BSM Risk Assessment Form RA - 01

Use this form only when RA PAL module is not available

Ship/Dept. Name: RA No: Rev No. Date:

Work / Activity Details

Sect.1. Risk Assessment Table

New
Severity Likeliho
Who / what is Rating (A) Likelihoo
affected by of d Rating od Decision
hazard conseque (B) Risk Agreed Rating(B Residu to
Sub Hazards (People / Consequences nces (Refer Level Control measures to reduce likelihood of Person time 1) al Risk ( proceed
Task/Activity Identified Environment / (Refer Table in (A X B) hazard occurring Responsible frame (after A x B1) with
Property) Table in Sect.2) control work Y/N
Sect.2) measur
es)

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

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BSM Risk Assessment Form RA - 01

Use this form only when RA PAL module is not available

Guidance of completion:
1.     Identify the task required for the work activity (preparation, execution, post work)
2.     Identify the hazards for each task
3.     Identify hazard type in terms of people, Environment, Property or Process for each hazard.
4.     Identify the ‘consequences’ if the hazard is realized for each hazard category.
5.     Determine the initial severity rating for each hazard category. Refer to table in sec. 2 and ' Reference chart for Hazards and Risk Rankings’ given in Ann.4 of RA manual.
6.     Determine the initial likelihood for each hazard category. Refer to table in sec. 2 and ' Reference chart for Hazards and Risk Rankings’ given in Ann.4 of RA manual.
7.     Multiply severity with likelihood to obtain initial risk for each hazard category.
8.     Apply controls to reduce risk to acceptable level (preferable green range or atleast yellow range) for each hazard category.
9.     List the person responsible for each control measure.
10.   List the agreed time frame for each control measure.
11.   Determine new likelihood for each hazard type.
12.   Multiply initial severity with new likelihood to obtain final risk for each hazard category.
13.   Indicate whether task is safe to continue for each hazard.

Comments : Time needed to prepare the RA:

Signed: For office use only:

Risk Assessor ( Name, Rank) Comments:

Reviewer’s Comments:

Signed: Procedural changes needed:

Y / N
Risk Assessment Reviewer (Name, Rank)
REV. 01 Page 2 of 5
BSM Risk Assessment Form RA - 01

Use this form only when RA PAL module is not available

SECT 2: Risk Ranking Matrices & Risk Level Tables

(Severity of)Consequence-A
Hospital:
Injury Perm Disability:
Fatality: Injury
FAC: First Aid LTI: Lost Time Incident requiring Injury resulting resulting in
TABLE 1 : SHIPBOARD - PEOPLE Case Hospitalizatio in permanent
n or LTI disability death
Rating 1 2 >24hours
3 4 5
Certain (Several times per annum on board) 5 5 10 15 20 25
Probable ( Happened once per annum on board) 4 4 8 12 16 20
Likelihood Possible ( Happened several times in our Company) 3 3 6 9 12 15
Unlikely ( Happened in our Company) 2 2 4 6 8 10
Highly Unlikely ( Never heard within the Company) 1 1 2 3 4 5

(Severity of)Consequence-A
Nil to Sea: Sheen on Sea: Evidence of loss
Contained to sea Les than 1m3 1 to 5 m3 to Sea More than 5 m3
TABLE 2 : SHIPBOARD - ENVIRONMENT to Sea to Sea
onboard
Rating 1 2 3 4 5
Certain (Several times per annum on board) 5 5 10 15 20 25
Probable ( Happened once per annum on board) 4 4 8 12 16 20
Possible ( Happened several times in our Company) 3 3 6 9 12 15
Likelihood
Unlikely ( Happened in our Company)
2 2 4 6 8 10
Highly Unlikely ( Never heard within the Company)
1 1 2 3 4 5

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BSM Risk Assessment Form RA - 01

Use this form only when RA PAL module is not available

(Severity of)Consequence-A
> USD 10000 <
USD 1000, > USD 5000 < > USD 100000,
> USD 1000 < USD 5000 / Off Hire< 4 USD 10000 / USD 100000 / P&I or H&M
Customer P&I or H&M
Complaint / off Hours / slight damage Off hire > 4 claim / off hire claim / off hire >
TABLE 3 : SHIPBOARD -PROPERTY / COMMERCIAL hire < hours / cargo one week
> one day
2 hours contaminatio
Rating 1 2 n / moderate
3 4 5
damage
Certain (Several times per annum on board) 5 5 10 15 20 25
Probable ( Happened once per annum on board) 4 4 8 12 16 20
Possible ( Happened several times in our Company) 3 3 6 9 12 15
Likelihood
Unlikely ( Happened in our Company) 2 2 4 6 8 10
Highly Unlikely ( Never heard within the Company)
1 1 2 3 4 5

(Severity of)Consequence-A
Negligible Minor Moderate Major Catastrophic
TABLE 4 : RA - MATRIX FOR MOC
Rating 1 2 3 4 5
Certain 5 5 10 15 20 25
Probable 4 4 8 12 16 20
Likelihood Possible 3 3 6 9 12 15
Unlikely 2 2 4 6 8 10
Highly Unlikely 1 1 2 3 4 5

Table 5: Risk Levels Meaning Action

Risk is acceptable and job can be undertaken. Consideration may be given for further reduction of risk if reasonably possible. However,
1-7 Tolerable in case value is above 4, continuous monitoring is required to ensure existing controls are maintained.
Efforts are to be made to reduce the risk by placing additional controls with an aim to bring down Risk Level to Green zone. Vessel: If the
risk cannot still be brought down to green zone, job can be undertaken but with continuous and heightened monitoring. The Technical
8-11 Moderate Superintendent or Fleet Manager may be contacted for advice if deemed necessary. MOC: The approving Authority or HOD may be
suitably consulted.

Efforts are to be made to reduce the risk to green/yellow rating by placing additional controls and taking appropriate action as defined
above. However, If the final risk level is in the red zone then no job shall be undertaken. The Technical Superintendent or Fleet Manager
REV. 01 12-25 Substantial must be advised of this situation immediately. Until the final risk level is reduced so that it is no longer in the red zone the job shall not Page 4 of 5
be undertaken.”
BSM Risk Assessment Form RA - 01

Effortsthis
Use form
are to onlytowhen
be made reduceRAthe PAL
risk tomodule is not
green/yellow available
rating by placing additional controls and taking appropriate action as defined
above. However, If the final risk level is in the red zone then no job shall be undertaken. The Technical Superintendent or Fleet Manager
12-25 Substantial must be advised of this situation immediately. Until the final risk level is reduced so that it is no longer in the red zone the job shall not
be undertaken.”

REV. 01 Page 5 of 5