Chapter 1

Introduction to Risk Assessment

On any given day, in every corner of the world people are actively working, going to school, driving or taking mass transit to work, relaxing at home or on vacation, or even working at home. Some people are even finding the time to sleep. Those who are working perform jobs that range from cleaning animal kennels to being the head of state of a country and every type of job in between. Every job, in fact, every activity a human performs, has a hazard associated with it. The common hazards we all are exposed to include

• slips, trips, and falls;
• illness and disease;
• food borne illness;
• transportation: car accidents, pedestrian accidents, and bicycle accidents;
• sports: organized sports (football, basketball, soccer) accidents, individual sports accidents (skiing, water sports, skate boarding);
• electrical;
• fires;
• snow removal.

On top of these more common hazards, every job has specific hazards associated with it. The major hazards associated with cleaning animal cages, for example, include

• being attacked by the animal;
• the bacteria, viruses, and parasites that might be in the animal waste;
• the design of the cage might pose problems: size, shape, material of construction, and sharp edges;
• the maintenance of the cage might pose problems: cleanliness, jagged metal or wood, and faulty locks/latches/gates/door;
• the condition of the floor;
• the electrical and/or Heating Ventilation and Air Conditioning (HVAC) system in the building;
• the building's environmental conditions.

The major hazards associated with being a head of state include

• stress from decision making;
• stress from the potential for war;
• stress from political rivals;
• potential for assassination;
• potential for transportation accidents: airplane crashes (i.e., the President of Poland died in an airplane crash in Russia in 2010 (1).)

Hazardous occupations, for instance, fire fighting, have numerous hazards associated with day-to-day activities. Risk assessment tools and techniques can be used to analyze individual jobs for risks. It is obvious that every activity the President does is analyzed for hazards. Jobs or tasks such as fire fighting, chemical plant worker, electrician, and even office workers are usually analyzed using tools such as job hazard analysis (2).

The focus of this book is on analyzing complex systems, tasks, and combinations of tasks for hazards and the associated risks. Most of the major accidents that occur each year result from a series of events that come together in an accident chain or sequence and result in numerous deaths, environmental consequences, and property destruction. These accidents can occur anytime in the system's life cycle. One of the events from history that demonstrates this is the sinking of the Swedish ship Wasa (pronounced Vasa) on August 10, 1628 (3). The ship was fabricated between 1626 and 1628. In those days, engineering of the ships was performed by the shipwright, and he used his experience to determine factors such as center of mass and the amount of ballast the ship should have. Because of various events, pressure was put on the shipbuilders to complete the ship ahead of the planned delivery time. The ship was completed and ready for sail on August 10, 1628. The ship was very ornately decorated and was heavily laden with armament. As the ship left port on its maiden voyage on that calm morning, a gust of wind hit the ship, filling her sails. The ship heeled to port and the sailors cut the sheets. The ship righted itself, but then another gust of wind hit the ship and it tipped to port far enough that water entered the gun ports. This was the event that led to the loss of the ship and approximately 30–50 lives. However, the loss of the ship was probably due to one of the two design flaws. The first factor being that the ship was probably too narrow for its height, and second, the ship did not carry enough ballast for the weight of its guns on the upper decks. A contributing factor was the height above sea level of the gun ports that allowed water to enter the ports when the ship listed to port. Since, as stated above, engineering of ships was more seat of the pants than a systematic design process, the real reason(s) for the disaster can only be speculated. The ship was raised from her watery grave in 1959 and has since been moved to a beautiful museum facility in Stockholm. Therefore, the ship itself can be studied, but other factors such as whether the guns were properly secured, how much provisions were on the ship, and so forth will remain a mystery. The Wasa accident occurred in the ship's initial phases of its life cycle. Accidents can occur in any phase of a system's life cycle.

A much more recent accident occurred on December 24, 2008, in Rancho Cordova in which a natural gas leak caused an explosion and fire, killing one person and injuring five others including one firefighter and a utility worker. The explosion also destroyed one house completely and severely damaged two others adjacent to the destroyed house. Several other houses in the neighborhood were damaged. Pacific Gas and Electric Company, the utility owner and operator, operates 42% of California's natural gas pipe lines. According to Pacific Gas and Electric Company, the property damage from this explosion and fire was $267,000 (4). The incident involved piping that had been originally installed in 1977 and repaired in 2006. The accident investigators found that a piece of piping that was used in the repair was actually polyethylene pipe used as packing when transporting the ASTM D-2513 grade polyethylene piping. The wall thickness of the packing piping did not meet specifications and there were no print lines of the piping used in the repair. The repair personnel, for whatever reason, selected a piece of the packing piping as the repair material, rather than ensuring the pipe was of the proper grade. Therefore, as with the Wasa event, human error was the primary driver in the event. Although, in both events, hardware components were involved as well.

Risk assessment tools and techniques, if applied systematically and appropriately, can point out these types of vulnerabilities in a system. The key term here is “systematic.” A risk assessment must be systematic in nature to be most effective. A risk assessment should begin early in the life cycle of complex systems. Preliminary hazard analysis (PHA) is an example of a tool that can be applied at the earliest phase of system development. As the design of a system progresses other tools can be applied, such as failure mode and effect analysis (FMEA) and fault tree analysis (FTA). Probabilistic risk assessment (PRA) and human reliability analysis (HRA) are techniques used to analyze very complex systems. These tools usually require a well-developed design, an operating philosophy, and at least working copies of procedures to provide enough material to perform analyses. However, even mature systems benefit from risk assessments. The analyses performed on the space shuttle after the Columbia accident are a good example (5). These assessments pointed out vulnerabilities of the space craft that were previously unidentified or viewed as being not as important.

Using the six sigma/total quality management philosophy of continuous improvement, risk assessment techniques applied throughout the design life of a system can provide insights into safety that might arise at various points of the system's life cycle (6). Reliability engineers use the bathtub curve to illustrate the classic life cycle of a system (Fig. 1.1) (7). In the first part of a system's life, there is a higher potential for early failure. The failure rate then decreases to a steady state until some point in the future when systems wear out or old age failure occurs.

Figure 1.1 Bathtub curve.

Manufacturers usually warranty a system, a car for instance, for the period of time from birth till just before system wear out. This way they maximize their public image, while minimizing their risks or obligations.

Risk analysts are also interested in such curves but from a safety perspective. Accidents commonly occur early in a system's life cycle because of several reasons, including

• mismatch of materials;
• hardware/software incompatibilities;
• lack of system understanding;
• operator inexperience or lack of training.

The system then enters a long phase of steady-state operation that, as long as no changes perturbate the system, remains safe. In later system life, accidents occur for the same reason as why systems wear out, components wear out. However, in terms of accident risk, when a component fails in old age it might lead to a catastrophic failure of the system, for instance, the Aloha Flight 243 accident (8). In this case, the aircraft structure had become fatigued with age and failed during takeoff. Workers have fewer accidents in their later working years; however, the severity of the injuries may be greater (9). In addition, latent conditions can lay dormant for many years in a system (10). These conditions could be a piece of bad computer code or a piece of substandard pipe that when challenged leads to a failure. Performing risk assessments on systems throughout their life cycle can help to elucidate these vulnerabilities. Once these vulnerabilities are found, measures can be taken to eliminate them and/or mitigate the consequences of failures. This is the most important step of any risk assessment. That is, eliminating the vulnerabilities and reducing the risk of a system.