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GUIDE FOR MAKING ACUTE RISK DECISIONS

GUIDE FOR MAKING ACUTE RISK DECISIONS

CENTER FOR CHEMICAL PROCESS SAFETY of the AMERICAN INSTITUTE OF CHEMICAL ENGINEERS New York, NY

This edition first published 2020 © 2020 the American Institute of Chemical Engineers

A Joint Publication of the American Institute of Chemical Engineers and John Wiley & Sons, Inc.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The rights of CCPS to be identified as the author of the editorial material in this work have been asserted in accordance with law.

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While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source publisher and authors endorse the information or or recommendations it may make. This in rendering professional situation. You websites

Library of Congress Cataloging-in-Publication Data is available.

Hardback ISBN: 9781118930212

Cover Design: Wiley

Cover Images: Silhouette, oil refinery © manyx31/iStock.com; Stainless steel © Creativ Studio Heinemann/Getty Images; Dow Chemical Operations, Stade, Germany/Courtesy of The Dow Chemical Company

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1

It is our sincere intention that the information presented in this document will lead to an even more impressive safety record for the entire industry; however, neither the American Institute of Chemical Engineers (AIChE), its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers officers and directors, warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented in this document. As between (1) AIChE, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers’ officers and directors, and (2) the user of this document, the user accepts any legal liability or responsibility whatsoever for the consequence of its use or misuse.

5.1.1

5.2

5.2.2

5.3

5.3.1

5.3.2

5.3.2

5.3.3

5.4

5.5.3

5.5.4

5.6

6.3

6.3.1

6.4

6.4.1

6.5

6.6

6.7.4

6.8

12.2.3

12.2.4

12.2.5

LIST OF TABLES

Table 1.1.Comparisonof RBPS, Original CCPS PSM Elements, and Responsible Care® Code Practices.......................................................38

Table 2.1. Example Consequence Categories – Qualitative Risk Matrix52

Table 2.2. Example Frequency Categories – Qualitative Risk Matrix...52

Table 2.3. Example Risk Ranking/Response Categories – Qualitative Risk Matrix....................................................................................................52

Table 2.4. Example Semi-Quantitative Risk Matrix ...........53

Table 3.1 Ammonia AEGLs and ERPGs (ppm) .......................................65

Table 3.2 Probit Value vs Percent Affected ...........................................66

Table 3.3 Typical HAZOP review table format.......................................73

Table 3.4. Hazards and associated scenarios, measures and impacts...74

Table 4.1. Example Objectives and Outcomes Table.............................85

Table 4.2. Simple Ranking for Table 4.2 Alternatives ...........................86

Table 4.3. Weighted Scores for Example from Table 4.1.......................87

Table 5.1 Decision Characteristics 97

Table 5.1. Example Consequence-Based Consequence Categorization (Releases) ............................................................................................106

Table 5.2. Example Business Impact Consequence Categorization 107

Table 5.3 Decision Level, Risk Tools, Decision Aids Summary 115

Table 6.1. Framing example 123

Table 7.2. Phosgene dispersion distance to ERPG-2. F Stability, 1.5 m/s wind 136

Table 7.3. Phosgene dispersion distance to ERPG-2 (0.8 ppm). F Stability, 1.5 m/s wind .......................................................136

Table 8.1. Incidents involving inadequate MOC..................................139

Table 8.2. Example MOC Form Approval Section ...............................144

Table 9.1. Example Consequence Categories – Qualitative Risk Matrix .............................................................................................................153

Table 9.2. Example Frequency Categories – Qualitative Risk Matrix.153

Table 9.3. Example Risk Ranking/Response Categories – Qualitative Risk Matrix..................................................................................................153

Table 9.4 Example of EHS impact categories and magnitudes used in hazard evaluations for use with Figure 9.2. ........................................154

Table 9.5 Example initiating cause frequency scale (order-of-magnitude basis) for use with Figure 9.2..............................................................155

Table 9. . Summary LOPA Sheet ...................................157

.................... . ......................

Table 9.7 Frequency Categories for Risk Matrix in Figure 9.4............162

Table 9.8 Consequence Categories for Risk Matrix in Figure 9.4.......163

Table 9.9. On-Site Base Case Risk – Flexible hose failure...................166

Table 9.11. On-Site Mitigated Risk – Flexible hose failure 168

Table 9.12 Off-Site Mitigated Risk – Flexible hose failure...................170

Table 10.1 BASF Risk Matrix...............................................................183

Table 10.2. Comparative complexity and tools used at four companies .........................................................................183

Table 10.3. Properties of Bromine.......................................................189

Table 10.4 Risk scenarios for bromine unloading and feed system.....189

Table 10.5 Distances to Individual Risk Contours 191 ....................................

LIST OF FIGURES

Figure 1.1. Risk Decision and Risk Management Road Map.................42

Figure 2.1. Risk Assessment Process (Adapted from ISO 3100)............48

Figure 2.2. Qualitative Risk Matrix Example.........................................52

Figure 2.3. Example of risk graph modeled on IEC 615 11 ...............................................................................................................54

Figure 2.4. Framework for the tolerability of Risk ............58

Figure 3.2. Secondary dust explosion ...................69

Figure 4.1. Damage Impact Decision Tree ............................................92

Figure 6.1. Debris of Columbia Space Shuttle from AH-64 Apache helicopter near Fort Hood, Texas. Courtesy NASA. ............................124

Figure 6.2. Briefing slide from Flight Readiness Review, October 2002, .............................................................................125

Figure 7.1 A systematic approach to loss prevention and identification of alternatives .................................134

Figure 9.1. Qualitative Risk Matrix example ....................15

Figure 9.2. Example of a Semi-Quantitative Risk Matrix

Figure 9.4. Phosgene cylinder hookups at DuPont Belle, WV Plant .....................................................................................160

Figure 9.5. Baseline risk for on-site (light grey) and off-site (dark grey) for phosgene cylinder example. 165

Figure 9.6. On-site risk reduction alternatives (light grey) 165

Figure 10.1. QRA process 174

Figure 10.2. Example fault tree for a fire 175

Figure 10.3. Example of an Event Tree ............................176

Figure 10.4. Example Bow Tie diagram 177

Figure 10.5. Example Individual (or Geographic) Risk Contour..........180

Figure 10.6. Example F-N Curve ...................................181

Figure 10.7. Dutch Societal Risk Criteria ..................182

Figure 10.8. BP’s group societal risk profile .............................................................................................................185

Figure 10.9. Schematic of emergency relief effluent treatment system that included a scrubber and flare tower in series .....187

Figure 10.10. Individual risk contours for bromine storage tank system ...............................................................................190

Figure 10.11. Individual risk contours for bromine cylinder system ..............................................................................191

Figure 10.6. PEMEX LPG terminal showing domino effects, note multiple fires......................................................................................................194

ACRONYMS AND ABBREVIATIONS

ACC American Chemistry Council

ACGIH American Conference of Governmental Industrial Hygienists

AEGL Ambient Air Exposure Guidelines

AIChE American Institute of Chemical Engineers

AIT Auto Ignition Temperature

API American Petroleum Institute

ASME American Society of Mechanical Engineers

BLEVE Boiling Liquid Expanding Vapor Explosion

BMS Burner Management System

CCA Cause Consequence Analysis

CEI Chemical Exposure Index (Dow Chemical)

CFR Code of Federal Registry

CMA Chemical Manufacturers Association

CSB US Chemical Safety and Hazard Investigation Board

CCPS Center for Chemical Process Safety

CCR Continuous Catalyst Regeneration

COO Conduct of Operations

CPI Chemical Process Industries

DCU Delayed Coker Unit

DDT Deflagration to Detonation Transition

DIERS Design Institute for Emergency Relief Systems

ERS Emergency Relief System

ERPG Emergency Response Planning Guidelines

EPA US Environmental Protection Agency

FCCU Fluidized Catalytic Cracking Unit

F&EI Fire and Explosion Index (Dow Chemical)

FMEA Failure Modes and Effect Analysis

HAZMAT Hazardous Materials

HAZOP Hazard and Operability Study

HIRA Hazard Identification and Risk Analysis

HTHA High Temperature Hydrogen Attack

HRA Human Reliability Analysis

HSE Health & Safety Executive (UK)

I&E Instrument and Electrical

IDLH Immediately Dangerous to Life and Health

ISD Inherently Safer Design

IPL Independent Protection Layer

ISO International Organization for Standardization

ISOM Isomerization Unit

ITPM Inspection Testing and Preventive Maintenance

LFL Lower Flammable Limit

LNG Liquefied Natural Gas

LOPA Layer of Protection Analysis

LOTO Lock Out Tag Out

LPG Liquefied Petroleum Gas

MAIT Maximum Auto Ignition Temperature

MAWP Maximum Allowable Working Pressure

MCC Motor Control Center

MEC Minimum Explosible Concentration

MIE Minimum Ignition Energy

MOC Management of Change

MOOC Management of Organizational Change

MSDS Material Safety Data Sheet

NASA National Aeronautics and Space Administration

NDT Non- Destructive Testing

NFPA National Fire Protection Association

NPV Net Present Value

OCM Organizational Change Management

OIMS Operational Integrity Management System (ExxonMobil)

OSHA US Occupational Safety and Health Administration

PHA Process Hazard Analysis

PLC Programmable Logic Controllers

PRA Probabilistic Risk Assessment

PRD Pressure Relief Device

PRV Pressure Relief Valve

PSB Process Safety Beacon

PSE

PSI

PSI

Process Safety Event

Process Safety Information

Process Safety Incident

PSM Process Safety Management

PSO Process Safety Officer

PSSR Pre-Startup Safety Review

QRA Quantitative Risk Analysis

RBPS Risk Based Process Safety

RAGAGEP Recognized and Generally Accepted Good Engineering Practice

RMP Risk Management Plan

SACHE Safety and Chemical Engineering Education

SCAI Safety Controls Alarms and Interlocks

SHE Safety, Health and Environmental

SHIB Safety Hazard Information Bulletin

SIS Safety Instrumented Systems

SME Subject Matter Expert

TQ

Threshold Quantity

UFL Upper Flammable Limit

UK United Kingdom

US United States

UST Underground Storage Tank

GLOSSARY

Acute Toxicity

Asset integrity

Atmospheric Storage Tank

Boiling-LiquidExpandingVapor Explosion (BLEVE)

The adverse (acute) effects resulting from a single dose or exposure to a substance. Importance: Ordinarily used to denote effects in experimental animals.

A PSM program element involving work activities that help ensure that equipment is properly designed, installed in accordance with specifications, and remains fit for purpose over its life cycle. Also see asset integrity and reliability.

A storage tank designed to operate at any pressure between ambient pressure and 0.5 psig (3.45kPa gage).

A type of rapid phase transition in which a liquid contained above its atmospheric boiling point is rapidly depressurized, causing a nearly instantaneous transition from liquid to vapor with a corresponding energy release. A BLEVE of flammable material is often accompanied by a large aerosol fireball, since an external fire impinging on the vapor space of a pressure vessel is a common cause. However, it is not necessary for the liquid to be flammable to have a BLEVE occur.

Bow Tie Diagram

Checklist Analysis

A diagram for visualizing the types of preventive and mitigative barriers which can be used to manage risk. These barriers are drawn with the threats on the left, the unwanted event at the center, and the consequences on the right, representing the flow of the hazardous materials or energies through its barriers to its destination. The hazards or threats can be proactively addressed on the left with specific barriers (safeguards, layers of protection) to help prevent a hazardous event from occurring; barriers reacting to the event to help reduce the event’s consequences are shown on the right.

A hazard evaluation procedure using one or more pre-prepared lists of process safety considerations to prompt team discussions of whether the existing safeguards are adequate.

Combustible Dust

Conduct of Operations (COO)

Consequence

Consequence Analysis

Dispersion Models

Domino Effects

Any finely divided solid material that is 420 microns or smaller in diameter (material passing through a U.S. No. 40 standard sieve) and presents a fire or explosion hazard when dispersed and ignited in air or other gaseous oxidizer.

The embodiment of an organization’s values and principles in management systems that are developed, implemented, and maintained to (1) structure operational tasks in a manner consistent with the organization's risk tolerance, (2) ensure that every task is performed deliberately and correctly, and (3) minimize variations in performance.

The undesirable result of a loss event, usually measured in health and safety effects, environmental impacts, loss of property, and business interruption costs.

The analysis of the expected effects of incident outcome cases, independent of frequency or probability.

Mathematical models that characterize the transport of toxic/flammable materials released to the air and/or the water.

The triggering of secondary events, such as toxic releases, by a primary event, such as an explosion, such that the result is an increase in consequences or area of an effect zone. Generally only considered when a significant escalation of the original incident results.

Emergency Response Planning Guidelines

Event Tree Analysis

A system of guidelines for airborne concentrations of toxic materials prepared by the AIHA. For example, ERPG-2 is the maximum airborne concentration below which it is believed nearly all individuals could be exposed for up to one hour without experiencing or developing irreversible or other serious health effects or symptoms that could impair an individual's ability to take protective action.

A method used for modeling the propagation of an initiating event through the sequence of possible incident outcomes. The event is represented graphically by a tree with branches from the initiating cause through the success or failure of independent protection layers.

Explosion

Failure Mode and Effects Analysis

Fault Tree Analysis

F-N Curve

Flammable Liquids

Frequency

Frequency Modeling

Hazard

Hazard Analysis

A release of energy that causes a pressure discontinuity or blast wave.

A hazard identification technique in which all known failure modes of components or features of a system are considered in turn, and undesired outcomes are noted.

A method used to analyze graphically the failure logic of a given event, to identify various failure scenarios (called cut-sets), and to support the probabilistic estimation of the frequency of the event.

A plot of cumulative frequency versus consequences (often expressed as number of fatalities).

Any liquid that has a closed-cup flash point below 100 F (37.8 C), as determined by the test procedures described in NFPA 30 and a Reid vapor pressure not exceeding 40 psia (2068.6 mm Hg) at 100 F (37.8 C), as determined by ASTM D 323, Standard Method of Test for Vapor Pressure of Petroleum Products (Reid Method). Class IA liquids shall include those liquids that have flash points below 73 F (22.8 C) and boiling points below 100 F (37.8 C). Class IB liquids shall include those liquids that have flash points below 73 F (22.8 C) and boiling points at or above 100 F (37.8 C). Class IC liquids shall include those liquids that have flash points at or above 73 F (22.8 C), but below 100 F (37.8 C). (NFPA 30).

Number of occurrences of an event per unit time (e.g., 1 event in 1000 yr. = 1 x 10-3 events/yr.).

Development of numerical estimates of the likelihood of an event occurring.

An inherent chemical or physical characteristic that has the potential for causing damage to people, property, or the environment.

The identification of undesired eventsthat lead to thematerializationofahazard,theanalysisofthe mechanisms by which these undesired events could occur and usually the estimation of the consequences.

Hazard and Operability Study (HAZOP)

Hazard Identification

Hazard Identification and Risk Analysis (HIRA)

Hot Work

Impact

Inertion

Incident

A systematic qualitative technique to identify process hazards and potential operating problems using a series of guide words to study process deviations. A HAZOP is used to question every part of a process to discover what deviations from the intention of the design can occur and what their causes and consequences may be. This is done systematically by applying suitable guide words. This is a systematic detailed review technique, for both batch and continuous plants, which can be applied to new or existing processes to identify hazards

The inventorying of material, system, process and plant characteristics that can produce undesirable consequences through the occurrence of an incident.

A collective term that encompasses all activities involved in identifying hazards and evaluating risk at facilities, throughout their life cycle, to make certain that risks to employees, the public, or the environment are consistently controlled within the organization's risk tolerance.

Any operation that uses flames or can produce sparks (e.g., welding).

A measure of the ultimate loss and harm of a loss event. Impact may be expressed in terms of numbers of injuries and/or fatalities, extent of environmental damage and/or magnitude of losses such as property damage, material loss, lost production, market share loss, and recovery costs.

A technique by which a combustible mixture is rendered non-ignitable by addition of an inert gas or a noncombustible dust.

An event, or series of events, resulting in one or more undesirable consequences, such as harm to people, damage to the environment, or asset/business losses. Such events include fires, explosions, releases of toxic or otherwise harmful substances, and so forth.

Independent Protection Layer (IPL)

Individual Risk

A device, system, or action that is capable of preventing a scenario from proceeding to the undesired consequence without being adversely affected by the initiating event or the action of any other protection layer associated with the scenario. A protection layer meets the requirements of being an IPL when it is designed and managed to achieve the following seven core attributes: Independent; Functional; Integrity; Reliable; Validated, Maintained and Audited; Access Security; and Management of Change

The risk to a person in the vicinity of a hazard. This includes the nature of the injury to the individual, the likelihood of the injury occurring, and the time period over which the injury might occur.

Inherent Safety

Inherently Safer Design

Interlock

Layer of Protection Analysis (LOPA)

A condition in which the hazards associated with the materials and operations used in the process have been reduced or eliminated, and this reduction or elimination is permanent and inseparable from the process. Inherently safer technology (IST) is also used interchangeably with inherent safety in the book.

A way of thinking about the design of chemical processes and plants that focuses on the elimination or reduction of hazards, rather than on their management and control.

A protective response which is initiated by an outof-limit process condition. Instrument which will not allow one part of a process to function unless another part is functioning. A device such as a switch that prevents a piece of equipment from operating when a hazard exists. To join two parts together in such a way that they remain rigidly attached to each other solely by physical interference. A device to prove the physical state of a required condition and to furnish that proof to the primary safety control circuit.

An approach that analyzes one incident scenario (cause-consequence pair) at a time, using predefined values for the initiating event frequency, independent protection layer failure probabilities, and consequence severity, in order to compare a scenario risk estimate to risk criteria for determining where additional risk reduction or more detailed analysis is needed. Scenarios are identified elsewhere, typically using a scenariobased hazard evaluation procedure such as a HAZOP Study.

Likelihood

Management of Change (MOC)

Management System

Mechanical Integrity

Near-Miss

Off-Site Population

Operating Procedures

Organizational Change

Organizational Change Management (OCM)

OSHA Process Safety Management (OSHA PSM)

A measure of the expected probability or frequency of occurrence of an event. This may be expressed as an event frequency (e.g., events per year), a probability of occurrence during a time interval (e.g., annual probability) or a conditional probability (e.g., probability of occurrence, given that a precursor event has occurred).

A system to identify, review and approve all modifications to equipment, procedures, raw materials and processing conditions, other than “replacement in kind,” prior to implementation.

A formally established set of activities designed to produce specific results in a consistent manner on a sustainable basis.

A management system focused on ensuring that equipment is designed, installed, and maintained to perform the desired function.

An unplanned sequence of events that could have caused harm or loss if conditions were different or were allowed to progress, but actually did not.

People, property, or the environment located outside of the site property line that may be impacted by an on-site incident.

Written, step-by-step instructions and information necessary to operate equipment, compiled in one document including operating instructions, process descriptions, operating limits, chemical hazards, and safety equipment requirements.

Any change in position or responsibility within an organization or any change to an organizational policy or procedure that affects process safety.

A method of examining proposed changes in the structure or organization of a company (or unit thereof) to determine whether they may pose a threat to employee or contractor health and safety, the environment, or the surrounding populace.

A U.S. regulatory standard that requires use of a 14element management system to help prevent or mitigate the effects of catastrophic releases of chemicals or energy from processes covered by the regulations 49 CFR 1910.119.

Pre-Startup Safety Review (PSSR)

Preventive Maintenance

A systematic and thorough check of a process prior to the introduction of a highly hazardous chemical to a process. The PSSR must confirm the following: Construction and equipment are in accordance with design specifications; Safety, operating, maintenance, and emergency procedures are in place and are adequate; A process hazard analysis has been performed for new facilities and recommendations and have been resolved or implemented before startup, and modified facilities meet the management of change requirements; and training of each employee involved in operating a process has been completed.

Maintenance that seeks to reduce the frequency and severity of unplanned shutdowns by establishing a fixed schedule of routine inspection and repairs.

Probit A random variable with a mean of 5 and a variance of 1, which is used in various effect models. Probitbased models derived from experimental doseresponse data, are often used to estimate the health effect that might result based upon the intensity and duration of an exposure to a harmful substance or condition (e.g., exposure to a toxic atmosphere, or a thermal radiation exposure).

Process Hazard Analysis

Process Knowledge Management

Process Safety Culture

An organized effort to identify and evaluate hazards associated with processes and operations to enable their control. This review normally involves the use of qualitative techniques to identify and assess the significance of hazards. Conclusions and appropriate recommendations are developed. Occasionally, quantitative methods are used to help prioritize risk reduction.

A Process Safety Management (PSM) program element that includes work activities to gather, organize, maintain,and provide information to other PSM program elements. Process safety knowledge primarily consists of written documents such as hazard information, process technology information, and equipment-specific information. Process safety knowledge is the product of this PSM element.

The common set of values, behaviors, and norms at all levels in a facility or in the wider organization that affect process safety.

Process Safety Incident/Event

Process Safety Information (PSI)

Process Safety Management (PSM)

Process Safety Management Systems

Qualitative Risk Analysis

Quantitative Risk Analysis (QRA)

Reactive Chemical

An event that is potentially catastrophic, i.e., an event involving the release/loss of containment of hazardous materials that can result in large-scale health and environmental consequences.

Physical, chemical, and toxicological information related to the chemicals, process, and equipment. It is used to document the configuration of a process, its characteristics, its limitations, and as data for process hazard analyses.

A management system that is focused on prevention of, preparedness for, mitigation of, response to, and restoration from catastrophic releases of chemicals or energy from a process associated with a facility.

Comprehensive sets of policies, procedures, and practices designed to ensure that barriers to episodic incidents are in place, in use, and effective.

Based primarily on description and comparison using historical experience and engineering judgment, with little quantification of the hazards, consequences, likelihood, or level of risk.

The systematic development of numerical estimates of the expected frequency and severity of potential incidents associated with a facility or operation based on engineering evaluation and mathematical techniques.

A substance that can pose a chemical reactivity hazard by readily oxidizing in air without an ignition source (spontaneously combustible or peroxide forming), initiating or promoting combustion in other materials (oxidizer), reacting with water, or self-reacting (polymerizing, decomposing or rearranging). Initiation of the reaction can be spontaneous, by energy input such as thermal or mechanical energy, or by catalytic action increasing the reaction rate.

Recognized and Generally Accepted Good Engineering Practice (RAGAGEP)

A term originally used by OSHA, stems from the selection and application of appropriate engineering, operating, and maintenance knowledge when designing, operating and maintaining chemical facilities with the purpose of ensuring safety and preventing process safety incidents.

It involves the application of engineering, operating or maintenance activities derived from engineering knowledge and industry experience based upon the evaluation and analyses of appropriate internal and external standards, applicable codes, technical reports, guidance, or recommended practices or documents of a similar nature. RAGAGEP can be derived from singular or multiple sources and will vary based upon individual facility processes, materials, service, and other engineering considerations.

Responsible Care©

Risk

An initiative implemented by the Chemical Manufacturers Association (CMA) in 1988 to assist in leading chemical processing industry companies in ethical ways that increasingly benefit society, the economy and the environment while adhering to ten key principles.

A measure of human injury, environmental damage, or economic loss in terms of both the incident likelihood and the magnitude of the loss or injury. A simplified version of this relationship expresses risk as the product of the likelihood and the consequences (i.e., Risk = Consequence x Likelihood) of an incident.

Risk Contour Lines that connect points of equal risk around the facility ("isorisk" lines).

Risk Management Program (RMP) Rule

Risk Matrix

EPA’s accidental release prevention Rule, which requires covered facilities to prepare, submit, and implement a risk management plan.

A tabular approach for presenting risk tolerance criteria, typically involving graduated scales of incident likelihood on the Y-axis and incident consequences on the X-Axis. Each cell in the table (at intersecting values of incident likelihood and incident consequences) representsa particular level of risk.

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