Factors in offshore planning that affect the risk for major accidents

The purpose of this paper is to systematically analyse a typical planning process in the offshore industry from the perspective of causes of major accidents, with the ultimate aim of identifying factors that affect the risk for major accidents occurring. We first study and describe a typical planning process for offshore oil and gas operations in Norway. Then we analyse a number of theories of major accidents, to see how the different theories and their explanations of causes and contributing factors can be of relevance for future plans and planning processes. Finally, we review accident investigations to search for evidence of how weaknesses in planning processes can contribute to major accidents through the above identified factors. Also, we try to identify any additional factors that have not been recognised through the theoretical review. This provides empirical support for the theoretical basis. Thirteen factors which directly or indirectly can influence the planning process causing a major accident potential are identified. These are exemplified through a review of investigation reports. The paper suggests that planning process should focus more on increasing quality in the plans at an early phase, with examples from incidents, and illustrate the relation between planning quality and potential for major accidents.     

Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models

The purpose of this paper is to reflect on accident causation models and accident investigation methods. Theories on accident causation and the modelling of accident mechanisms, as well as a number of methods for accident investigation have been developed and described in the literature. The evolution of accident causation models over time shows a shift from the sequence of events to the representation of the whole system. Respectively, the evolution of accident investigation methods over time reveals a gradual shift from searching for a single immediate cause, to the recognition of multiple causes. In order to evaluate the accident investigation methods, specific plausible requirements were established in order to verify that a specific accident investigation method fulfils the principles of a specific accident causation model or give evidence to the degree of alignment between them. Since different models approach accident causation in different ways, methods linked to these models provide fragmentary information regarding the accident. It is therefore expected that using a combination of model-method pairs could provide a more reliable platform for accident analysis.     

The critical re-action: Learning from accidents

How do organizations react and learn from accidents? The current paper deals with the justified necessity of acting upon, and learning from accidents. The aim is to discuss organizational dynamics and interplay, evoked and put into (re)action ‘after the fact’.The paper is part of an interview study that was designed to invite individuals to reflect back, and search for patterns in terms of how they interpret the learning impact of an accident, not just in terms of changes within their own organization that can be traced back to accidents, but for the sector as a whole. A presumption for this study was the importance to look at organizational interaction, i.e. how organizations act, affect, and speak with each other. In all 30 people from the rail and marine sector were interviewed with regard to (1) revealed changes in the aftermath of the accident, and (2) conditions for learning from accidents. Thematically, the interviews had two major accidents in Norway as a background theme: The high-speed craft MS Sleipner-accident (1999) and the railway accident at Åsta (2000).The paper reports and discusses key findings from the study, with a specific focus on the interplay between actors and parallel processes in the aftermaths of an accident.     

对建立第三方事故调查机制的探讨

事故调查的根本目的在于查找事故的可能原因并提出事故的预防措施,而事故调查的独立性对此根本目的起关键作用。我国安全生产管理体制建设起步较晚,事故管理机制发展不成熟,与国外先进事故调查理念相比,我国事故调查机制缺乏独立性的保障,主要表现在技术调查与司法调查未能分离、事故调查报告未能完全公开、事故调查的客观性保障不足,限制了我国事故调查水平的进一步提高。通过分析国外第三方事故调查的机制的优势并结合我国国情,从第三方事故调查的任务、人员编制、人员培训、责任与权利、法律义务等方面提出我国第三方事故调查机制的框架,并规划了构建第三方事故调查的三阶段进程及其主要内容,以逐步实现第三方事故调查的公正、客观、高效,更好地促进我国安全生产管理水平的提高。     

基于循证理论的事故隐患排查治理研究

为更好对企业进行事故隐患排查治理,本文从知识可及性和知识转移等角度,分析导致企业隐患排查治理差异的因素;然后提出基于循证理论的企业隐患排查治理方法并进行实证分析。研究表明:将循证理论引入到企业事故隐患排查治理中具有可行性和有效性。     

Rating accident models and investigation methodologies

This is a report of research to identify, rate, and rank accident models and accident investigation methodologies. Models and methodologies used in 17 selected government agencies were examined. The examination disclosed 14 accident models and 17 different accident investigation methodologies in those agencies. To determine their relative merit, evaluation criteria and a rating scheme were developed from user data, statutes, applications, and work products, and each model and methodology was rated. The ratings indicated significant differences in their relative merit. The highest rated model and methodology were tested to determine if the estimated ratings were supported by observable differences in actual performance and to compare investigative results against previously reported cases. Differences found prompted further examination of the benefits and problems that would result from implementation of the preferred model and methodology. Additional exploration of comparative performance measurement techniques disclosed further differences affecting the selection decisions. The models, methodologies, criteria, ratings, rankings, test results, and initial measurement findings are summarized in this report. Issues ranging from oversimplification to ethical questions were discovered during this work. The findings strongly suggest that significant accident investigation program changes should be considered in agencies and organizations using lower-ranked accident models or investigation methodologies and that a compelling need exists for more exhaustive research into accident model and accident investigation methodology selection decisions.     

Risk assessment and land-use planning regulations in France following the AZF disaster

After the disaster of AZF plant in Toulouse on 21 September 2001 (31 people killed, 3000 injured and 3 billion dollars of damage), France adopted a new law relative to safety reports and land-use planning on 30 July 2003. This law asks for the investigation of all representative scenarios and the assessment of their probabilities to demonstrate the acceptable level of safety of an industrial facility. Therefore significant changes were introduced in the way of doing risk analysis in France and some difficulties were found for the implementation of a probabilistic approach.This paper presents the new approach of risk analysis established by the French Ministry of the Environment, and particularly focuses on:? the benefits and limits of the semi-quantitative probabilistic assessment method;? the benefits and difficulties to use a quantitative probabilistic assessment method;? some learning from the risk analysis approaches carried out in the nuclear industry;? some discussion about the national matrix to appreciate the gravity of human consequences from an accident outside facilities.     

公安消防部队化学事故救援装备现状及需求分析

如何提高化学事故救援装备的整体水平,已成为当前公安消防部队面临的一个重要课题。对我国公安消防部队化学事故救援装备现状进行了研究,从消防员防护装备、化学事故抢险救援器材、化学事故救援车辆和灭火药剂等四个方面总结了消防部队化学事故救援装备建设的特点,重点分析了装备建设中存在的问题,并从实战救援的角度,提出了当前以及未来几年加强化学事故救援装备建设和发展的初步需求。     

On the analysis of hydrocarbon leaks in the Norwegian offshore industry

There have been several major offshore accidents in different offshore regions since 2005. In Norway there have been several very serious near-misses during the last ten years, several of which involving serious hydrocarbon leaks with catastrophic fire and explosion potential. All these severe occurrences demonstrate the importance of learning from major accident precursors in order to appraise the risk potential involved in critical offshore operations. This paper is based on analysis of about 175 hydrocarbon leaks in the period 2001–2010. Regulatory requirements in Norway are aimed at preventing as far as possible such occurrences during night time, but the analysis shows that this has been far from successful. The industry has for many years claimed that the maintenance personnel are the main group of employees involved in causing these leaks. This study has shown that leaks during the execution of maintenance and modification are less than half of the leaks, and that failures during the preparation for carrying out maintenance tasks are more frequent. Such preparations have often been conducted during night shift. The analysis gives a strong incentive to change this practice.     

A study of maintenance-related major accident cases in the 21st century

This paper is based on a review of 183 detailed, major accident investigation and analysis reports related to the handling, processing and storage of hydrocarbons and hazardous chemicals over a decade from 2000 to 2011. The reports cover technical, human and organizational factors. In this paper, the Work and Accident Process (WAP) classification scheme is applied to the accident reports with the intention of investigating to what extent maintenance has been a cause of major accidents and what maintenance-related causes have been the most frequent.The main objectives are: (1) to present more current overall statistics of maintenance-related major accidents, (2) to investigate the trend of maintenance-related major accidents over time, and (3) to investigate which maintenance-related major accident causes are the most frequent, requiring the most attention in the drive for improvement.The paper presents statistical analysis and interpretation of maintenance-related major accidents’ moving averages as well as data related to the types of facility, hazardous substances, major accidents and causes. This is based on a thorough review of accident investigation reports.It is found that out of 183 major accidents in the US and Europe, maintenance was linked to 80 (44%) and that the accident trend is decreasing. The results also show that “lack of barrier maintenance” (50%), “deficient design, organization and resource management” (85%) and “deficient planning/scheduling/fault diagnosis” (69%) are the most frequent causes in terms of the active accident process, the latent accident process and the work process respectively.     

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.     

一起塔式起重机冲顶事故的技术分析

某桥梁施工企业在对桥面施工时,塔式起重机空载起升发生冲顶事故,起升钢丝绳断裂,造成吊钩装置坠落砸死1人伤害事故.本文介绍了事故情况、事故勘查要点和模拟试验及相关计算方法,分析事故技术原因,提出预防事故的建议.     

国外安全生产事故独立调查机制的启示

事故调查的根本目的是为了找出导致事故发生的可能原因，进而提出防止类似事故再次发生的对策措施，而保持事故调查的独立性达成此根本目的起着至关重要的作用。从事故调查的独立性进行考虑，剖析了事故调查的法律制定、调查机构、经济支持、技术与司法调查分离、公众知情权等独立性表现，分析了我国目前事故调查的工作现状及存在的一些问题。对比分析了发达国家的事故调查机构的独立运作机制和特点。最后，针对上述问题，对我国安全生产事故独立调查机制的建立提出了一些建议。     

Survey-based analysis on the diffusion of evacuation advisory warnings during regional evacuations for accidents that release toxic vapors: A case study

This paper analyzes the diffusion of evacuation advisory warnings during regional evacuations for accidents that release toxic vapors. Investigations results on the propagation of evacuation advisory warnings in the ‘4.16’ chlorine release and the explosion accident at Chongqing Tianyuan Chemical Factory in China, and a comparison analysis of the evacuation notification process of six typical leakage accidents are presented in this paper. After conducting the evacuation notification investigation on the ‘4.16’ accident, in which 401 valid questionnaires were collected from people who should have evacuated during the accident, the methods and channels of the evacuation notification, the notification efficiency, and the actual response efficiency of the recipients after the issuing of the evacuation advisory warnings were analyzed. A comparison analysis of the evacuation notification process is performed by analyzing six typical leakage accidents, and basic principles of evacuation notification for a regional evacuation for toxic vapor release accidents are proposed.     

构建民用航空安全体系探讨

探讨民用航空安全的研究体系,构建以基础层、过程层以及阶段层为主的空间结构研究体系。通过对空间结构体系的研究,针对我国民用航空安全管理现状及未来,提出了航空事故预防理论、事故救援理论和安全保障理论体系及技术体系,使民用航空安全的研究具备系统性、理论性、标准性及可持续性。     

中国民航事故调查的客观公正探讨

为了防止同类事故重复发生、缓解社会和行业的猜忌和矛盾、提高中国在国际社会的形象和声誉,关注航空事故调查的客观公正已然迫切。从结果和过程两个方面探讨了事故调查中客观公正的内涵,分析了阻碍我国民航事故调查客观公正五个方面的影响因素,系统性提出了解决问题的途径。结果表明,从机构设置、规章建设、人员培养、工程能力、监督机制等方面加以完善,可以改进事故调查的结果客观和过程公正。     

Learning from accidents – What more do we need to know?

A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.     

事故调查分析方法与技术述评

根据事故的原因结果模型、过程模型、能量模型、逻辑树模型、SHE管理模型将事故调查分析技术方法归纳为5大类,介绍了广泛使用的事故调查分析技术方法的特点,并按一定的标准进行分析和比较。分析表明:每种方法都有其不同的应用领域和优缺点,应针对不同领域问题选用合适的分析方法,多种调查技术组合分析适用于复杂事故的调查;考虑事件次序及其影响因素的调查方法,便于提出预防事故再次发生和减少风险的建议,图表阐述有利于鉴别信息缺陷,并使调查组之间的沟通有力;笔者在调查过程中注重于非正常分析方法得出的结果,宜采用更为先进的事故分析技术方法以保证事故调查的客观性。     

论BS OHSAS18001：2007在事故分析中的应用

通过对国内外事故分析方法和先进安全管理经验的调研，本文根据BSOHSAS18001：2007标准核心要素的要求，对1984年印度博帕尔危险化学品泄漏事故从活动的策划、实施、检查、改进四个环节进行重新剖析。旨在找出事故发生的各方面原因、推进事先预防的科学、系统的安全管理。     

我国化工企业火灾爆炸事故统计分析及事故表征物探讨

从事故统计分析的角度,对2001—2006年我国化工企业发生事故的设备、事故介质进行分析;对设备发生事故的规律以及事故介质的分布特征进行总结;对在火灾爆炸事故调查中具有普遍代表性的事故表征物:爆炸抛射物、火灾爆炸容器、喷溅物和烟尘及烟熏痕迹的特征进行分析;从定量、半定量化的角度,对事故原因进行探讨,事故分析结果,对于从理论的角度分析事故原因、有效预防事故都具有重要的作用。