTIONS

6.1
6.1 TASK 3.1: FOCUSING 6.1
6.2 TASK 3.2: RATIFICATION OF FOCUSED RISK CONTRIBUTION TREE
6.2
6.3 TASK 3.3: RISK CONTROL MEASURES LOG
6.2
6.4 TASK 3.4: RISK CONTROL ATRIBUTES
6.4
6.5 TASK 3.5: CAUSAL CHAINS
6.4
6.6 TASK 3.6: RISK CONTROL OPTIONS
6.5

6.7 TASK 3.7: DEFINITION OF RISK CONTROL OPTION ATTRIBUTES

6.10
6.8 TASK 3.8: ASSESSMENT OF RISK CONTROL EFFECTIVENESS
6.10
6.14
7. TRIAL APPLICATION TO HSC - FSA STEP 4 – COST BENEFIT

ASSESSMENT 7.1
7.2 IDENTIFICATION OF INDIVIDUAL RCO COSTS
7.2
7.3 EVALUATION OF COST PER UNIT RISK REDUCTION (CURR)
7.5
8. TRIAL APPLICATION TO HSC - FSA STEP 5 – RECOMMENDATIONS FOR

DECISION
MAKING
8.1
8.2 COLLISION RISK CONTROL OPTIONS – BASE RISK BALANCE
8.1
8.3 RISK BALANCE WITH CRC02 (EXTERNAL VESSEL MANAGEMENT
APPLIED) 8.2
8.4 SUMMARY OF RCO, CURR AND RISK BENEFIT
8.3
8.5 RECOMMENDATIONS FOR DECISION MAKING
8.4
9. CONCLUSIONS AND RECOMMENDATIONS

9.1
9.1 GENERAL
9.1
9.2 CONCLUSIONS FOR HSC
9.2
9.3 RECOMMENDATIONS FOR FUTURE METHODOLOGY
DEVELOPMENT 9.5
10. REFERENCES
10.1

GLOSSARY OF TERMS
Risk The product of the Frequency and Consequence of a specified accident.
Cause A fault or event, possibly of little significance in isolation, providing an

important link
in the chain of events leading to an accident.
Hazard A condition with the potential to result in an accident or commercial loss.
Accident The realisation of a Hazard.
Frequency The number of occurrences of a specified accident per unit time.
Consequence The outcome or loss to shipping, people or the environment

resulting from an accident.
Accident Categories
Collision is defined as the ship striking or being struck by another vessel, regardless of
whether under way, anchored or moored. Collision does not include striking underwater
wrecks. Contact is defined as the ship striking, or being struck, by an external object (eg.
navigation buoy or berth), but not another ship or the sea bottom.
Fire is defined as an uncontrolled process of combustion characterised by heat or smoke or

flame or any combination of these.
Loss of Hull Integrity is the consequence of certain initiating events and is used to denote
any damage to the external hull, or to the internal structure and sub-division, such that any
compartment or space within the hull is opened to the sea or to another compartment or
space.
Abbreviations
ILO International Labour Organization

IMO International Maritime Organization
LMIS Lloyds Maritime Information Services
MAIB Marine Accident Investigation Branch
MCA Maritime and Coastguard Agency (UK)
MSC Maritime Safety Committee (of the IMO)
NMD Norwegian Maritime Directorate

1. INTRODUCTION
The Maritime and Coastguard Agency* (hereinafter referred to as the Agency)

awarded Phase 2 of its Formal Safety Assessment (FSA) research programme
(Research Project 404) to a consortium led by BOMEL, comprising BOMEL, BMT
and Human Reliability Associates (HRA). The project involved a trial application of
the FSA methodology to High Speed Passenger Catamaran Ferries (HSC). The
methodology used is described in detail in Reference 1 and is that previously
developed under a suite of Agency research projects for which BOMEL had been
the Project Suite Manager.
The project team drawn from the BOMEL consortium was supplemented by a large
number of experts. Many made contributions throughout the trial application by
attendance at structured review meetings or by individual input. In addition BOMEL
undertook extensive checking and quality assurance activities in accordance with
its ISO 9001 certified Quality Management System. In fulfilment of the Agency's
requirement for an independent review of the study, BOMEL chose to assemble an
Independent Project Review Panel (IPRP) consisting of acknowledged experts in
HSC operations, risk and safety assessment and international maritime regulation.
This report summarises the work done for Agency Research Project 404 starting
with a brief introduction to the development of FSA for maritime application. The
report then describes further methodology development carried out under this
project and summarises the trial application to HSC. It concludes with a
commentary on the practicability of the methodology and by making
recommendations as to how the methodology and its application might be further
improved and how the results of the trial application might be extended and used in
the improvement of regulations.
1.1 BACKGROUND TO THE FSA APPROACH
FSA is a new approach to the regulation of shipping safety, stemming from

recommendations in Lord Carver's report (Reference 2). It is based on the
principles of identifying hazards, evaluating risks and cost benefit assessment, and
has as its objective the development of a framework of safety requirements for
shipping in which risks are addressed in a comprehensive and cost effective
manner. The adoption of FSA for shipping represents a fundamental cultural
change, from a largely reactive and piecemeal approach, to one which is
integrated, proactive, and soundly based upon the evaluation of risk.
C705\27\001R Rev A August 1998 Page 1.1 of 1.4

* As from 1 April 1998 the Marine Safety Agency merged with the Coastguard Agency to
form the Maritime and Coastguard Agency
Previous Agency funded projects considered the benefits of applying FSA to the
shipping industry and then went on to develop a detailed methodology for
application of FSA to the IMO rule making process. The objective of this approach
is to concentrate resources on high risk areas and to ensure that new regulations
were developed with a clear understanding of the risks being addressed and the
effect of the regulations in reducing such risks. The resulting methodology
consisted of five principal steps as follows:
Step 1
Identification of hazards in which different types of accident scenario are
identified. These scenarios fall within one of ten generic Accident Categories (eg.
Collision and Contact, Grounding, Fire, Loss of Hull Integrity). Factors contributing
to the causes of accident initiation, escalation and the level of loss are identified.
Step 2
Assessment of risks associated with the hazards identified in Step 1 in which
the events and factors which influence the likelihood of an accident occurring and
its outcome in terms of losses or consequences are structured and then quantified
by reference to historic data or with the assistance of expert judgement.
Step 3
Consideration of alternative ways of managing the risks assessed in Step 2
in which risk control methods (RCMs) are identified, grouped into comprehensive
risk control options (RCOs) and assessed for their effectiveness in reducing risk.
Step 4
Cost benefit assessment of alternative risk management options in which the
RCOs from Step 3 are assessed in terms of their cost of implementation, the
monetary benefits which may result and therefore the resulting net cost per unit
reduction in risk (CURR).
Step 5
Recommendation of options for decision making in which the costs and
benefits for each stakeholder (or interested entity) affected by an RCO are
considered to ensure, that as far as possible, the principle of ‘the risk imposer
pays’ is satisfied and the most cost effective and equitable regulations result.
The UK papers discussing the FSA methodology developed through the Agency’s
Phase 1 research programme were presented to the IMO at MSC 66. Additionally,

an FSA Working Group was established at MSC 66 and started compilation of

guidelines for the effective introduction of FSA to the rule making process of IMO.
The Working Group at MSC 66 recommended to the Committee that interested
administrations undertake trial applications of the FSA methodology for reporting to
future MSC meetings.
The Working Group met again at MSC 67 and MSC 68 and finalised IMO Guidelines
which were subsequently adopted by the Committee at MSC 68 (Reference 3).
The trial application was reported in two detailed documents prepared by the
BOMEL project team. The first (Reference 4) describes the work and results of the
trial application itself, whereas the second (Reference 5) describes methodology
improvements developed during the project as described in Section 2 of this
summary report.
1.2 PROJECT OBJECTIVES
The scope of work for the trial application was defined by the Agency Project
Specification (Reference 6) and was as follows:
• To complete a trial application of the entire FSA methodology for a particular

type of vessel (high speed catamaran passenger ferries) operating
internationally.
• To report the results in a form suitable for submission to the IMO's Maritime
Safety Committee, so as to promote understanding and acceptance of the
methodology amongst all IMO members.
Subsidiary objectives included the following:
• To validate the FSA approach and demonstrate its practicability, thus facilitating
its future use by the IMO.
• To extend the scope and contents of the HSC database produced by Project
384, to include data relevant to Steps 3, 4 and 5 of FSA.
• To generate a hierarchical risk profile for HSC covering the accident categories
considered.
• To propose tentative risk-based regulatory requirements for HSC appropriate to

the scope of the project, concentrating on principles and regulatory goals rather
than specific detail.

• To facilitate a review of the safety regulation of HSC operating within UK

jurisdiction.
• To identify what further research is needed to complement ongoing

development of FSA at the IMO and to facilitate consideration of the possible
adoption of FSA for UK domestic rules.
1.3 SCOPE OF WORK
The scope covers all five Steps of the FSA approach. The project was faced with
tight time constraints in order that the findings of the study could be reported to
MSC 68. Therefore the scope of the project was limited to the following three major
categories of accident.
• Collision and Contact

• Fire
• Loss of Hull Integrity (including structural failure).
This enabled the methodology to be tested over significantly differing types of

accident whilst demonstrating the integrated nature of the approach.

2. METHODOLOGY AND METHODOLOGY IMPROVEMENTS
2.1 INTRODUCTION
The methodology specified for the trial application was that which had been
developed under Phase 1 of the Agency’s FSA research programme referred to in
Section 1 (Reference 1). However additional methodology development was
undertaken in three areas as discussed below. A major requirement of Phase 1
had been to incorporate methods for accounting for the contribution of human error
to marine incidents and for evaluating the effectiveness of risk control approaches
to reducing human error. An approach, based on a hierarchical network of
influences (Influence Diagrams) from the regulator, through the implementation of
regulations within an organisation, to the direct influence on performance of
personnel and equipment, had been identified as the most promising approach.
Within the constraints of Phase 1, this had not been developed into a generic and
user friendly tool. Therefore additional work to make improvements in both the
structuring and quantification of influence diagrams was included in this project.
Another methodology development activity carried out in this project concerned the
elicitation and use of expert judgement. This becomes particularly important for
topics such as HSC where much of the technology is new and rapidly developing
and where, due to limited operational experience, historic incident data are not
statistically reliable. In such cases the judgement of experts is vital in estimating
risk levels and the likely effectiveness of identified risk control approaches.
Therefore alternative methods to incorporate judgement were investigated. The
Delphi methodology appeared to be an appropriate and widely recommended
approach and therefore this was investigated and subsequently used in the trial
application.
The third area of methodology development undertaken was to consider how

societal aversion to large scale incidents causing multiple deaths affected
regulatory decision making and therefore how this effect might be allowed for in
Steps 4 and 5.
Each of the three areas of methodology development outlined above is described

below.
2.2 INFLUENCE DIAGRAM DEVELOPMENTS

During Phase 1 both the Tavistock Institute and HRA provided input on the
influences which are thought to affect human performance. In parallel an IMO
correspondence group on the human element had also been collecting useful
thinking in this field. Therefore the first task was to collate and review this
information to ascertain whether a generic set of influences covering all aspects of
both human and hardware performance and the effect of external events on
accident causation could be identified.
The second stage in the work was to improve the quantification process and make
it transparent and easily understandable to the marine practitioners and experts
who would be required to make judgements on which the quantification would be
based.
2.2.1 The Generic Influence Diagram

In order to assist in the structuring of an Influence Diagram for a specific event, a
Generic Influence Diagram was developed along with a clear definition of each of
the Influences. The Generic Influence Diagram for HSC (Figure 2.1) would be
modified and more detail added, as appropriate, to model the unique influences on
a specific event.
Any accident event may be considered to be caused by one of or a combination of

human, hardware or external failures (Direct Causes). The primary influences or
factors, which are considered to influence these Direct Causes, fall into four
categories or levels which are defined as: Direct Level, Organisational Level, Policy
and Regulatory Implementation Level, and Regulatory Level Influences (Figure 2.1).
The definitions for each of the direct level influences are given below:
Influence Definition
Competence The capacity or ability to perform a task.
Motivation / Morale The strength and direction of human behaviour
Health The well-being of body and mind.
Physical Working The levels of noise, temperature, motion, light and

Environment (Internal) vibration existing in the place of work.
Physical Working The time of day; weather in terms of wind, visibility,

Environment (External) temperature, and precipitation; the sea in terms of
wave height and frequency, and state and speed of the
tide (ebb, flow, spring or neaps); the density of traffic

and proximity to land.
Fatigue The state of readiness for action.
Availability of Resources The relationship of supply to demand

Figure 2.1 Generic Influence Diagram for HSC

Quality of Materials & The extent to which materials and manufacture

Manufacture of Equipment conform to best design and production principles.
Quality of Maintenance The extent and frequency with which equipment is

inspected and maintained.
Availability of Information / The extent to which people can access information

Advice that is accurate, timely and reliable.
Communication The extent to which the frequency, clarity, and integrity

of communications is important.
Compliance (Misuse / The extent to which people comply with or obey

Negligence) company / equipment procedures, rules, regulations,
and standing orders.
The definitions for each of the organisational influences are given below:
Recruitment and Selection The system that facilitates the employment of

personnel that are suited to the job demands.
Training The system that ensures that the skills of the

workforce are matched to their job demands.
Company (Safety) Culture The system of behaviour modification in an

organisation: it consists of assumptions about the way
work should be performed; what is and what is not
acceptable; what behaviour and actions should be
encouraged and discouraged.
Procedures The system that ensures that the mode of conducting

business or operations is explicit and based on actual
tasks.
Equipment Purchasing The system that ensures that equipment that is

purchased meets user requirements and is value for
money.
Information / Operational The system of information management that ensures

Feedback high quality information is available for decision-

making.
Inspection / Maintenance The system that ensures equipment is maintained in
good working order.
Management / Supervision The system which ensures human resources are

managed and supervised sufficiently.
Work Organisation The system that ensures resources are placed to

meet demand.
Communications The system that ensures information is

communicated to its intended recipients.
Design Quality The system that ensures designs are fit for purpose
and meet user requirements.
Operating Environment The physical, economic and social climate within

which the organisation operates.
It is also important to define clearly the range of each influence from best to worst
conceivable practice. Within the trial application it was found useful to define best,
worst and medium scalar positions for each influence. Examples at both the direct
and organisational level are provided below.
Direct Level – Physical Working Environment (Internal)

Scalar positions
Worst - Sub-optimum: Noise levels are damaging, temperature is extreme,
motion is violent, lighting levels are extreme, and
vibration is constant and of high frequency.
Medium - Tolerable: Occasionally and transiently one environmental
factor is extreme.
Best - Optimum: All environmental factors are at an optimum
level, with infrequent and minor deviations from this level.
Direct Level – Quality of Maintenance

Scalar positions
Worst - Inadequate: Equipment is never or rarely inspected, serviced or
maintained.
Medium - Adequate: Equipment is inspected, serviced and maintained, but on
occasion this is poorly performed.

Best - Excellent: Equipment is inspected / maintained as

directed by the manufacturer and to a high standard
consistently.
Organisational Level – Procedures

Scalar positions
Worst - Inadequate: There are no procedures in place to guide or inform personnel
how to perform the necessary tasks. Any procedures that are
in existence do not represent actual tasks or are so poorly
presented / inaccessible as to render them ineffective.
Medium - Moderate: There are procedures in existence, but they are of
inconsistent quality: eg. they may be well presented but out of
date.
Best - Excellent: Procedures are systematically updated involving personnel
whose responsibility it is to perform the tasks. They are well
presented, and organised and are effective in guiding
operations.
Organisational Level – Inspection / Maintenance

Scalar positions
Worst - Inadequate: There is no system of maintenance or inspection. The
operational life of equipment is frequently exceeded. Any
repairs are aimed at maintaining operation but not at
preventing further equipment degradation. Engineering
procedures, if in existence are unplanned and haphazard.
Medium - Moderate: Systems of maintenance and inspection conform to minimum
requirements to ensure surveys are passed. Equipment is
maintained past its operational life, to avoid new purchases.
Engineering procedures are planned, but have no
contingencies for unexpected failures.
Best - Excellent: Systems of maintenance and inspection supersede class and
flag requirements. Equipment is operated up to its operational
life, and then is updated or replaced. Engineering procedures
include long-term planning and contingency management.
The scalar positions should be defined for each influence in order that there is a
clear and precise understanding prior to embarking on quantification.
2.2.2 Influence Diagram Quantification

The quantification method outlined below assumes that any influence at any level
can affect any influence at a higher level or directly affect the likelihood of

occurrence of the top event. These relationships between influences are identified
and linked in a network which forms the quantification model as described below.
The contributory influences on the influences at a higher level are weighted. For
any particular circumstance each influence can be rated as described below. In
principle, the weighting factors are generic, ie. applicable to all circumstances;
whereas the ratings are assigned for a specific situation, eg. a particular level of
operating procedure. The weighting factors and ratings are then used to evaluate
the overall influence on the likelihood of the top event occurring.
It is proposed that the diagram is constructed from the top level using a top-down
approach. Thus, from the top level, the lower level influences affecting the event
are identified and weighted. This is repeated at the next level down, and so on
through the diagram. The weighting factors should be between 0 and 1 (or 0 and
100%) and at any particular node the weighting factors, W, from the immediate
lower level influences should sum to unity (or 100%). Thus, for n contributory
influences at a node j:
∑W ji =1 Equation 2.1
i =1
At the bottom level under consideration the influences are rated on their relation to
best possible and worst practice. The scale can be over any range, but each
influence should have the same range. A typical scale is 0 to 1, with 0 having the
worst or no effect, and 1 representing the best identifiable practice as defined in
Section 2.2.1.
Assigning the weighting factors and ratings to the various influences are the most
important tasks of the work. The weighting factors and ratings may be obtained by
expert judgement for example by:
• Sending out a (large) number of questionnaires to

qualified/knowledgeable/experienced people - a Delphi approach; or
• One or more formal meetings of qualified/knowledgeable/experienced people

with an experienced facilitator/mediator.
Using the approach discussed above the overall influence can be evaluated very
simply. Starting at the bottom of the diagram, for any particular node j the influence
rating, r, is evaluated as:
n
r j = ∑ W ji r ji
i =1
Equation 2.2

This is repeated for all nodes at this level, and then for the next level up, until the top
level is reached.
Since all of the weighting factors sum to unity at each node the range of each
influence rating is the same as the range at the bottom level, eg. from 0 to 1.
It may be noted that the quantification approach described above consists of

assigning weighting factors at each level of the Influence Diagram but only
assigning ratings at the lowest level. Ratings at higher levels are calculated
automatically from Equation 2.2. Ratings at higher levels can also be evaluated
directly by expert judgement. Where such evaluation produces a different rating
from that calculated from Equation 2.2 this could be due to:
• Incomplete representation of all factors influencing the rating under

consideration;
• Incorrect evaluation of lower level ratings;
• Incorrect assignment of weighting factors;
• Incorrect judgement by the selected experts; or
• Uncertainty in the rating process.
At this stage of development of the methodology it is felt useful to have the ability to
compare the ratings calculated from Equation 2 with expert judgement and where
differences arise to modify the ratings to take this judgement into consideration.
One method for this would be simply to average the calculated value and the expert
value thus giving equal weight to both sources. This method was adopted in the
trial application.
Evaluation of Risk
The quantification process described above results in ratings for the direct causes
(human failure, hardware failure and external events). Weighting factors are
assigned to each and an index for the top event results. This index (the Influence
Diagram Index) can be calibrated to an established risk level for the top event in
order to calculate how the risk will be affected by changes in influence weighting
factors or ratings brought about by application of a risk control measure (RCM) or
package of measures (RCO). In order to do this it is necessary to establish a
transformation function between the Influence Diagram Index and risk magnitude.
A suggested transformation function is shown in Figure 2.2 which shows a linear

relationship between Influence Diagram Index and the log of risk.
Figure 2.2 relates the range of worst to best practice for all relevant influences (0 to
1 in the index) to a three orders of magnitude change in the risk. Three orders of

magnitude are selected on the basis that individual risks span 103 from the border
of tolerability to the level where society currently places no demand for further risk
reduction however low the cost (see Reference 7). The literature on occupational
risk across a range of industries indicates this as the range of risk from the most to
least dangerous occupations.
Figure 2.2 is presented in a log-linear format such that changes in the index
translate to a relative change in risk. If Ro is the baseline risk under present
practice and Rrco is the risk after implementation of the RCO with Io and Irco the
corresponding Influence Diagram Indices:
Rrco / Ro = 10 –3 (Irco – Io)
Note that in Figure 2.2, n is a number such that for a given value of the Influence
Diagram index (lo) and corresponding level of risk (Ro), the intercept on the risk axis
(ie. the x value) is such that log (Ro) = n + x. Thus the whole range of variation of
risk, corresponding to the range of variation of the Influence Diagram index from
zero to 1, comprises three orders of magnitude, or from zero to 3 on the scale of n
+ x.
Figure 2.2 can be applied to all Accident Categories to assess the effectiveness of
the respective RCOs in terms of a relative reduction in risk. For each Accident
Category, the absolute risk depends on the specification of n (shown in Figure 2.2)
which is calibrated against an established risk level.
Figure 2.2 Conversion between RCO Improvement and Reduced Risk

The logarithmic representation of risk reduction in Figure 2.2 implies that the same
absolute improvement in index has a larger absolute reduction in risk when the
baseline index is low, and less effect when practice is already delivering a high
index value.
It might be considered that an S-curve would be more appropriate to capture the

extremes but to provide for both improvements and deterioration in practice a
hysteretic model would be required. Furthermore for the Accident Categories
under consideration, expert rating of the influence diagrams has shown the current
baseline to be around the mid range of conceivable practice. Similarly the
individual RCOs do not take the index to the extremes. A log-linear representation
is therefore proposed as an appropriate and reasonable approximation.
2.2.3 Conclusions Regarding Influence Diagrams
The Influence Diagram methodology described above was used in the trial
application. It was found to be straightforward and practical to apply such that the
experts involved were able to reach judgements on ratings and weighting factors
which resulted in measures of RCO effectiveness which they could support.
Further development of the Influence Diagram approach particularly to calibrate the

risk transformation function and RCO effectiveness predictions is recommended.
2.3 ELICITATION OF EXPERT JUDGEMENT
Some difficulties were encountered in elicitation of expert judgement from group

sessions during the trial application, for example where certain individuals tended to
dominate the proceedings and outcome. Alternative methods for gathering group
information were therefore examined and the Delphi technique, described below,
was implemented.
The Delphi technique is a forecasting technique which elicits and refines expert
judgement and has been extensively used to support decision making in a wide
variety of applications. It is a particularly appropriate method when there is a lack of
available historical data.
The classic Delphi technique was developed and first used by the US Air Force in
the early 1950's. The primary objective was to obtain `the most reliable consensus
of opinion from a group of experts by a series of interactive questionnaires
interspersed with controlled opinion feedback'.

The widespread use of the Delphi technique has resulted in the evolution of a
number of Delphi variations. The general view amongst Delphi users seems to be
that there is no hard and fast rule for applying the technique, although the classic
Delphi typically involves four rounds of questionnaires and feedback and appears
to take about 4 weeks. There also appears to be no firm consensus on the number
of iterations which are required, although most applications of the technique which
have been identified involve between two and six iterations. A study into the
optimum number of rounds (Reference 8) concluded that `.... Delphi groups
reached stability in their decision making after the fourth iteration, thereby providing
empirical support for the length of the classic Delphi'. Nevertheless, many of
studies have used as few as two iterations.
The key features of Delphi are anonymity, repeated iterations of knowledge

elicitation, resolution of differences, justification of refined opinion and group
feedback, all of which are key elements in effective group decision making.
The Delphi technique essentially consists of the following steps:
• Develop a questionnaire for completion by experts with a comprehensive

knowledge or experience in the subject. The questionnaire should concentrate
on ranking or quantifying specified alternatives rather than being free format. A
very important feature is the need to provide a justification for each quantified
value in order to expose the expert’s thinking.
• The questionnaires are collated and average values calculated. Where there
are significant differences, the range of responses and justifications are
circulated back to the experts for reconsideration and further justification.
• This process is repeated until reasonable convergence is obtained.
By way of example, a typical question set drawn from the hazard ranking exercise
in Step 1 is shown in Figure 2.3.
Question: In your opinion, in what percentage of incidents in each Generic Vessel

Location
would you expect the consequence to be Minor, Moderate, and Major?
Contact
Minor Moderat Major Total Justification
e (This is essential)
It is likely that most contacts

Berthing/Berthed/ 95 4 1 100% occur whilst coming alongside

Unberthing and will be at slow speed,

therefore most have low
consequence.
Most contacts which occur
Manoeuvring in 93 5 2 100% whilst manoeuvring in harbour
Harbour will be between 5 to 10 knots,
therefore possibility of higher
casualties.
Most contacts which occur
At Sea – Coastal 91 6 3 100% whilst at sea will be at high
speed, likely to result in higher
casualties.
At Sea – Open Sea 89 7 4 100% As above but further from

emergency services.
Very unlikely to result in
Dry Dock 98.5 1 0.5 100% casualties. Any incidents would
occur whilst manoeuvring to or
from drydock, therefore
Manoeuvring in Harbour
applies.
Note: The estimates in this table would suggest that approximately 95% of all Contacts which occur whilst Berthing,
Berthed, or Unberthing would have minor consequence (ie. less than 10 minor injuries), 4% would have moderate
consequence, and 1% would have major consequence.
Figure 2.3 An Example of a Completed Consequence Question Set for Contact

The Delphi method could be used for any situation requiring quantification using
expert judgement such as:
• Event tree nodal probabilities and outcomes;

• Influence diagram ratings and weighting factors; and
• Influence diagram requantification in Step 3.
Advantages
The Delphi Technique has been applied to a broad range of problems throughout
the world, including Cost-Benefit Assessment and Risk Assessment. It is seen by
many researchers to be one of the most successful predictive tools available.
Some of the reasons for this are:
• The technique has some of the benefits of group decision making, whilst at the
same time reducing the negative effects of group interactions and any tendency
towards domination;
• The perceptions of an expert who is competent (ie. trained, experienced, skilled

and appointed) in the area being considered provides a useful indication of
reality; and

• Consensus of a group of experts is not essential and the diversity of opinions of

the experts reflects the amount of inherent uncertainty there is in the underlying
issues.
Disadvantages
An effective and thorough application of the Delphi Technique requires substantial
effort and a great deal more time than some other decision making techniques and,
consequently, there is a tendency to reduce the number of rounds to as few as
possible. This temptation should be resisted as the iterative process and
associated justifications are a major strength of the technique.
2.4 ALLOWING FOR AVERSION IN COST BENEFIT ASSESSMENT AND

DECISION MAKING
An HM Treasury report of 1996 stated "It is widely held among regulators, but much
less often among academic or other commentators, that people should as a
general rule be less well protected from the risk of incidents that effect only one or
a few people at once than from the risks of incidents which affect many people,
such as a major rail or air crash, although there is no consistent evidence that this
reflects the preferences of those at risk" (Reference 9).
‘Risk Aversion’, which is sometimes described by the terms 'scale effect' or

'incident size effect’, refers to the situation where a cost-benefit appraisal values
accidents involving different numbers of fatalities in a nonlinear fashion. In
particular, the appraisal regards the costs of an accident involving n.x fatalities as
greater than n times the cost of n accidents each involving x fatalities. This means
that the accident valuation curve is convex, as shown in Figure 2.4

Figure 2.4 Relationship Between Valuation of Loss

and Number of Fatalities in a Single Accident
In such circumstances the valuation of a fatality will be dependent on the numbers

of other fatalities which accompany the accident in which the particular fatality
occurs. Hence fatalities occurring in different sizes of accidents will need to be
weighted. If the impact of the RCOs on different types of accident can be identified,
then the crucial next step is to decide on the relative weighting factors.
Since cost-benefit analysis and cost-effectiveness analysis are based on

preferences, the weighting factors used to reflect aversion factors must in turn be
based on preferences. The relevant issue is that of whose preferences are to
count. The main alternatives are:
• Those of the individuals at risk;

• Those of the population at large, as electors or taxpayers or consumers; and
• Those of the government agencies and commercial agencies, who in principle
represent individuals in the implementation of safety measures, but whose
valuations also reflect political and commercial institutional concerns.
Valuation in cost-benefit analysis is generally based on two main approaches, the

revealed preference approach, which infers valuations from observations of actual
behaviour, and the stated preference or contingent valuation approach, which infers
valuations from surveys of peoples’ attitudes and responses in experimental
situations.
The Revealed Preference Approach

The revealed preference approach would involve observing the willingness to pay to
avoid different types of maritime accidents. It might be possible to show how
regulatory agencies have been prepared to spend (or to require others to spend)
different sums of money for different types of reduction in accidents. However,
exercises of this type generally show that different safety measures imply very
different valuations of safety improvements, and it may be difficult to justify these

sums on rational grounds. Indeed an objective of the introduction of FSA is to

strengthen the rationality of decision-making in maritime safety, and valuations
based on previous decisions will reflect previous, less rational, decision-making
processes.
The Contingent Valuation Approach

For valuations of those at risk there are two considerations: context and scale.
Context is concerned with the circumstances in which death would occur (eg. in
the dark, underground, in water) and has been found to be an important factor in
studies conducted on alternative modes of transport, whereas scale has been
found to be unimportant for those at risk. The Treasury's 1996 Report on "The
Setting of Safety Standards" also concluded that there was no consistent evidence
of risk aversion from the preferences of those at risk.
Valuations of Regulators
There is evidence that safety regulators give more than directly proportionate
weight to the prevention of accidents which cause large numbers of deaths. This
would seem to reflect institutional concerns about, for example, adverse publicity
and political or commercial consequences, rather than the preferences of those at
risk or of the public at large. Evidence on the sizes of risk aversion factors by
regulators is scarce, while risk aversion factors are likely to vary from industry to
industry. Clearly what would be of particular value would be risk aversion studies in
the shipping industry but, so far as we are aware at present, no such studies exist.
In financial terms there are very few examples in transport where risk of death
(either in a small or a large accident) affects human behaviour. In shipping neither
the Herald of Free Enterprise or the Estonia adversely affected the growth of
passenger journeys in Ro-Ro ferries. The only examples identified that could be
considered to be aversion are the general reduction in air traffic following the Gulf
War and the reduction in French traffic accidents following the French School Bus
collision in the 1980s. However in both these cases there is no evidence to
determine if people were influenced by the severity of the accident or just by its
occurrence and attendant publicity.
While it is difficult to assess the preference of an individual in human terms, or of

an organisation in financial terms, it can be argued that regulators aim to reflect
individual preferences and overall financial benefit. In regulatory terms there is
evidence that large accidents result in a greater response from regulators than a
series of small accidents, SOLAS 90 after the Herald of Free Enterprise and the
local agreements following the Estonia being notable examples.

It should therefore be possible to use the current priorities for action by the IMO as
an indication of the comparative level of risk to which, by implication, the IMO are
reacting. Three of the main priorities of the IMO at present are the general level of
worldwide shipping losses, Ro-Ro ferry losses and Bulk Carrier losses.
Based on accident statistics it is possible to calculate an estimate for Potential

Loss of Life (PLL) for worldwide shipping losses, Ro-Ro ferry losses and Bulk
carrier losses. This is shown in Table 2.1 and Figure 2.5.
Type of loss Time Ships Lives Frequenc Severity PLL

period lost lost y (Average (Worldwid
(Ships lives lost e lives lost
lost per per per year)
year) incident)
Worldwide 1980-1991 3494 8479 318 2 771
shipping (11 years)
losses
1950-1995 7 1285 0.2 184 29
Ro-Ro (45 years)
shipping
losses 1975-1990 279 approx 18.6 approx 298
(15 years) 4,464 16
Bulk carrier
losses
Table 2.1 Relationship of Worldwide Shipping Losses and

Vessel Types in Terms of Historical PLL
If the IMO were acting to reduce Potential Loss of Life then the relative focus of IMO
activities should be in line with the PLL, ie. they should be spending 27 times more
effort (771/29) on worldwide shipping losses than on Ro-Ro ferries.
If it can be assumed that by their actions IMO can be considered to be attaching

approximately equal focus to each of these three areas then the IMO can be
considered to be acting as if they have aversion to high severity accidents. As they
are not spending 27 times more effort on worldwide shipping losses than Ro-Ro
ferries it seems that the IMO are behaving as if the loss of a life in a Ro-Ro ferry
scores as 27 times more important than a loss of life in worldwide shipping. This
scoring is, in effect, a measure of aversion.

Figure 2.5 PLL Versus Severity from Table 2.1
Therefore it does appear that the regulators’ decisions have been affected by
aversion although, as stated above, there have not yet been comprehensive
studies or debate to determine reliable values. In the trial application it was found
that, for all accident categories considered, the range of outcomes included large
scale losses and therefore the inclusion of aversion would not affect the rankings
between accident categories. Furthermore many of the RCOs developed were
aimed at reducing accident frequency rather than being aimed at any specific size
of outcome. Therefore it was decided to present a unified picture of the risk profile
and to value costs and benefits across all accident categories and outcomes with
no weighting for aversion.

3. DATA GATHERING FOR THE TRIAL APPLICATION TO HSC
Successful application of the FSA methodology relies heavily on the availability of

knowledge and expertise about the subject to be studied (in this case HSC
accidents involving collision, contact, fire and loss of hull integrity) and historical
data about relevant incidents and accidents. In order to assist the project team in
gaining a rapid and consistent understanding of the important issues, the
background information and data were assembled during the early stages of the
trial application and are presented here prior to reporting on the FSA.
3.1 THE GENERIC HSC MODEL
Within the FSA methodology it is recommended that a generic description of the

shipping activity under study is developed in order to capture and describe the
principal features of the relevant vessel type and the organisational, physical,
social, economic and political environment in which it is operated.
The underlying function of the generic model is to provide a database of relevant

information for use in all five steps of the methodology; assisting in hazard
identification, risk assessment, development of risk management options, cost
benefit assessment and in the decision making process. In particular it can be
used in conjunction with the accident categories to provide the basis of the likely
accident sub-categories, as indicated in Figure 3.1. In order to assist readers not
familiar with HSC the principal components and areas are shown in Figure 3.2.
3.2 RULES AND REGULATIONS
It is important to associate the existing risk profile with the risk control measures
required by relevant international and national regulations. Apart from the IMO HSC
Code other IMO Rules such as MARPOL, STCW, ISM, IMDG, IRPCS and SOLAS
together with Flag State interpretations and requirements, Port State requirements
and Classification Society Rules contain provisions affecting HSC.

Figure 3.1 Relationship Between Generic Shipping Descriptions and Accident Categories


Figure 3.2 Typical Layout of a High Speed Twin Hull Passenger Ferry
3.3 HSC STAKEHOLDERS (OR INTERESTED ENTITIES)
The stakeholders in HSC operation are those influencing or affected by accidents

or by the cost effectiveness of the industry such as:
• Crew • Other Vessels

• Passengers • Flag State
• Coastal State • Cargo Owner
• Crew Provider/Trainer • Insurance Companies
• Designer/Constructor • Emergency Services
• Classification Society • Environmental interests
• Owner/Charterer/Operator • Leisure activities
• Port of Call • Fishermen
• Port State • Franchisees/vendors.
These stakeholders are considered further in later steps of the FSA process. The
Risk Control Options may lead to significant changes to risks and costs
disproportionately affecting one or more of these stakeholders and therefore these
differences may be significant and need to be addressed during Step 5 (Decision
Making).
3.4 HUMAN FACTORS
Human expertise and decision making are fundamentally involved in all aspects of
the design, construction, operation and maintenance of HSC and human error is a
major contributor to most shipping incidents. To develop an understanding of how
human factors contribute to incidents in the shipping industry, it is first necessary to
understand the environment in which those responsible work. In coming to
understand this environment it is necessary to consider such factors as the man-
machine interface, the working environment (physical and psychological), working
relationships and motivation and the various factors influencing them. It is usual to
gather the information required using a combination of formal and informal
interviews and most importantly, by observation.
Task Inventories identify those tasks which are carried out by HSC personnel that
are important to the successful operation of the vessel and were developed during

the course of interviews with HSC Masters and Officers on craft engaged in short
sea "international" voyages between the UK and France, UK and the Channel
Islands, and Scotland and Northern Ireland.
The task inventory serves a number of purposes:
• It attempts to define "generic best practice" in the routine operation of HSC.

• Critical tasks are identified as an aid to establishing causation of accident
events.
• Principal interfaces and communications links are identified.
• Influencing factors relevant to each task are identified.
The Task Inventory identified fourteen principal activities, the first thirteen of which
follow the pattern of normal operation of an HSC, as follows:
• Master reports for duty prior to first sailing.

• Crew report for duty.
• Preparations prior to passenger / cargo operations.
• Loading vehicles and passengers.
• Preparing vessel systems for sea.
• Final preparations for departure.
• Unberthing.
• Proceeding out of harbour to open sea.
• Open sea passage.
• Approach to port of destination.
• Berthing.
• Passenger / vehicle port operations (turnaround).
• Transition from Day (Operational) to Night (Maintenance) Mode.
The fourteenth item deals with emergency preparedness drills and real situations in
which HSC crews have been able to put their emergency preparedness training
into practice.
The factors which influence performance of the above tasks were identified as
being:
• Environmental Conditions - weather, visibility, motion, noise, temperature, etc

• Skill Levels – These are a direct function of and map onto Training, Experience
and Certification (the elements recognised as inherent parts of Competence).
• Service Resources – These are external to the ship and crews, and include
shore side berthing crews, booking and vehicle loading staff, maintenance
personnel etc
• Manning and Work Organisation - This factor includes the provision of sufficient
personnel to do the tasks required at the appropriate skill level, the organisation
of those tasks among different ship’s personnel and between ship and shore
crew and the scheduling and rostering of work to ensure that staff do not suffer
from fatigue and enjoy a socially acceptable life style.
• Communication - This term is used in the broadest sense and encompasses

verbal and radio (VHF) communication, the ability of systems to display and
communicate information, as well as other methods.
• Information - This is inclusive of all types of information which those who

operate the ship have at their disposal to take decisions. Information sources
can be as diverse as radar and alarm displays, log books, check sheets,
operations manuals, Admiralty charts, tide tables, etc.
• Operational Practices – These may be defined as the methods which are

followed to accomplish tasks. They are thus wider than formal Procedures and
include methods which crew members have been taught to follow as "the
standard way of doing things".
• Regulations/Operating Licence - In some cases, Operational Practices are the

result of direct provisions in eg. the IMO High Speed Craft Code (or its
implementation by the Flag or Port state) or of the Operating Licence (which is
the result of application and/or interpretation of the Code).
• Equipment Design - This concerns the design and function of any single piece
of equipment.
• System Design – This implies two or more items of equipment functioning

together, controlled by a software envelope or a man-machine interface.

• Equipment Reliability and Condition – This reflects the quality of maintenance

and proper use of the equipment.
• Time Pressure may be short term (eg. the requirement to process navigational
information and take collision avoidance decisions within seconds) or long term
(eg. too many tasks for the allotted resource or "not enough hours in the day").
The former problem tends to be a function of personal performance and the
latter, of Work Organisation.
• Stress in this context correlates with high levels of personal performance, ie. if
stress levels are high, the individual may give less than best performance. The
causes of stress may be straightforward, eg. a requirement to process
information and take decisions in too short a time span, or more subtle, eg.
social and family pressure brought about by working antisocial hours or shift
patterns.
• Commercial Pressure - In this context refers to direct pressure brought to bear

by commercial staff on mariners, eg. to maintain the service in circumstances
where the Master might prefer to suspend it.
The above factors were later used as input to the Influence Diagram definitions in
Step 2.
3.5 TECHNICAL AND OPERATIONAL ISSUES
Experts within the project team on each of the accident categories developed a
description of the technical and operational issues known to be of current concern
to HSC regulators, designers, constructors and operators in order to establish the
state-of-the-art for the project team as a whole and to establish the current base
line benchmark for the risk assessment. A summary for each accident category is
given below.
Collision and Contact

Collision is defined as the vessel striking or being struck by another vessel,
regardless of whether under way, anchored or moored. Contact is defined as the
vessel striking or being struck by an external object (eg. navigation buoy or berth)
but not another vessel or the sea bottom.
Obviously collisions may occur in either confined waters or open sea. Confined
waters, by their very nature, tend to be busy as they are usually port approaches,

rivers, estuaries, canals etc. in which the traffic must come into closer proximity
than it would in the open sea. Contacts generally occur in confined waters.
One of the main uses of the Generic Model described above is to provide sufficient
information for the Accident Categories to be broken down into their relevant
Accident Sub-categories. In the case of collision it is likely that consideration of the
environment will be of primary importance, in particular the generic locations of an
HSC. Thus collisions in specific locations such as docks, berths, harbours,
coastal waters and open sea were considered. Other considerations include
operational phases which are covered under the Managerial heading in the Generic
Shipping Model. Thus collisions during such operations as starting, manoeuvring,
berthing, anchoring, shutting down, dry-docking and maintenance were also
considered.
The main differences between HSC and conventional ships are that HSC travel at
approximately twice the speed, are of lightweight construction using aluminium or
composite materials for main hull and superstructure construction and have
significantly higher power to weight ratio propulsion systems. Also HSC are
regulated using a different approach from that for conventional shipping in the
limitation of operational sea conditions and the need for more advanced evacuation
and rescue arrangements.
The following aspects of the generic HSC were considered in relation to likelihood
and consequences of collision and contact:
• Hull design • Collision energy

• Control systems • Impact protection
• Navigation equipment • Compartmentalisation
• Propulsion systems • Extent of damage
• Traffic management • Evacuation
• Traffic density • Collision deceleration
• External environment • Collision modelling
Fire
The general approach to design for fire is to compartmentalise the ship based on
the compartmentalisation occurring for other reasons (cargo hold bulkheads,
separation between machinery spaces and other areas, deck separation, damage
stability etc). The boundaries of each compartment are then designed to prevent
spread of fire from one compartment to the next. The approach to boundary design
has in the past been to select a boundary construction which gives a known
performance in a standard fire test. The fire test is based on the type of cellulosic
fires which typically occur in buildings which assume (relative to a hydrocarbons

fire) a gradual temperature rise with the temperature at 60 minutes being 945EC.
In contrast a hydrocarbon fire could reach this temperature almost instantaneously.
The advent of composite materials which give the lighter weight for HSC, together
with the promise of low maintenance, have moved technology away from the more
traditional approach of using "non burning materials" such as steel. HSC are now
constructed with products which are inherently combustible but are engineered to
give their fire restricting characteristics.
One of the most notable HSC fires resulting in the total destruction of the vessel
originated from an electrical fire understood to have started in a void space.
Thankfully due to the immediate availability of numerous leisure craft, rescue of all
personnel was achieved without loss of life but, in a different location, a major
catastrophe could have occurred.
Fires which develop large amounts of smoke (as most do) in a contained area
make identification of the source and its extinction very difficult. Unmanned and
effectively closed compartments can be flooded with inert gas, presenting an
opportunity to control escalation, even for large initial inventories, which is not an
option for occupied areas.
The following aspects of the generic HSC were considered in relation to fire:
• Material behaviour – loss of strength of metallic materials (aluminium), loss of

strength and combustibility of composites with temperature gradient and time
• Design approaches – evaluation of structural performance, determination of fire
protection requirements, fire properties of protection materials
• Structural requirements for load bearing members
• Generation of heat, smoke and toxic gases
• Fire engineering and modelling
• HSC combustible contents – fuel
• HSC fire ignition sources.
It appears that the consideration of fire in the design of HSC is largely driven by the
regulations and as yet few designs embody the HSC Code requirements. The
HSC requirements represent a half way house between design based on a
standard fire test and that based on fire engineering principles which would now
typically be used in hazardous industries and offshore platforms and are seeing
increasing use in building structures. Fire engineering comprises the estimation of
realistic heat flux-time-temperature relationships for the realistic fire load for the

space under consideration and the evaluation of the boundary structure subjected
to such heat flux-time-temperature relationships.
There are a number of concerns with the present situation:
• The standard fire test curve may not represent the actual fire conservatively.
• Engine room fires will almost certainly involve hydrocarbons which will have a
much faster rate of temperature rise than the standard fire test.
• The HSC Code space classification is ambiguous and the classification of fuel
tank compartments as being of minor risk can be compromised by a fire in an
adjacent compartment.
Loss of Hull Integrity

Loss of hull integrity is defined as any damage to the external hull, or to the internal
structure and sub-division, such that any compartment or space within the hull is
opened to the sea or to another compartment or space. This type of damage may
be caused by impact with an external object, by structural damage due to
overloading, by cracking for example due to fatigue, or by events within the vessel
such as loose cargo or corrosion from leakage of corrosive fluids. In addition hull
integrity can be lost if a hull penetration leaks or is open when it should be closed.
In order to understand the probable mechanisms and likely consequences of loss
of hull integrity on HSC it is necessary to consider the way in which these vessels
are designed and constructed.
For HSC to operate efficiently at high speed their hulls need to be of lightweight
construction. Thus there is commercial and technical pressure to use minimum
acceptable scantlings and, where possible, low density materials. The individual
properties and characteristics of different material are traded-off in the design
process to arrive at an acceptable compromise between cost and weight for a ?fit
for purpose? structure. In this context, fitness for purpose requires consideration of
adequate strength, stiffness, corrosion performance, brittleness and fatigue
properties of the structure in a marine environment.
The following aspects of HSC design, construction and operation were considered
in relation to loss of hull integrity:
• Loading – hydrostatic, hydrodynamic, inertia, propulsion system thrust and

torque, vibration, impact
• Determination of loading – by testing, analysis or from classification society
rules
• Global and local stress analysis

• Material properties – high strength steel, aluminium and composites

• Fatigue – stress concentrations, inspectability, repair
• Structural component strength
• Failure modes – cracking in plating and stiffeners, cracking near water jets,
plastic deformation in bow plating and stiffeners due to slamming, buckling of
forward above water structure, superstructure failure due to hull deformations
or failure of flexible mounts
• Collision energy absorption and damage including damage stability
• Leakage at penetrations
• Deterioration with age.
The structural and loading aspects of HSC important to Loss of Hull Integrity can be
summarised as follows:
• Their optimised lightweight structures are less rugged and experience different
loads from traditional vessels
• Non traditional materials are used which require different practices in design
and construction and greater attention to detail
• High speeds lead to high specific impact energies in contacts or collisions.
The following specific aspects of the Generic HSC, which are relevant to Loss of
Hull Integrity were identified:
• Systems which have salt water inlets or outlets.

• Control, in respect of remotely operated valves.
• Mooring
• Loading
• Ride Control
• Structure
• Towing
3.6 HISTORIC INCIDENT DATA
Historic HSC data were collected from a number of sources (commercial data
bases, regulators and individual operators) and from human factors interviews with
experienced HSC personnel. Although the trial application is concerned with high
speed catamaran ferries, the data have been supplemented with data for all high
speed craft reflecting the similarity in operational characteristics (human and

hardware) to help identify accident causes and consequences. Quantification

relates only to HSC.
3.6.1 Data Sources

Data have been sourced in many ways, for example direct approaches to
operators, National Agencies (eg. Hong Kong, Norway, MAIB, MCA, LMIS, etc), Fast
Ferry magazine and conference papers. Visits have been made to Norway and
Hong Kong to seek new data or enhance that already known. All data were
compiled into an HSC Database in which the data were classed under one of three
categories:
• International incidents (ie. those reported in public conferences/papers, Fast

Ferry Magazine, etc) that are generally the more serious incidents
• Local Authority incidents (ie. those reported to regional bodies such as MAIB,
LMIS, Hong Kong Government, NMD, etc) which are notable incidents and
generally the identity of the vessels involved have been withheld
• Company Logs which record all events including individual passenger

accidents (only included if they involve the HSC design), machinery
breakdowns, hazardous incidents and near misses through to the most serious
incidents. The data are used statistically but individual events are not reported
in the public domain HSC Database.
Where an incident is reported in two or more sources it is retained only under one
category. Category 2 is considered to be the most comprehensive and balanced
dataset. Category 2 therefore takes precedence followed by the Category 1 public
domain dataset. These data have then been related to the corresponding fleet
sizes as described below.
Category 1 incidents are the most widely reported. In the HSC database it is
considered that a significant proportion of such incidents have been sourced, given
the worldwide scatter of incidents under this category which cover most regions of
operation except for USA and Japan. The data in this class have been related to
the world fleet for all HSC as illustrated in the Fast Ferry International Database
(Reference 10). From this it can be calculated that there have been a total of 3888
vessel operational years from 1981 to 1995 corresponding to all but one of the
incident dates within the Category 1 data.

Category 2 incidents are well reported in a limited number of regions. In the HSC
database it is estimated that in excess of 95% of such incidents have been
obtained from UK, Norway, Finland and Hong Kong/China. Therefore, the data in
this class have been related to this limited fleet covering UK, Norway, Finland, Hong
Kong and China. In Category 2, data are drawn from the last 15 years for Norway
and Finland and the last 5 years for the UK and Hong Kong/China. These Category
2 data form the basis of the frequency numbers used in this study.
The fleet size corresponding to the Category 2 data has therefore been calculated
on the basis of new vessel ownership between 1991 and 1995 for the UK, January
1991 and August 1996 for Hong Kong/China and between 1981-1990 and 1991-
1995 in Norway. The vessel operating years total 1093, broken down as follows:
UK/Finland 1991-1995 66
Hong Kong/China 1991-Aug 1996 591
Norway 1981-1990 202
Norway 1991-1995 234
Category 3 incidents were collected in detail for a very limited number of HSC
based on some 15 vessel operating years of data in the 1990s.
3.6.2 Data by Accident Category

The 301 HSC incidents have been categorised by the type of Accident as illustrated
in Table 3.1. For each Accident Category the table shows the number of incidents
and percentage of the total, the distribution between data source categories and the
number of fatalities, major injuries and minor injuries. Unfortunately, injuries are
rarely reported in terms of severity. For the purpose of this study, the main
measure of severity has been the need for a person to be taken to hospital. A
difficulty within this approach is that even minor injuries can result in a passenger
being taken to hospital as a precaution, although the approach is conservative. In
the assessment of incident severity, an equivalence of 10 major injuries or 100
minor injuries to one fatality is assumed.
It can be seen in Table 3.1 that the two highest Accident Categories in terms of
numbers of incidents are Collision and Contact. However, there is a substantial
difference between these categories in that there are significantly more injuries
from collisions, while contacts tend to be with the berth/pier which are relatively
minor occurrences. Groundings are significantly less frequent, although
groundings on submerged or visible rocks, rather than sandbanks, tend to be the

highest consequence incidents affecting HSC. The other Accident Categories are
less significant in terms of both frequency and severity, however within the
“other/unknown/near miss” category there are a few incidents with a significant
number of serious injuries and one fatality.
More detailed information on the Accident Categories considered in this study is

described below. Table 3.2 shows the Collision and Contact data broken down by
incident location. It can be seen that the majority of collisions occur in the harbour
or in coastal waters where other vessel traffic is relatively dense. It should be
noted that these areas are also the regions with the highest likelihood of harm to
people, although a significant number of fatalities occurred on small vessels in
collision with HSCs. The difference between these two locations is slightly blurred
by the data from Hong Kong/China where there is a large natural harbour, leading
to an increased number of incidents under the `Manoeuvring in Harbour'
subcategory relative to the UK and Norwegian data where smaller harbour areas
predominate.
The contact data show the predominance of incidents occurring near the berth with
90% of incidents occurring during berthing or unberthing.
No human casualties have been recorded for the Fire and Loss of Hull Integrity
Accident Categories. The data show that 93% of fires (14 incidents) have occurred
in the engine room and that 78% of fires have occurred during high speed passage.
Loss of Hull Integrity incidents have affected most principal components and
appurtenances and almost 80% of these incidents have occurred during high
speed passage.
Considerable effort was expended in ensuring that the Category 2 data were
checked and a number of anomalies were identified and resolved, in some cases
by screening out data where they were found to be unsatisfactory (eg. ownership
outside the operational fleet being considered).
The screened Category 2 data show that the frequency of contacts and collisions
is greater in Hong Kong/China than in Europe. This may be considered to reflect
the congestion in the region. Nevertheless reliance on the Hong Kong data alone
would bias the results, where exclusion may give figures which are
unrepresentative of a worldwide HSC fleet.
There is further contrast between the UK and Norway, there being a lower incident
rate across all accident categories in the latter case if the vessel population is

accounted for. This may be due to differences in operational contexts or reporting

practices in the two regions.
To assess the sensitivity, incident frequencies are calculated for each Accident
Category as shown in Table 3.3. Although Table 3.3 indicates some variability in
the frequencies, it is important to note that the values generally remain of a similar
order within each category despite significant physical and reporting differences in
the regions. These figures are considered to provide justification for the use of the
screened Category 2 data set with frequency and severity given in the final row of
Table 3.3.

Cat Accident Category Total % Category of Data Source

Number of
Incidents
1 2 3
Incident Fata Major Minor Incidents Fata Major Minor Incident Fata Major Minor
s l- l- s l-
ities ities ities
1 Accident to Personnel 10 3.3% 0 0 0 0 9 0 3 7 1 0 1 0
2 Collision 103 34.2% 29 4 51 39 71 9 72 143 3 1 0 0
3 Contact 82 27.2% 4 0 2 0 49 0 4 7 29 0 0 0
4 Loss of Hull Integrity 9 3% 0 0 0 0 4 0 0 0 5 0 0 0
5 Fire 16 5.3% 2 0 0 0 9 0 0 0 5 0 0 0
6 Flooding 6 2% 5 0 0 0 1 0 0 0 0 0 0 0
7 Grounding / Stranding 36 12% 5 2 88 164 26 0 49 15 5 0 0 0
8 Machinery / 15 5% 4 0 0 0 6 0 0 0 5 0 0 0
Electrical Failure
9 Payload Related 0 0% 0 0 0 0 0 0 0 0 0 0 0 0
10 Procedural 0 0% 0 0 0 0 0 0 0 0 0 0 0 0
11 Explosion 0 0% 0 0 0 0 0 0 0 0 0 0 0 0
20 Other/Unknown/Near- 24 8% 4 1 22 10 13 0 0 0 7 0 0 0
Miss
TOTAL 301 100.0% 53 7 163 213 188 9 128 172 60 1 1 0
Note: It should be noted that in some instances a detailed examination of the accident reports may result in a different categorisation of accidents from that shown
above especially regarding machinery failures
Table 3.1 HSC Incident Data by Accident Category
Collision Contact
Location of
Incident
No. of % known Fatalities Major Minor No. of % known Fatalities Major Minor
Incidents Incidents Injuries Injuries Incidents Incidents Injuries Injuries
Repair Yard 1 1.4% 0 0 0 0 0.0% 0 0 0

Berthed 4 5.7% 0 0 0 2 2.6% 0 0 0
Unberthing 4 5.7% 0 1 0 13 16.9% 0 0 0
Berthing 10 14.3% 0 0 0 56 72.7% 0 4 7
Manoeuvring in 32 45.7% 9 55 77 2 2.6% 0 0 0
Harbour
HSP (Coastal) 18 25.7% 4 48 75 3 3.9% 0 2 0
HSP (Remote) 1 1.4% 0 9 14 1 1.3% 0 0 0
Unknown 33 - 1 10 16 5 - 0 0 0
TOTAL 103 -100.0% 14 123 182 82 100.0% 0 6 7
Table 3.2 HSC Incident Data for Collision/Contact Sub-categories (all data sources)

Frequency / Severity by Accident Category

Date Used Vessel Years (Incidents/vessel year) / (Equivalent fatalities per incident)
Collision Contact Fire LoHI
HK / China only 591 0.0964 / 0.284 0.0474 / 0.008 0.0034 / 0 0/0
UK/Finland only 66 0.0758 / 0.350 0.0909 / 0 0.0758 / 0 0.0454 / 0
UK/HK/China/Norway 891 0.0741 / 0.271 0.449 / 0.009 0.0079 / 0 0.0034 / 0

1991 onwards
Norway 81-95 436 0.0138 / 0.003 0.0344 / 0.017 0.0023 / 0 0.0023 / 0
All screened category 2

data 1093 0.0622 / 0.264 0.0448 / 0.010 0.0073 / 0 0.0037 / 0
UK/HK/China, 91-95/6
Norway 81-95
Table 3.3 Calculations of Incident Frequencies and Incident Severity based on Screened Category 2 Data


10. REFERENCES
1. MCA Research Project 383, A Methodology for Formal Safety Assessment

of Shipping, Deliverable D1.4: Full Methodology Report, BOMEL Document
C674\15\001R, Rev A, May 1996.
2. House of Lords, Select Committee on Science and Technology, ‘Safety

aspects of ship design and technology’. HMSO, 1992.
3. International Maritime Organization, ‘Interim Guidelines for the Application

of Formal Safety Assessment (FSA) to the IMO Rule Making Process'.
MSC/Circ.829 and MEPC/Circ.355, IMO, London, 1997.
4. MCA Research Project 404, ‘FSA of Shipping Phase 2 – Trial Application

to HSC – Deliverable D5: Final Application Report’, BOMEL Document
C705\23\008R, Rev F, April 1998.
5. MCA Research Project 404, ‘FSA of Shipping Phase 2 – Trial Application

to HSC – Deliverable D6: Methodology’, BOMEL Document
C705\24\001R, Rev B, April 1998.
6. MCA Research Project 404. ‘FSA of Shipping Phase 2 – Trial Application

to HSC – Project Specification’, Maritime and Coastguard Agency, 27
September 1996.
7. Health and Safety Executive. Quantified risk assessment: its input to

decision making, HSE Books, ISBN: 0 717 60520 5.
8. Erffmeyer R.C., Erffmeyer E.S., & Lane I.M. The Delphi Technique: An
Empirical Evaluation of the Optimal Number of Rounds. Groups &
Organization Studies, Vol 11, 1986.
9. H M Treasury. The setting of safety standards. Report by an Independent

Group and External Advisors, 1996.
10. The Fast Ferry Internal Database Version 2.0, Fast Ferry International,
Tenterden, Kent, 1996.

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MCA P404 – D9 SUMMARY REPORT

MARITIME AND COASTGUARD AGENCY

MCA RESEARCH PROJECT 404

DELIVERABLE D9 – SUMMARY REPORT

C705\27\001R Rev B August 1998 Page 0.1 of 0.4

GLOSSARY OF TERMS 0.5

2. METHODOLOGY AND METHODOLOGY IMPROVEMENTS

3. DATA GATHERING FOR THE TRIAL APPLICATION TO HSC

4. TRIAL APPLICATION TO HSC – FSA STEP 1 – HAZARD IDENTIFICATION

C705\27\001R Rev B August 1998 Page 0.2 of 0.4

4.1 TASK 1.1 – PROBLEM DEFINITION

5. TRIAL APPLICATION TO HSC – FSA STEP 2 – RISK ASSESSMENT

5.6 STEP 2 CONCLUSIONS

6. TRIAL APPLICATION TO HSC - FSA STEP 3 – RISK CONTROL OPTIONS

C705\27\001R Rev B August 1998 Page 0.3 of 0.4

6.7 TASK 3.7: DEFINITION OF RISK CONTROL OPTION ATTRIBUTES

7. TRIAL APPLICATION TO HSC - FSA STEP 4 – COST BENEFIT

8. TRIAL APPLICATION TO HSC - FSA STEP 5 – RECOMMENDATIONS FOR

9. CONCLUSIONS AND RECOMMENDATIONS

C705\27\001R Rev B August 1998 Page 0.4 of 0.4

Risk The product of the Frequency and Consequence of a specified accident.

Cause A fault or event, possibly of little significance in isolation, providing an

Hazard A condition with the potential to result in an accident or commercial loss.

Accident The realisation of a Hazard.

Frequency The number of occurrences of a specified accident per unit time.

Consequence The outcome or loss to shipping, people or the environment

Fire is defined as an uncontrolled process of combustion characterised by heat or smoke or

ILO International Labour Organization

C705\27\001R Rev B August 1998 Page 0.5 of 0.4

The Maritime and Coastguard Agency* (hereinafter referred to as the Agency)

1.1 BACKGROUND TO THE FSA APPROACH

FSA is a new approach to the regulation of shipping safety, stemming from

C705\27\001R Rev A August 1998 Page 1.1 of 1.4

C705\27\001R Rev A August 1998 Page 1.2 of 1.4

an FSA Working Group was established at MSC 66 and started compilation of

1.2 PROJECT OBJECTIVES

• To complete a trial application of the entire FSA methodology for a particular

Subsidiary objectives included the following:

• To propose tentative risk-based regulatory requirements for HSC appropriate to

C705\27\001R Rev A August 1998 Page 1.3 of 1.4

• To facilitate a review of the safety regulation of HSC operating within UK

• To identify what further research is needed to complement ongoing

1.3 SCOPE OF WORK

• Collision and Contact

This enabled the methodology to be tested over significantly differing types of

C705\27\001R Rev A August 1998 Page 1.4 of 1.4

2. METHODOLOGY AND METHODOLOGY IMPROVEMENTS

The third area of methodology development undertaken was to consider how

Each of the three areas of methodology development outlined above is described

2.2 INFLUENCE DIAGRAM DEVELOPMENTS

C705\27\001R Rev A August 1998 Page 2.1 of 2.16

2.2.1 The Generic Influence Diagram

Any accident event may be considered to be caused by one of or a combination of

Motivation / Morale The strength and direction of human behaviour

Health The well-being of body and mind.

Physical Working The levels of noise, temperature, motion, light and

Physical Working The time of day; weather in terms of wind, visibility,

C705\27\001R Rev A August 1998 Page 2.2 of 2.16

Fatigue The state of readiness for action.

Availability of Resources The relationship of supply to demand

C705\27\001R Rev A August 1998 Page 2.3 of 2.16

Figure 2.1 Generic Influence Diagram for HSC

C705\27\001R Rev A August 1998 Page 2.3 of 2.16