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By: William T. Fine
ABSTRACT: To facilitate expeditious control of hazards for
accident prevention purposes, (^) two great needs have been rec- ognized. These are for (1) a method to determine the relative seriousness of all hazards for guidance in assigning priorities for preventive effort; and (2) a method to give a definite determination as to whether the estimated cost of the contem- plated corrective action^ to^ eliminate^ a^ hazard^ is^ justified.
To supply these needs, a formula has been devised which weighs the controlling factors and "calculates the risk" of a hazardous
situation,, giving a numerical evaluation to the urgency for remedial attention to the hazard. Calculated Risk Scores are then used to estabiish priorities for corrective effort.^ An additional formula^ weighs^ the^ estimated^ cost^ and^ effectiveness of any contemplated corrective action against the Risk Score and gives a determination as to whether the cost is justified.
The methods described in this (^) report were conceived and developed by the author in recognition of needs for a method of determining relative urgencies for attention to hazards, and for a simple system to give guidance as to whether the estimated cost of an engineering project to eliminate a hazard is justified. These needs are satisfied by the use of formulae which weigh the vary- ing degrees of the controlling factors.
In a few months of actual use at the Naval Ordnance Laboratory, these formulae have furnished solid foundation for safety recom- rendations for engineering action; they have saved many thousands of dollars by cancelling costly projects which the risks did not justify; and they have given better direction to the entire safety program by indicating the relative potential seriousness of all hazards.
Since weights or values assigned to the various factors of the formulae are empirical, extended experience may indicate advis- ability of raising or lowering some of the criteria. However since results are primarily for comparative purposes, relative evaluations will be valid within any organization as long as standards of judgment are consistent.
These methods are promulgated for information and for any use desired by addressees. It is believed they have universal appli- cation and should provide advancement in the state of the art of the safety engineering profession.
Captain, USN
By direction
ii
Chapter 1
INTRODUCTION
GENERAL. The purpose of^ this^ chapter^ _s^ to^ illustrate^ the need for quantitative evaluations to^ aid^ in^ the^ control^ of^ haz- ards and to explain the general plan^ of^ this^ report.
A problem frequently facing the head of any (field type) safety organization^ is^ to^ determine^ just^ how^ serious^ each^ known hazard is,^ and^ to^ decide^ to^ what^ extent^ he^ should^ concentrate his resources and strive to get each situation corrected. Normal safety routines such^ as^ inspections^ and^ investigations usually produce^ varying^ list^ of^ hazards^ which^ cannot^ all^ be corrected at once.^ Decisions^ must^ be^ made^ as^ to^ which^ ones^ are the most^ urgent.^ On^ costly^ projects,^ management^ often^ asks whether the risk due to the hazard justifies^ the^ cost^ of^ the work required to^ eliminate^ it.^ Since^ budgets^ are^ limited, there is necessity to^ assign^ priorities^ for^ costly projects^ to eliminate hazards.
The question of whether a costly engineering project is justified is usually answered^ by^ a^ general^ opinion^ which^ may be little better^ than^ guesswork.^ Unfortunately^ in^ many^ cases, the decision to undertake any costly correction of^ a^ hazard depends to a great extent on the salesmanship of safety personnel. As a result, due to insufficient information, the cost of cor- recting a^ very^ serious^ hazard^ may^ be^ considered^ prohibitive^ by management, and the project postponed; or due^ to^ excellent selling jobs by Safety, highly expensive engineering or^ construc- tion jobs may be^ approved^ when^ the^ risks^ involved^ really^ do^ not justify them.
In Chapter 2 of this report, a formula is presented to "calculate the risk" due to a^ hazard,^ or^ to^ quantitatively evaluate the^ potential^ severity^ of^ a^ hazardous^ situation.^ Use of this formula will provide a logical system^ for^ safety^ and management to determine priorities for^ attention^ to^ hazardous situations, and guidance for^ safety^ personnel^ in^ determining the areas where their efforts should be^ concentrated.
In Chapter 3 of this report, a formula is presented for determining whether or not the cost of eliminating a hazard is justified. Use of the formula will provide a solid foundation upon which safety personnel may base their recommendations for engineering-type corrective action. It will assure that proj- ects which are not justified will not be recc.mended.
This report deals with justification of costs to eliminate hazards. This does not inply in any way that a cost, no matter how great, is not worthwhile^ if^ it^ will^ prevent^ an^ accident^ and save a human life. However we must also consider accident pre- vention with reason and judgment. Budgets are not unlimited. Therefore the maximum possible benefit for safety must be derived from any expenditure for safety. When an analysis results in a decision that the cost of certain measures to eliminate a hazard "is not justified," we do not say or suggest that the hazard is not serious and may be ignored. We do say that, based on evalu- ation of the controlling factors, the return on the investment, or in other words, the amount of accident prevention benefit, is below the standards we have established. The amount of money involved will^ no^ doubt^ provide^ greater^ safety^ benefit^ if^ used^ to alleviate other higher-risk hazards which this system will iden- tify. As for the hazard in question, less costly preventive measures should be sought.
DEFINITIONS. For the purpose of this presentation, three factors are defined as follows.
a. HAZARD: Any unsafe condition or potential source of an accident. Examples are: an unguarded hole in the ground; defec- tive brakes on a vehicle; a deteriorated wood ladder; a slippery road.
b. HAZARD-EVENT: An undesirable occurrence; the combination of a hazard with some activity or person which could start a sequence of events to end in an accident. Examples of hazard- events are: a person walking through a field which contains a hazard such as an unguarded well opening; a person not wearing eye protection while in an eye hazardous area; a person driving a vehicle that has defective brakes; a man climbing up a defec- tive ladder; a vehicle being driven on a slippery road.
Chapter 2
GENERAL. The purpose of this chapter is to present a complete explanation (^) of the method for quantitatively evaluating the seri- ousness of hazards, and some of the benefits that may be derived from such analyses.
The expression "a calculated risk" is often used as a catch- all for any case when work is to be done without proper safety measures being taken. But usually such work is done without any actual calculation. By means (^) of this formula, the risk is calcu- lated. The seriousness of the risk due to a hazard is evaluated by considering the potential conse&uences of an accident, (^) the exposure or frequency of occurrence of the hazard-event that could lead to the accident, and the probability that the hazard-event will result in the accident and consequences.
THE FORMULA is as follows:
Risk Score = Consequences x Exposure x Probability
Abbreviated: (^) R = C x E x P
Definitions of the elements of the formula (^) and numerical ratings for the varying degrees of the elements are given below.
a. CONSEQUENCES C: The most probable results of a potential accident, including injuries and property damage. This i3 based upon an appraisal of the entire situation surrounding the hazard, and accident experience. Classifications and ratings are:
Description Rating
(1) Catastrophe: numerous fatalities; extensive damage (over $1,000,000); major disruption of activities
(2) Multiple fatalities; damage $500,000 to $1,000,000 .............................................. 50
Description Rating
(3) Fatality, damage $100,000 to $500.000 (^) ...... 25
(4) Extremely serious injury (^) (amputation, permanent (^) disability); damage $1000 to $100,000 ......... (^15)
(5) DisablinC injuries; damage up to $1000 (^) ..... 5
(6) Minor (^) cuts, bruises, bumps; minor damage... (^1)
b. EXPOSURE E: Frequencv of occurrence of the hazard-event (the undesired event which could start the (^) accident-sequence). Classifications (^) are below. Selection is based (^) on observation, experience (^) and knowledge of the activity concerned.
Description Rating
The (^) hazard-event occurs:
(1) Continuously (or many (^) times daily) ......... 10
(2) Frequently (^) (approximately once daily) ...... (^6)
(3) (^) Occasionally (from once per week to once per month) .............................................. (^3)
(4) Unusually (^) (from once per month to once per year) (^) ...................................... (^2)
(5) Rarely (it has been known to occur) ........ (^1)
(6) Very (^) rarely (not known to have occurred,
but considered remotely possible)...................... (^) 0.
c. PROBABILITY P: This is (^) the likelihood that, once the hazard-event occurs, the conylete (^) accident-seauence of events will follow (^) with the necessary timing and coincidence (^) to result in the (^) accident and conseczuences. This is determined (^) by careful consideration (^) of each step in the accident (^) sequence all the way to the consequences, (^) and based upon experience and knowledge (^) of the activity, (^) plus personal observation. Classifications (^) and ratings are:
1 It is a wet or snowy day, making the grass along the road wet and (^) uninviting to walk on.
(^2) At quitting time, a line of vehicles, (^) and some pedestrians (^) are leaving the grounds, using this road.
3 One pedestrian walks on the (^) right side of this road, (^) and he has an attitude which makes (^) him oblivious to the traffic. (^) (This is the hazard-event.)
4 Although traffic (^) is "one way" out at this time, one (^) vehicle comes from the opposing direction (^) causing the outgoing (^) traffic line to move to the right (^) edge of the road.
5 The (^) pedestrian on the right side of the road fails (^) to observe the vehicles, and he remains (^) in the road. 6 The (^) driver of one vehicle fails to notice the pedestrian (^) and strikes him from the rear.
7 Pedestrian is killed.
(b) Step (^) 2. Determine values for elements of formula:
1 Conseauences: A fatality. Therefore (^) C = 25.
2 Exposure: (^) The hazard-event is event 3 above, the pedestrian remaining (^) in road and refusing to notice the line of traffic. It is considered (^) that this type individual appears or is "created" (^) by conditions occasionally. Therefore E = 3. 3 Probability of all events (^) of the accident- sequence following the hazard-event is: (^) "conceivably possible, although it has (^) never happened in many years." Reasoning (^) is as follows: events 4, 5, 6 and 7 are (^) individually unlikely, so the combination of their occurring simultaneously (^) is extremely remote. Event 4 is unlikely (^) because traffic is "one way" at (^) quitting time. Event (^5) is unlikely because a number of (^) drivers would undoubtedly sound their (^) horns and force the pedestrian's attention. Event 6 is unlikely because most drivers are (^) not deliberately reckless. Event 7, a fatality, is unlikely (^) because vehicle speeds are not great on the road, and the (^) most likely case would be a glancing blow and minor injury. (^) Not even a minor injury has ever (^) been reported here. (^) In view of the above Probability (^) P = 0.5.
(c) Step 3. Substitute into formula and determine the Risk Score. R = C x E x P = 25 x 3 x 0.5 = (^) 37.
(NOTE: The Risk Score of one case alone is meaningless. (^) addi- tional hazardous (^) situations must also be calculated for compar- ative purposes and a definite pattern. (^) Five additional cases are similarly calculated below.)
b. Example No. 2 (Actual situation several (^) years ago. Hypothetical case now.)
(1) Problem. Fifty (50) compressed air hoses are in use for general (^) cleaning purposes in a machine shop, being used without proper pressure-reduction nozzles at various pressures some up to 90 pounds per (^) square inch. This causes potential eye hazards, although (^) eye protection is worn by most men. The most probable consequence (^) of this hazard is a serious eye injury.
(2) (^) Using the Risk Score Formula:
(a) Step 1. List the sequence of events to cause an eye injury accident:
1 Many machine operators use compressed air streams to blow metal chips (^) from work.
(^2) Most employees occasionally remove their safety glasses while still in the hazardous area. (^) (This is the hazard-event.)
3 One employee (^) who is not wearing eye protection walks past a machine while an air (^) hose is being used.
4 A metal chip blows into the employee's eye.
5 A serious eye injury results.
(b) Step 2.
2 Exposure: The hazard-event (an (^) employee removing his eye protection while still in an eye hazardous area) is considered (^) to occur many times daily. E = 10.
4 The driver loses his steering control at a point when he is uphill from and approaching the tank.
5 Brakes fail to stop the vehicle from sliding.
6 Vehicle heads out of control toward the tank.
7 Vehicle strikes the tank with enough force to rupture it and permit the propane gas to leak out.
8 A spark ignites the propane.
9 Explosion and conflagration occur.
10 Building and equipment damage is $200,000, and one man is killed.
(b) Step 2. Substitute numerical values into formula:
1 Conseauences: One fatality and Damage loss of $200,000. Therefore C = 25.
2 Exposure: The hazard-event that would start the accident sequence is event No. 3, the truck starting to slide on this road. This has happened "rarely." Therefoe E = 1.
-3 Probability: To decide on the likelihood that the complete accident-sequence will follow the occurrence of the hazard-event, we consider the probability of each event:
a Consider (^) event 4: Loss of steering control to occur at the precise point in the road approaching the tank is possible but would be a coincidence.
b Consider event 5: failure of brakes. Once the vehicle started to slide, if the road were ice covered, it would be expected that the brakes would fail to stop the slide.
c Consider event 6: the vehicle heading toward the tank. This is highly unlikely. Momentum would cause the vehicle to continue straight down the road.
_ Consider event 70 the vehicle striking the tank with great force, and squarely. Extremely unlikely.
If a vehicle were sliding on an ice (^) covered surface toward the tank, it would be easily diverted from its direction of travel by (^) a number of obstructions between the road and the tank. When roads are slippery, travel is curtailed and drivers are cautioned to drive slow. A slow rate of speed would be unlikely to produce enough force to damage the tank. The shape and position of the tank are such that a vehicle would tend to glance off it.
e Events 8 through 10 are likely to (^) follow if event 7 took place.
f In summary, the (^) highly unlikely nature of most of the events from 4 through 2 gives a net Probability of almost a "one in a million" possibility. It has never happened, but it is conceivable. (^) Therefore P = 0.5.
4 R = 25 x 1 x 0.5 = 12.
(c) Step 3. Repeat the entire above (^) process for the second hazard (location near the high pressure air lines and equipment): (^) List the sequence of events:
1 Normal daily activities involve operation of equipment and (^) pressurizing of pipelines some of which are in the vicinity of the propane storage tank.
2 A pipeline containing air compressed to 3000 pounds (^) per square inch, approximately 50 feet away from the storage tank, has become deteriorated or damaged. (:This is the hazard-event.)
3 The pipeline bursts.
4 Metal debris is thrown by the blast in all directions, several pieces flying and striking the propane tank with such force that the tank is ruptured.
5 Propane starts to leak out of the tank.
6 A spark ignites the propane fumes.
7 The propane and air mixture explodes.
8 Building damage is $200,000, and one man is killed.
(a) Several ovens are in use, each containing five pounds of explosives undergoing test.
(b) Persons are usually present in the area outside the building on the blowout side. This is a normal and accepted condition.
(c) The thermostatic controls of one oven in use
(d) The secondary emergency shutoff control fails to function. (e) The oven overheats.
(f) The explosive content of the oven (^) explodes.
(g) A passerby near the building is fatally injured by the blast and flying debris.
(3) Formula use:
(a) Consequence: A fatality. (^) C = 25.
(b) Exposure: The hazard-event, the malfunctioning of the oven heat controls, has happened before, but very "rarely." E -1.
(c) Probability (^) of the complete accident sequence following the hazard event: all ovens have been equipped with secondary emergency shutoff controls. Monthly maintenance pro- cedures have now been established to ensure their proper function- ing. Failure (^) of the secondary shutoff if it should be needed is considered highly unlikely. It would be a remotely possible coincidence if the secondary failure occurred at the same time and on the same oven on which a thermostatic control failed. Therefore the Probability rating P = 1.
(d) Substituting in the formula:
R = 25 x 1 x 1 = 25
e. Example No. 5 (Actual case)
(1) Problem. There (^) are approximately 100 household- type refrigerators (^) in use in which various kinds of chemicals are stored. (^) Many of these refrigerators are not sparkproof Flanmuable volatile solvents (^) stored in nonsparkproof refrig- erators could leak, vaporize, (^) contact electrical sparks and result in an explosion (^) or fire. Most likely results would be minor injuries and possible damage estimated at $200.00.
(2) Necessary (^) sequence of events for an accident:
(a) Various kinds of chemicals are placed and stored in approximately (^) 100 refrigerators (normal practice).
(b) Occasionally flaxruable volatile (^) solvents are placed (^) in a nonsparkproof refrigerator (a violation of safe
practice. This is the (^) hazard-event).
(c) A solvent container (^) leaks (or the cover is not on tight).
(d) Fumes (^) reach an electric spark.
(e) Fumes explode and cause $200.00 damage.
(3) Formula use:
(a) Consequence: Damage is (^) $200.00. C = 5.
(b) Exposure: The hazard-event, the violation in event (b) above, is believed to occur frequently. E = 6.
(c) Probability: (^) The probability of the accident sequence following the violation (^) and resulting in the accident is considered (^) "remotely possible." Therefore P = 1.
(d) Substituting in the (^) formula:
R = 5 x 6 x 1 = 30
f. Example No. 6 (Actual case)
Table 1
RISK SCORE SUMl, RY AND ACTION SHEET
HAZARD DESCRIPTION RISACTION
Window washer on third floor, without safety belt,A hangs on with one hand and leans out.............. 1500 Men working in ditch six feet deep, ditch not shored, dirt is soft, subject to sliding.................. 750 Painters on scaffold without handrail, 30 feet high, not using safety belts............................ 750 Benzene used for cleaning floor of shop, a^ busy^ area,^ Ismmediate^ correction men smoke, other spark sources nearby .............. 450 required.should be (^) discon-Activity Compressed flammable^ gas^ cylinders^ standing^ unsecured^ snue^ tiscazr on pallet, along^ busy^ aisle,^ caps^ on..............^375 is reduced. Uncontrolled compressed air used in machine shop, up to 90 psi, for general cleaning ................... 300 Men smoking in flammiable storage warehouse, no sprin- kler system, highly flammable material ............^270 Portable electric drill in use without ground wire, getting rough usage by several people ............. 200 Conpressed air receiver without safety^ relief^ valve, automatic shut-off at 200 psi, old equipment...... 180 People walking past deep unguarded ditch, considerable traffic, poor lighting ............................ 150 Urgent.^ Requires
case, subject to bumping by employees ............. 150 (as^ possible. Trucks rounding blind corner without stopping, opposing traffic and pedestrians,^10 MPH^ limit....^135 Steps of main building slippery whenever wet,^ no handrail, many pedestrians daily .................. 90 Compressed oxygen cylinder standing unsecured near wall, little traffic^ or^ movement..................^85 Pedestrian and hand-cart traffic at blind corner in hallway of shop building^ .......................^60 Oxygen and acetylene cylinders stored together, caps on, good ventilation, fireproof surroundings ...... 45 Inadequate handrailing along outside stairway, occasional use every day .......................... 40 Large propane storage tank in busy area: vehicle traffic, and high pressure air operations ......... 37. Both pedeccrians and^ vehicles^ using^ same^ road.^ Road^ Hazard^ should^ be not always wide enough^ for^ both^ ...................^ 37.5^ eliminated^ without Chemicals stored in nonsparkproof refrigerators,^ delay,^ but^ situation occasionally including flammable^ volatile^ liquids.^30 is^ not^ an^ emergency. Broken sidewalk, occasional pedestrian^ traffic,^ holes and loose concrete.................................^^30 Persons near explosives building, within range of possible missiles:^ safe^ procedures^ in^ building^ ....^^25 Portable vacuum^ pump^ lacking^ belt^ guard.^ Pump^ moved around occasionally^ by^ several^ employees^ ..........^18 Machinist using heavy^ file^ without^ file^ handle,^ in daily use ......................................... 18 Workman using hammer^ with^ loose^ head,^ in^ use^ daily for odd jobs ...................................... s
RESULTS AND USES OF SUMb1IRY OF RISK SCORES.
a. The Risk Score Summary and Action Sheet on Table 1 is now a very useful (^) device. If necessary or advisable, the list should be presented to management for top level concurrence and approval of the ACTION column.
b. Beneficial uses of this list are as follows:
(1) Establishes priorities for attention by both Safety and Management. Hazardous situations (^) are listed in the order of their importance. The position on the list of any item can be lowered (^) by corrective action which will decrease its possible Consequences, Exposure, or Probability.
(2) It provides guidance to indicate urgency of newly discovered hazards. For each new hazardous situation, (^) compute the Risk Score. Its urgency is indicated (^) by the ACTION area in which its Risk Score falls. In particular, (^) it would serve as guidance as to whether a job must be stopped when a highly hazardous situation is (^) noted in a highly essential operation. If the Risk Score is above the upper (^) critical line, job must be stopped until some corrective action can be taken to, at the least, lower any one of the three factors (^) to get the Score into a less urgent category.
(3) It would provide a means of setting goals and objectives for (^) the Safety Program, other than or in ad~dition to the (^) use of accident statistics. For example, a safety program can be rated, or safety accomplishment can be (^) demonstrated by the number of cases for which corrective action has been taken and caused the cases to be placed in less urgent categories. A goal could be to have no hazardous situations above the lowest category. The safety status of an organization can be indicated by the number of items in each category (^) at any time.
NOTE: With reference to Table 1, the author hastens to point out that very few of the listed hazardous situations presently exist at the Naval Ordnance Laboratory, (^) the locale where this program originates. Most of the severe cases were selected for expediency from previous years' experience, (^) are hypothetical, or combine experience and hypothesis.^ It^ is^ recommended^ to^ poten- tial users of this system, that they also compile workable lists as soon as possible from their past experience and hypotheses, to be used as guidance for (^) co.parative evaluation of hazardous situations as they occur or are discovered.