ANNEX II Form 67 “Risk Assessment Worksheet” Revision: 1 Issued: 01/06/2011

RISK ASSESSMENT WORKSHEET

01-31.12.2020

Name & location of equipment,

Ship NORDRUBICON machinery, task or work activity Cargo holds cleaning
Prepared by: Team
Department / Rank / Name:
Deck / Chief Officer / Manike A. Composition: Bosun and Deck Crew

Consequences X Likelihood = Risk BEFORE AFTER

Risk Control Recommendation

Hazard Identified C L R Action Taken To Mitigate
C L R Action Key

Personnel Experience of Working Aloft, Careful

Inspection of Ladder, Safety Harnesses and Life Lines. Continuous
Falling from the Height, Personal Injury 4 1 4 4 1 4
Good Housekeeping. PPE, Life Lines and Safety Monitoring
Harnesses to be Used Wherever Necessary.
Continuous
Falling Equipment / Objects, Personnel Injury 4 1 4 All Tools to be Safely Secured. No Loose Objects. 2 1 2
Monitoring

Equipment Inspection, Suitable Leads, Chafe Protection. Continuous

Stage / Chair Failure 4 1 4 4 1 4
Good Housekeeping. Monitoring

Continuous
Uncoordinated or Unauthorized Actions 4 1 4 Very Careful Liaison With Other Parties. 4 1 4
Monitoring

Personal Awareness, Training, Supervision, Ensure Continuous

Misuse of Equipment 4 1 4 2 1 2
Proper Tools are Used. Monitoring

Continuous
Weather Conditions 2 1 2 Monitor Forecasts, Personal Awareness, Supervision 2 1 2
Monitoring

Safety Instruction, Description of the Procedures for All

Human Error, Fatique, Lack of Experience or Training 4 1 2 2 1 2 NONE
Crewmembers Involved Before Job is Started

Master Head Of Department Supervisor

Signature Signature Signature

REEDEREI NORD GMBH 1

ANNEX II Form 67 “Risk Assessment Worksheet” Revision: 1 Issued: 01/06/2011

RISK ASSESSMENT GUIDELINE

C x L = R
RISK C ONSEQUENCES
CRITERIA LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

SAFETY First Aid Case – FAC Restricted Work Case – RWC Lost Time Injury – LTI Partial Disability / Single Fatality Multiple Fatalities

HEALTH Health Treatment Onboard Health Medical Treatment Health Repatriation Case Single Health Related Fatality Multiple Health Related Fatality

Minor Impact – effect to small Long Term Impact – severe

ENVIRONMENT Low Impact – no lasting effect
area
Medium Term Impact Long Term – effect to large area
effect on sensitive area
Minor failure – vessel taken out Moderate failure – vessel taken Major failure – vessel taken out Very serious failure – vessel
OPERATIONAL ISSUE No impact on vessel’s operation
of service for < 1 day out of service for 1 - 7 days of service for 7- 15 days taken out of service > 15 days

MEDIA ATTENTION No Coverage Local Coverage Regional Coverage National Coverage International Coverage
IKELIHOOD

1 – RARE SLIGHT – 1 SLIGHT – 2 MINOR – 3 MINOR – 4 MODERATE – 5

2 – UNLIKELY SLIGHT – 2 MINOR – 4 MODERATE – 6 MODERATE – 8 HIGH – 10

3 – POSSIBLE MINOR – 3 MODERATE – 6 MODERATE – 9 HIGH – 12 EXTREME – 15

4 – LIKELY MINOR – 4 MODERATE – 8 HIGH – 12 EXTREME – 16 EXTREME – 20

5 – CERTAIN MODEARTE – 5 HIGH – 10 EXTREME – 15 EXTREME – 20 EXTREME – 25

L

R ISK

ACTION KEY
SLIGHT 1-2 No action is required.

MINOR 3-4 No additional controls are required, however monitoring is required to ensure no changes in circumstances.
Maximum efforts should be made to reduce a risk / job to be performed under direct supervision of Officer.
MODERATE 5-9
Job can ONLY be performed after - AUTHORIZATION FROM OFFICE VERIFICATION TEAM - (Technical and Safety Department)
Maximum efforts should be made to reduce a risk / job to be performed under direct supervision of Senior Officer.
HIGH 10 - 14
Job can ONLY be performed after - AUTHORIZATION FROM OFFICE VERIFICATION TEAM - (Technical and SafetyDepartment)
EXTREME 15 - 25 INTOLERABLE RISK – JOB IS NOT AUTHORIZED.

REEDEREI NORD GMBH 2