The unfolding of ‘12.23’ Kaixian blowout accident in China

In this research, which takes the ‘12.23’ Kaixian blowout accident in Chongqing as an example, firstly the basic information of the accident, including the affected area, the accident process and the accident consequences, was described. Secondly, the development of the accident and other correlative things were researched in detail, especially the monitoring result of concentrations of toxic gases at different times. Thirdly, the blowout accident was categorized into three stages, and the causes of each stage were analyzed in depth together with the events and causal factors charting. Lastly, the profound problems exposed in the disaster were thoroughly discussed. The analysis on ‘12.23’ Kaixian blowout accident indicates that deficiencies in the proper understanding of the hazards by the crew/management as well as inadequacies in risk assessment, management, and the absence of effective countermeasures resulted in the loss of lives.     

CFD simulation study on gas dispersion for risk assessment: A case study of sour gas well blowout

Compared with general blowout, the process of sour gas well blowout is more complex. The exchange of gas state is affected by many factors, and the consequences of the accident are serious. It is difficult to find out the rule of gas dispersion and predict the distribution of toxic gas. Fluent code was used to model the sour gas dispersion in the atmosphere after well blowout. The “12.23” sour gas well blowout, which was happened in Kai County, Chongqing, Sichuan, China, was the research background. The blowout accident model was set up to simulate the real process. Models were built based on real topography. Wind speed and atmospheric stability of the day which the accident happened were set as the operation conditions, and the composition, injection rate, and temperature of the gas at the actual time were set as the boundary conditions of numerical simulation. The analysis of gas dispersion based on simulation results conducted from two aspects, height and dispersion time. A comparison of field data with simulation data demonstrated that CFD technology can be an effective aid to describe the process of sour gas dispersion and can also predict the tendency of gas dispersion and gas distribution. Furthermore, it can provide guidance on design emergency response zone (ERZ).     

The Merseyside Accident Information Model (MAIM) can reveal components of accidents that lead to attendance at fracture clinics and cause disability: a new approach to accident prevention

The objectives of this study were to identify components of accidents that cause the most disability and to discover the principal sources of injuries treated in the fracture clinics. Patients attending fracture clinics of the Royal Liverpool University Hospital were interviewed using a portable computer-based questionnaire, the Merseyside Accident Information Model (MAIM). Patients were followed up by telephone interview or letter to enquire about disability continuing after discharge. Disability was measured by the pre-accident to post-discharge changes in scores for 11 normal functions. Of the 1326 patients interviewed, 900 (68%) were successfully followed up and 37% reported disability after discharge. First events ‘tripping’, ‘slipping’ and ‘other underfoot events’ accounted for 433 patients (194 reporting disability), and ‘collapsed/fainted — no other event' for 66 patients (27 reporting disability). Activities at the time of accident most frequently associated with disability involved moving about on foot. Among first event objects, ground surfaces and underfoot hazards were reported in 35%. Sources of injuries included underfoot accidents (48%), sport (13%), and transport accidents (12%.). Underfoot accidents contributed to 58% of patients reporting disability, sport 6% and transport accidents 11%. Underfoot accidents together with ‘collapsed/fainted — no other event’ accounted for 79% of female patients reporting disability and 50% of men. Such data could be used for cost-effective targeting of preventative measures, and to study the effectiveness of accident prevention initiatives.     

Application of a predictive safety model in a combustion testing environment

A predictive safety model for accident prevention and system failure, called Continuous Hazard Tracking and Failure Prediction Methodology, is applied at the Marshall Space Flight Center's promoted combustion test chamber. It combines the underlying principles of work sampling, control charts, and multivariate analysis. The sampling is performed to observe the occurrence of conditions which may be becoming hazardous in a given system. These building blocks of hazards, which we have called dendritics, could result in an accident, system malfunction, or unacceptable risk conditions. The data collected is plotted to generate the appropriate control chart, which depends on the characteristics of the given system and the protection desired. Based on the pattern of the control chart, a system ‘under control’ is not disturbed whereas a system ‘out of control’ is investigated for potential conditions becoming hazardous. Then appropriate steps are taken to eliminate or control these conditions in order to maintain a desired safety status of the system. The continuously running characteristic of this model allows for the verification that the corrective measures taken to ameliorate the ‘out of control’ conditions were satisfactory or whether more proactive action is required. The results provided by the predictive model were validated with historical safety data.     

What-You-Look-For-Is-What-You-Find – The consequences of underlying accident models in eight accident investigation manuals

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know – or assume – about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause – or prevent – accidents, i.e., the accident “mechanisms”. Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models – for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the ‘What-You-Look-For-Is-What-You-Find’ or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called ‘What-You-Find-Is-What-You-Fix’ or WYFIWYF principle.     

Bifocal/varifocal spectacles, lighting and missed-step accidents

Good lighting and the correct use of spectacles generally improve vision and presumably reduce the risk of accidents. However, bifocal and varifocal spectacles can increase the risk of misjudging distances when negotiating underfoot hazards. In some circumstances, the portion of the lens used for close work may inadvertently be used where accurate judgement of distance is necessary. This paper reports results from two studies of patient interviews using the Merseyside Accident Information Model; the first a study of accidents which occurred during paid employment (1504 cases) and the second of 1326 accidents mainly in domestic and leisure activities. Underfoot accidents were identified by the first unforeseen event perceived by the patient. The relationship between underfoot events and the type of spectacles worn by the patient at the time of accident was analysed. In both studies there was a significant association between accidents where the first event was ‘missed edge of’ (step) and wearing bifocal/varifocal spectacles. Corporal movements reported in both studies indicated that ‘stepping down’ when wearing bifocal/varifocal spectacles, increased the risk of ‘missed edge’ accidents. In the work environment corporal movements associated with manual handling of loads also increased the risk of ‘missed edge’ accidents when wearing bifocal/varifocal spectacles.     

基于系统动力学的井喷事故仿真研究

为动态预测井喷事故发展过程,在分析导致井喷事故主要因素的基础上,结合系统动力学的相关原理,构建井喷事故系统仿真流图,并运用系统动力学仿真软件Vensim对井喷事故的整体流程进行仿真,实现了对油气井安全水平的动态监测和预警。结果表明:井喷事故的发生是由人为因素、管理因素、环境因素、设备因素和法律法规因素四大子系统的交叉耦合作用而导致整个油气井系统的安全水平低于井喷事故的安全临界点所造成的。     

Don't wait for accidents — possibilities to assess risk in traffic by applying the ‘Wiener Fahrprobe’

In Vienna during more than 10 years of research work a special traffic behaviour observation method has been developed, evaluated and applied by Risser et al. in the frame of many different traffic safety projects. Car drivers are accompanied by two observers who register not only errors in behaviour of drivers but also their communication and interaction with other road users. Malfunction of communication and interaction are judged as main sources for problems for danger in traffic. For example, if they lead to a bad traffic climate fealings of discomfort, anger and frustration will prevent cooperative actions of road users. Being able to recognize such negative or dangerous interaction patterns in time it seems to be easier to protect road users — most often the ‘unprotected’ ones — from getting involved in accidents. This contribution gives an impression about theory and practice of the observation method and shows results of different studies, where the method called ‘Wiener Fahrprobe’ has been applied. Furthermore it will show how the method and its results can be used in the frame of the European traffic (safety) research projects ‘PROMETHEUS’ and ‘DRIVE’. Till now no accident data exist in respect to new RTI systems. Therefore it seems to be important to have a sophisticated social-psychological method for testing the behaviour and interaction of road users in connection with these systems. This is a necessary prediction for deciding whether the systems are socially compatible or not.     

Making sense of invulnerability at work—a qualitative study of police drivers

This paper reports a qualitative study of 54 police drivers who were interviewed about their views on police driver training, driving strategies and their accident involvement. Study of the transcribed interviews indicated that officers constructed narratives of themselves as being highly aware of hazards presented by other road users and they used a variety of discursive devices to minimise their own culpability and attribute risk elsewhere. Rather than maintaining a straightforward ‘illusion of invulnerability’ they were formulating a ‘topography of risk’ in which they were responding to hazards presented by suspects or other road users. Their meticulously detailed accounts of the circumstances surrounding accidents serve to place them as knowledgeable and impartial participants and create a sense of expertise and authority. Training initiatives could profitably seek to challenge this ‘topography of risk’ and sense of authority so that drivers more fully appreciate the hazard they may present to themselves and the public.     

基于DEMATEL/ISM的深水井喷风险影响因素研究*

为提高深水井喷事故风险管理水平，提出研究深水井喷风险影响因素的分析方法。从技术、人员、环境和管理4个方面，识别深水井喷事故风险致因因素，建立深水井喷事故风险评价指标体系；运用矩阵决策实验室分析法（DEMATEL），研究风险因素之间的相互影响关系，计算不同风险因素的中心度和原因度，确定关键风险因素；进一步基于解释结构模型（ISM）划分不同影响因素的层次结构，分析风险因素之间的综合影响关系，建立深水井喷事故风险影响因素模型。结果表明:层级1为近邻致因，可直接导致井喷事故的发生；层级2~7为过渡致因，在风险传递过程中起到桥梁作用，对井喷事故的直接影响较小；而层级8则为本质致因，重视本质致因的改善有利于从根源上降低井喷事故的风险。研究结果可为深水井喷事故风险的预防和控制提供理论依据。     

点火因素对于重大井喷事故的影响分析

本文主要分析了高含硫气井点火时间的影响.首先分析国内某重大高含硫井喷事故的调查结果[1],其次采用大涡模拟方法对井喷气体扩散进行模拟,并将计算结果与现场实际调查结果进行对比.通过计算不同点火时间在事故中造成的灾难后果,得出点火时间对于灾难的影响.通过计算不同的气象条件下的扩散距离,提出15min的点火时间标准.     

Acute exposure to chemicals during ‘do-it-yourself’ activities: survey of enquiries to the Swedish Poisons Information Centre in 1996

In 1996 the Swedish Poisons Information Centre performed a follow-up study concerning poisonings related to ‘do-it-yourself’ activities. The study was supported by the National Institute of Public Health in Sweden. The objectives were to investigate and define monthly variations, route of exposure, type of products and, in particular, exposures to corrosives, age and sex groups, place of treatment, severity of symptoms, place of the accident, special risk products and risk situations. The Poisons Information Centre was contacted concerning 1609 cases, with a peak during the summer months. There was no or uncertain connection between exposure and symptoms in 117 cases. This means that 1492 cases were left to study. Inhalation and eye exposure were the predominant routes, followed by skin exposure and ingestion. Cleaning agents were the most common type of products involved. Of the 1492 cases included in the study 1033 were possible to follow up. Among these, 20–29 year olds and 30–39 year olds predominated, and there was a dominance for men. In total, 28% of those exposed were subject to medical attention, either in hospital or in outpatient clinics. According to the Poisoning Severity Score 78% had mild (grade 1) and 7% moderate (grade 2) symptoms. There were no severe intoxications and no deaths. Severity grade 2 occurred 3.6 times more often among those with exposures involving risk of corrosive damage than among others in the study population. Most accidents occurred in the home. Special risk products and risk situations were exposure to corrosive products, release of chlorine when mixing hypochlorite and acid, ‘fire-eating’, siphoning gasoline and diesel fuel, welding, and inhalation of carbon monoxide from exhaust gases. The Swedish Poisons Information Centre registered 1609 cases of poisoning accidents during ‘do-it-yourself’ activities, which means an average of four to five cases per day. Although this type of accidents is not uncommon, significant poisoning seems to be rare. Some special risk situations were identified.     

Lifting technique and abdominal belt usage: a biomechanical, physiological and subjective investigation

Some 10 male subjects carried out a repetitive lifting task for 15 min under four conditions on separate days. Subjects used either a squat lifting or a stoop lifting technique with or without an abdominal belt on each day. Measurements of spinal shrinkage, heart rate, perceived exertion and regional body pain were made under each condition. Although there was a significant difference in spinal shrinkage under all lifting conditions compared with shrinkage during 15 min of quiet standing (4.36 ± 2.24 vs. 1.13 ± 1.18 mm), there were no significant differences in shrinkage between the conditions. The subjects' heart rates were higher during the squat lift than the stoop lift (123 vs. 97 beats/min; p < 0.001). While the squat lift was perceived to be the safest lift by 90% of the subjects, 60% regarded this lift as the least preferred method (with or without the belt). Although all 10 subjects perceived the safest lifting method to involve the use of the belt, 50% rated the belt as their least preferred lifting condition. The findings cast doubt on the efficacy and acceptability of both abdominal belts and the practice of training workers in ‘safe’ lifting techniques and indicate that individual characteristics and preferences need to be considered when attempting to improve the safety of manual handling operations in industry.     

气田井喷硫化氢风洞模拟试验研究

为研究高含硫气田发生井喷事故后硫化氢的扩散运动规律,以重庆开县"12·23"井喷事故为研究对象,利用北京大学的2号环境风洞,制作了1∶2000的比例模型,利用乙烯和丙烯的混合气为示踪气体,采用长采样管方法测量浓度,首次在国内进行了井喷事故后硫化氢扩散的风洞试验,获得了低风速下(源处10m高风速为0.5m/s)N,NE,E,SE,S,SW,W,NW8个风向情况下的硫化氢浓度分布随时间的演化动画,定量地给出了各风向情况下硫化氢的最大浓度分布和各点的浓度时间序列,认为在低风速下,最大硫化氢浓度区域在撞山爬坡时出现,而爬过山坡后在背风区的硫化氢浓度会迅速降低。研究成果将为气田的井喷风险分级以及井喷事故后的应急处理提供参考。     

Assessing the reliability of diverse fault-tolerant software-based systems

We discuss a problem in the safety assessment of automatic control and protection systems. There is an increasing dependence on software for performing safety-critical functions, like the safety shut-down of dangerous plants. Software brings increased risk of design defects and thus systematic failures; redundancy with diversity between redundant channels is a possible defence. While diversity techniques can improve the dependability of software-based systems, they do not alleviate the difficulties of assessing whether such a system is safe enough for operation. We study this problem for a simple safety protection system consisting of two diverse channels performing the same function. The problem is evaluating its probability of failure in demand. Assuming failure independence between dangerous failures of the channels is unrealistic. One can instead use evidence from the observation of the whole system's behaviour under realistic test conditions. Standard inference procedures can then estimate system reliability, but they take no advantage of a system's fault-tolerant structure. We show how to extend these techniques to take account of fault tolerance by a conceptually straightforward application of Bayesian inference. Unfortunately, the method is computationally complex and requires the conceptually difficult step of specifying ‘prior’ distributions for the parameters of interest. This paper presents the correct inference procedure, exemplifies possible pitfalls in its application and clarifies some non-intuitive issues about reliability assessment for fault-tolerant software.     

Associations between driver training, determinants of risky driving behaviour and crash involvement

The core aim of the study is to examine associations between formal and informal practical driver training as well as driving experience on the one hand and young drivers’ safety attitudes, self-assessment of driving ability and self-reported driver behaviour on the other hand. An additional aim is to examine the associations between attitudes, self-assessment and behaviour on the one hand and crash involvement on the other hand. The results are based on a self-completion questionnaire survey conducted among a representative sample of Norwegian drivers aged 18–20 years (n = 1419). The results showed that there were small yet significant associations between driver training, on the one hand and traffic safety attitudes and risky driving behaviour on the other hand. The amount of formal driver training was negatively associated with the respondents’ evaluation of their driving skills; although the amount of lay instruction was positively associated with such self-evaluation. The results also showed that attitudes as well as self-assessment of driving ability were significantly associated with self-reported risk behaviour. This was especially true for attitudes related to rule violations. There was a strong association between crash involvement and exposure (measured as months holding a licence). Young novice drivers’ crash involvement seems stronger associated with driving skills (manifested as self-assessment of driving ability) than safety attitudes and self-reported driver behaviour. The consequences of the results for driver training and accident prevention are discussed.     

复杂山区地形高含硫气井安全防护距离研究

通过对国内某重大高含硫井喷事故进行调查,采用大涡模拟方法对3口井井喷气体扩散进行模拟,计算不同风速风向在事故中造成的灾难后果,得出地形因素对于灾难的影响。通过计算不同浓度下的扩散距离,提出分析及计算安全防护距离的方法。根据计算结果的综合分析可以看到,其浓度扩散的最远距离位于带状分布以内。     

基于Fluent的井喷失控有毒气体扩散模拟研究

井喷是石油工业生产中比较常见的一种事故,特别是高含硫气井井喷后会造成重大的人员伤亡,研究H2S气井井喷后毒气扩散规律具有重要现实意义.基于重庆开县“12·23”井喷事件的初始数据,建立了具有障碍物的含H2S气井井喷事故模型.运用Fluent软件对不同高度的障碍物、不同风速、不同井口释放速率三种工况下的含H2S气井井喷扩散情况进行了模拟研究,得出了三种工况下1000ppmH2S的最远扩散距离,为高含硫气井的应急疏散和安全规划提供参考.     

Accident risk and driver behaviour

The concepts of risk compensation and risk homeostasis are often used to describe or to explain drivers' tendencies to react to traffic system changes whether in roads, vehicles, weather conditions or in their own skills. However, it is important to distinguish between the general phenomenon and mechanisms underlying it. This paper first points out that to understand the basic mechanisms it is necessary to split accidents and exposure into smaller entities to arrive at basic units of exposure which also represent fundamental driver tasks. Risk-related behaviour should be considered at several hierarchical levels with different mechanisms to produce ‘risk compensation’. At a high level, trip decisions modify populations at risk in different circumstances, sometimes attenuating, sometimes amplifying population risk differences. At a low level of vehicle control and guidance in real dynamic traffic situations, simpler control mechanisms which result in behavioural adaptation can be identified. All these effects influence the end result of accident risk as separate mechanisms.