Study of Major Accidents Involving Chemical Reactive Substances: Analysis and Lessons Learned

The objective of this paper is to present the results of the analysis performed on a selection of accidents included in the MARS database. This is a database of past accidents that occurred in Europe maintained by the European Commission, in order to help the Member States to meet the requirements of the Seveso and Seveso II directives. The study is focused on those accidents that involve reactions between chemical substances, whether wanted or unwanted, that generated a hazardous situation by loss of control of such reactions. Runaway reactions are known to be especially dangerous, given that many times they are unexpected, or their possible consequences underestimated, so sometimes chemical industries are not ready to cope with the effects of loss of control of reactive processes. The aim of the analysis is to obtain lessons learned from past accidents in order to prevent similar situations in the future, or to reduce their consequences. Understanding the causes of past accidents, including equipment failures, deviations in the expected course of a reaction, or deficiencies in process operations performed, can help to a better understanding of similar processes. Industries working with potentially dangerous chemicals should consider introducing lessons learned into their safety management systems.     

Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

Building Safety indicators: Part 2 – Application,practices and results

Petroleum exploration and production in the Barents Sea is a controversial topic. The Goliat field outside the northern coast of Norway will be the first offshore oil development in this region, with planned production start in 2013–2014. Avoiding major accidents at Goliat is critical; not only to reduce the risks to human lives and the environment, but also to gain political acceptance. Providing early warnings of major accidents for Goliat is one of the main objectives of the research project ‘Building Safety’. The objective of this paper is to describe the development of early warnings in the form of indicators. In addition, the paper includes an overview of current status of early warnings of accidents in other major hazard industries; the nuclear power industry, the chemical process industry, and aviation. Experiences from these industries, including lessons learned from recent major accidents, have been used as important input to the development of early warning indicators.     

Lessons after Bhopal: CSB a catalyst for change

The Bhopal tragedy was a defining moment in the history of the chemical industry. On December 3, 1984, a runaway reaction within a methyl isocyanate storage tank at the Union Carbide India Limited pesticide plant released a toxic gas cloud that killed thousands and injured hundreds of thousands. After Bhopal, industrial chemical plants became a major public concern. Both the public and the chemical industry realized the necessity of improving chemical process safety.

Bhopal served as a wake-up call. To prevent the same event from occurring in the United States, many legislative and industrial changes were invoked—one of which was formation of the U.S. Chemical Safety and Hazard Investigation Board (CSB). The ultimate goal of CSB is to use the lessons learned and recommendations from its investigations to achieve positive change within the chemical industry—preventing incidents and saving lives.

Although it seems clear that the lessons learned at Bhopal have improved chemical plant safety, CSB investigations indicate that the systemic problems identified at Bhopal remain the underlying causes of many incidents. These include:

• Lack of awareness of reactive hazards.

• Lack of management of change.

• Inadequate plant design and maintenance.

• Ineffective employee training.

• Ineffective emergency preparedness and community notification.

• Lack of root cause incident investigations and communication of lessons learned.

The aim of this paper is to present common themes from recent cases investigated by CSB and to discuss how these issues might be best addressed in the future.

This paper has not been independently approved by the Board and is published for general informational purposes only. Any material in the paper that did not originate in a Board-approved report is solely the responsibility of the authors and does not represent an official finding, conclusion, or position of the Board.     

Process industry accidents in Sri Lanka: Analysis and basic lessons learnt

Accidents in the process industry could be prevented or reduced by having good safety management measures. Such preventive measures could be further improved through the experiences and lessons learnt from past accidents. Therefore, analysis results of past accidents are valuable sources of information for determining root causes and as case material to prevent and reduce the adverse consequences of accidents in the process industry.This paper looks at accidents in the process industry that have occurred in the past 10 years from 1997 to 2006 in Sri Lanka to gain an understanding of the nature and consequences of accidents. Lessons and main areas of concern to improve safety in the Sri Lanka process industry are discussed. The analysis is done for different event types based on specific operating process stage during which the accident occurred such as processing, loading and unloading, repair and maintenance and storage, the immediate effect types such as fire, explosion, chemical releases and emissions and the consequences of each accident. Fire incidents were observed in 38 accidents analyzed. The results show that the highest number of accidents has occurred during processing operations followed by accidents during maintenance and repair work. The cause analysis shows that many accidents have occurred due to technical and human failures.The accidents are then classified according to the severity of the consequences in order to compare the nature of accidents experienced in Sri Lanka with respect to accidents in other countries in the world.     

Causes and lessons of five explosion accidents

This paper describes five disastrous explosion accidents that occurred in recent years that had serious consequences for lives and property. The five explosions were: 1) The explosion at a TNT workshop of a chemical factory, Liaoning province, on February 9, 1991 in which 17 employees died and 107 were injured; 2) The nitro-amine explosive production workshop of a chemical factory in Hubei province on June 27, 1992, which led to the deaths of 22 employees and 13 injuries; 3) An explosion in storage warehouses containing dangerous goods in Shenzhen City on August 5, 1993, where 141 were injured; 4) A explosion of a truck loaded with 1.05 million detonators on October 23, 1994 causing 5 deaths and 95 injuries; and 5) An RDX explosive accident in Hunan province on January 31, 1996 in which 134 people died and 17 were injured. In this paper, the causes of these accidents are described and the lessons to be learned from these accidents are summarized.Great changes and significant achievements have taken place and the national economy has been developing at high speed since China reform and open policy. But as far as safety in production is concerned, catastrophic explosion accidents have occurred in recent times and some of them have been exceptionally serious. The author has participated in the investigation of many explosion accidents, which brought about heavy casualties and great economic losses. The bitter experiences have given us many beneficial lessons written in blood from which we must try to avoid such similar unnecessary accidents. In this paper, the causes of five disastrous explosion accidents are analyzed and lessons learned from these accidents are summarized. Proposals for safety production are also put forward.     

Korean experience of process safety management (PSM) regulation for chemical industry

From the 1960s, Korean industries have been encouraged by the government to nurture heavy and chemical industry and to modernize the economics and industrial structures. The development of chemical industry particularly became the turning point in industrial development, and played a major role in the construction of a new industrialized country. However, the process systems in the chemical industry have become more complex and larger, and the inventories of dangerous chemicals that are produced or consumed have continuously increased. Therefore, the hazards from potential accidents such as fire and explosion or release of toxic chemicals have also increased. In fact, from the end of 1980s to the beginning of 1990s in Korea, a number of major industrial accidents such as ABS extruder explosion, TDI release and dryer explosion, etc. Occurred and caused many fatalities. As the chemical companies recognized the importance of preventing major hazards, PSM system, the prevention of major industrial accidents, was introduced in January 1995 by amending Industrial Safety and Health Act, and it has been enforced from January 1, 1996. According to the law, the business owner of a workplace with hazardous or dangerous equipment shall submit a process safety report to the Government to prevent any accidents, which could inflict an immediate damage on workers or on areas in the vicinity of the workplaces. As a result of PSM implementation for 19 years, chemical accident prevention system has been stabilized and various kinds of effectiveness and desirable customer satisfaction have been made.     

Stock market responses to chemical accidents in Japan: An event study

Despite recent major chemical process accidents in Japan, the top management teams of firms still avoid taking costly risk reduction measures because of their low perceived impact on firm performance. The disclosure of information on accident risks might motivate managers to enhance workplace safety because of the subsequent evaluation of firms by investors in stock markets. If the disclosed risk information is newly available for investors, firms with a high risk of accidents would receive a poor evaluation by stock markets and thus managers would take risk reduction measures to prevent stock prices from declining. In this study, we conduct an event study analysis to examine whether accident risk information is already reflected in stock prices, using data on the Japanese chemical industry. The results of our event study show that the estimated cumulative average abnormal returns of firms' stocks are significantly negative after severe accidents actually occurred. This finding implies that risk information is not already reflected in the stock prices of Japanese chemical firms and that the disclosure of accident risk information has the potential to motivate the top management teams of firms to reduce their firms’ accident risk.     

2006-2010年我国危险化学品事故统计分析研究

本文基于＂十一五＂期间我国危险化学品事故统计数据,从事故类别、事故发生区域、事故发生时间、企业经济类型、危险化学品类别、危险化学品事故发生环节等方面进行分析,结果表明,中毒与窒息事故和爆炸事故占危险化学品事故主要类型,易燃液体、易燃气体、爆炸品和腐蚀性物质是引发危险化学品事故的主要危险物质类型,生产环节是事故发生的主要环节,违反操作规程或劳动纪律与设备设施工具附件有缺陷是导致事故的重要原因。从落实企业安全生产主体责任、提升本质安全化水平、开展重大危险源普查、建立安全监管网络、加强危险化学品产业布局、提高事故应急救援能力等方面提出了预防和控制危险化学品事故的对策建议。     

Model-based zero emission safety concept for reactors with exothermal reactions for chemical plants

To avoid major accidents caused by runaway reactions, a new safety concept called SmartHIP¹ is introduced, with the objective to prevent runaway reactions and avoid emissions. The basic principle is based on an online model-based approach by using safety instrumented systems. Different criteria exist for calculating the hazard potential of a runaway reaction and its early detection. The approaches of the literature from the last years are analysed and divided into three different groups: Divergence, Accumulation and Adiabatic Criterion. Each approach is compared to the other by applying it to an esterification reaction of acetic anhydride with methanol. The approaches are evaluated according to different requirements, like accuracy, wide range of application or reliability.     

过氧化氢热爆炸研究进展

过氧化氢作为绿色环保的氧化剂,广泛应用于工业的各个领域,同时也因其热分解爆炸危险性导致了一系列严重的火灾爆炸事故。过氧化氢在高温或与一些不兼容化学物质作用下,将会激发其热危险性,进而引发热失控反应,最终导致爆炸事故的发生。结合近年来国内发生的过氧化氢热爆炸事故,简要概述了其热爆炸事故历程,并从理论研究和实验研究两个方面综述了过氧化氢热爆炸的研究进展。理论研究方面,主要介绍了化学反应失控模型和基于热动力学的研究方法,尤其对基于热失控模型的热风险评估进行了详细的阐述。实验研究方面,分析了高温条件下与杂质催化作用下过氧化氢的热危险性,包括无机杂质和有机杂质。最后就过氧化氢热爆炸的研究提出了进一步的研究方向。     

石油钻井作业的安全葡萄图管理技术

石油钻井作业是一个高风险行业,其风险具有严重性、突发性、隐蔽性、随机性的特点,是石油石化行业中最主要的事故频发区之一.震惊世界的“12.23”事故以后,在国家和企业安全生产的指导与监督下,事故较以前明显减少,但钻井作业的特点决定了其风险因素不会被消除,只能通过人的因素去预防事故发生.安全葡萄图从人的因素考虑,结合了人体生物节律与葡萄图两者的优点,除了具有葡萄图的特点外,还具有预测性、记录性和选拔性,是安全管理方面的一种新方法.安全葡萄图是一种以人为本的安全管理方法,通过加强人员安全管理来减少和消除事故隐患的目的.该方法简单实用,适合于钻井等高风险行业使用.     

Rail ruminations for process safety improvement

Process safety practices have undergone multiple refinements over the past few decades, but major accidents continue to occur. Most organizations strive to improve performance by strengthening existing methods or by adopting new and/or different approaches. Central to these continual improvement efforts is the practice of applying lessons learned as a means to drive out potential risk exposures. Often, lessons learned may be transferred from other industries; indeed, high-performing organizations regularly benchmark practices outside of their immediate industry.In pursuit of continual process safety improvement, this paper examines risk management practices in the Rail Industry, and explores how methods intended for managing passenger and public rail safety may be transferred to drive continual improvement of process safety. Rail safety has its roots in engineered safety solutions; modern practices have additionally embraced the human aspects of safety performance. A selection of approaches for rail safety assessment and risk management are described in three areas considered fundamental to safety management: management of systems, management of technology, and management of human elements. In light of these examples, the authors provide views regarding how the field of process safety management may leverage the rail experience.     

公路施工安全事故诱因与预警管理的探讨

基于以往公路施工安全事故的分析,总结公路施工安全事故的特点,认为公路施工安全事故的发生,受到地质环境、社会外部环境、施工机械设备失控以及施工人员主观过错等因素的共同影响,并应用安全人机工程学的事故致因理论,分析各因素间的相互关系。针对事故诱因,提出构建公路施工安全事故的预控管理模式,对可能产生公路施工安全事故的主要因素、施工过程、紧急救援措施等进行监测与评价。通过预警分析,制定预控管理对策,以使公路施工事故的灾害损失尽量减少到最低。     

化工园区安全监控系统研究

化工园区内重大危险源数量多、密度大,存在着发生重特大事故的现实性和可能性。因此,亟需建立化工园区安全监控系统对化工园区内的固定危险源、危险工艺过程、危化品车辆和公共区域重要部位进行动态监控和安全监管,预防和消除事故风险,并为化工园区安全监控与事故应急提供技术支持。提出了化工园区安全监控系统系统硬件架构,介绍了化工园区安全参数设置方法、安全监控流程和事故预警机制,提出了系统软件的总体架构和功能。     

危险化学品公路运输事故新特点及对策研究

统计分析了2008年1月～2010年5月我国发生的485起危险化学品公路运输事故。从事故发生的原因、事故涉及的化学品、事故造成的危害、事故发生的月份分布及年份变化等几个方面,分析了近年来危险化学品公路运输事故的新特点及变化规律。经统计分析,道路交通事故是引发危险化学品运输事故的主要原因之一;侧翻是危险化学品车辆最容易发生的道路交通事故;而随着我国高速公路的迅猛发展,追尾造成的危险化学品运输事故数量呈上升趋势;危险化学品公路运输过程中易燃液体事故起数最多,爆炸品和毒性物质事故造成的人员伤亡最严重;春节前后取代夏季,成为近两年危险化学品运输事故高发期。针对这些特点,对我国危险化学品公路运输安全管理与监控提出了建议。     

影响危险化学品生产企业安全评价有效性的因素探讨

随着化学工业的迅速发展,化学品的产量和品种大幅增加,危险化学品生产企业各类事故频发,严重阻碍了化学工业的发展.为此,国家制定了一系列的法律法规,以期遏制恶性事故的发生.安全评价作为预防事故的重要手段,现已广泛应用于各个行业,危险化学品生产企业也不例外.但是,随着安全评价工作的开展,也暴露出与安全评价有关的一些问题.本文简要介绍了我国危险化学品生产企业的安全现状,详细分析了影响危险化学品生产企业安全评价有效性的各种因素,并提出了相应的对策措施.     

The effectiveness of process safety management (PSM) regulation for chemical industry in Korea

From the 1960s, Korean industries have been encouraged by the government to nurture heavy and chemical industry and to modernize the economics and industrial structures. The development of chemical industry particularly became the turning point in industrial development, and played a major role in the construction of a new industrialized country. However, the process systems in the chemical industry have become more complex and larger, and the inventories of dangerous chemicals that are produced or consumed have continuously increased. Therefore, the hazards from potential accidents such as fire and explosion or release of toxic chemicals have also increased. In fact, from the end of 1980s to the beginning of 1990s in Korea, a number of major industrial accidents such as ABS extruder explosion, TDI release and dryer explosion, etc. occurred and caused many fatalities. As the chemical companies recognized the importance of preventing major hazards, PSM system, the prevention of major industrial accidents, was introduced in January 1995 by amending Industrial Safety and Health Act, and it has been enforced from January 1, 1996. According to the law, the business owner of a workplace with hazardous or dangerous equipment shall submit a process safety report to the Government to prevent any accidents, which could inflict an immediate damage on workers or on areas in the vicinity of the workplaces. As a result of PSM implementation for 7 years, various kinds of effectiveness have been made. Accident rate including number of fatalities has been decreased, and productivity has been increased as well as product quality.     

Major accident hazard in bioenergy production

Some recent accidents involving the bioenergy production and feedstock supply chain raised concern on the safety of such technologies. A survey of major accidents related to the production of bioenergy (intended as biomass, bioliquids/biofuels and biogas) was carried out, and a data repository was built, based on past accident reports available in the open literature and in specific databases. Data analysis shows that major accidents are increasing in recent years and their number is growing faster than bioenergy production. The results obtained represent an early warning concerning the major accident hazard of bioenergies, and suggest the importance of risk awareness and safety culture in bioenergy production, in the perspective of a safe and sustainable exploitation of renewable resources.