基于蒙特卡洛模拟的多米诺事故风险量化管理*

为降低危化品相关的化工事故造成的人员伤亡和财产损失，以化工多米诺事故为研究对象，探讨由初始事故引发1个或多个次生事故的连锁反应机理与风险评估方法。提出应用蒙特卡洛模拟对多米诺事故风险进行动态量化的方法，梳理化工多米诺事故风险的识别、分析、评定、处理全周期管理流程，并以1个天然气压气站为案例，验证基于蒙卡模拟的化工多米诺事故风险量化方法的有效性。结果表明:该方法可以更准确地对化工多米诺事故风险进行定量评估。多米诺事故风险全周期管理流程的梳理能够有效指导化工企业开展安全管理、事故预防等工作。     

基于行为安全理论的化工事故统计及分析

行为安全理论是事故分析和预防的理论和方法,应用基于行为安全理论的事故致因“2-4”模型对10起化工事故的直接、间接、根本、根源原因进行分析。结果表明:该模型是化工事故分析的有效方法。10起事故的直接原因主要为一线员工在涉及高温加热工艺、带压设备、有毒有害环境和动火作业中的违规违章操作,管理人员未建立或运行安全管理体系等不安全动作及不安全物态,且不安全物态与管理人员不安全行为有关;间接原因是一线员工缺乏岗位安全操作等知识,管理人员缺乏安全管理、技术等知识,导致其安全意识薄弱,养成不良的安全习惯;根本原因是组织安全教育等管理程序缺失和执行不力;根源原因是组织成员对安全的重要度等安全文化元素缺乏理解。     

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.     

基于“2-4模型”的化工生产事故原因分析

为进一步研究化工生产事故发生的原因,运用“2-4模型”对从安全管理网等网站收集的125起化工生产安全事故进行分析,结果表明对于事故的直接原因方面,作业人员的不安全动作主要表现在违规操作和无证上岗,管理人员的不安全动作主要表现在其工作不认真等方面,不安全物态最主要的是设备年久失修。对于事故的间接原因,主要表现在安全意识不够、安全知识不足、安全习惯不佳3方面。事故的根本原因则主要表现在缺乏安全培训等方面。为制定化工生产事故预防措施提供了依据。     

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.     

事故的组织管理原因文献综述

组织管理原因是一类重要的事故致因,对其全面了解才能有效预防事故。就组织管理原因对事故的作用机理、定义与内容、事故分析对其研究的现状进行文献综述。通过文献梳理发现,在一维链式事故模型和系统论为基础的事故模型中,组织管理原因对事故作用机理不同,但对事故发生都具有重要作用。现阶段研究中,组织管理原因没有统一的定义和内容,但具有的区别于其他事故致因的特性能得到共识。现阶段常见的事故分析模型对组织管理原因进行定量和定性分析,但仍需继续完善。最后,对组织管理原因的研究方向提出展望。     

基于HFACS-BN模型的危险化学品事故人因路径分析*

为提高危险化学品安全管理水平,收集我国134起以人为主因的危险化学品事故,构建危险化学品事故的HFACS-BN模型,并基于贝叶斯网络对危险化学品事故中的人因路径及各因素灵敏度进行分析。研究结果表明:行为违规是导致事故的最主要不安全行为;在复杂路径中,环境因素和操作者状态具有较高的灵敏度,与其相关的风险认知与处理不当是阻碍事故预防的关键因素;在非复杂路径中,操作者状态与运行计划不当具有较高的灵敏度,其所涉及的监督违规、组织过程和组织氛围,是导致危险化学品事故的根本起点,并可依此分析事故直接原因和间接原因;操作者状态在2种路径中均表现出高灵敏度,因此化工企业在人员管理上要加强关注职工状态,减少不安全行为的出现。     

From a survey on accidents in the downstream oil industry to the development of a detailed near-miss reporting system

A historical analysis with statistical investigation on accidental events in the oil industry from the beginning of the XX century till now, was performed in order to identify historical trend and go deeper into accident causes. The classification methodology was developed referring to three headings, namely plant/process, environment and organization and trying to go deeper into the analysis of the causes of the accidents reported and understand more of what is probably behind the accidents. The accident types and severity were studied, plotting the accumulated frequency–fatality curve for each item. In the subsequent applicative phase, we applied a similar classification approach to near-misses directly collected over nine years observation in a large downstream oil firm. The historical analysis was extended on each section of the refinery, paying a careful attention to all causes and consequences of the event. Data were structured for analyzing trends and identifying possible precursors of unwanted events. According to the step-by-step approach we try to evidence how immediate causes of a near-miss could be linked in some kind of causal chain to underlying causes that should be controlled by middle or higher management, or are part of the corporate safety culture.     

基于数据挖掘的化工生产事故致因主题抽取

为充分挖掘化工生产事故数据中的有效信息和潜在规律,提高对化工事故认知水平,针对某化工集团2010—2016年共1 578起事故数据,利用社会网络分析等方法揭示事故要素间的关联关系;运用潜在狄利克雷分配（LDA）模型进行事故聚类,并抽取到5个事故致因主题。研究结果表明:LDA主题模型等数据挖掘技术能有效挖掘大量事故数据中的潜在信息;5个事故致因主题中,4个涉及到人因或组织层面的缺陷;员工注意力不集中和现场风险管理不足这2个致因主题间具有较强相关性;员工注意力不集中、现场风险管理不足以及设备问题是导致事故发生的主要原因。     

基于灰色系统理论的煤矿人因事故关键因素分析

通过对煤矿人因失误事故致因因素进行分析,统计出相关的关键影响因素,运用灰色系统关联理论,根据国家安监局近十年煤矿事故统计数据,对煤矿人因失误事故影响类型进行了分析。以煤矿事故发生起数和事故死亡人数作为参考指标,计算和分析行为失误致因、个人违章、组织管理失误等十项主要与煤矿人因事故相关的灰色关联度,进而推算出这些因素的灰色关联序,确定出导致煤矿人因失误事故的关键因素,最终得到煤矿人因事故与关键影响因素之间的定量化分析结果。采用灰色关联理论对煤矿人因失误影响因素进行分析,能够很好地说明人因失误与各关键影响因素之间的权重关系,对煤矿人因事故主致因机理有更加深刻的理解,为煤矿事故的预防和控制提供重要的参考依据。     

The use of current risk analysis tools evaluated towards preventing external domino accidents

Risk analysis is an essential tool for company safety policy. Risk analysis consists of identifying and evaluating all possible risks. The efficiency of risk analysis tools depends on the rigueur of identifying and evaluating all possible risks. The diversity in risk analysis procedures is such that there are many appropriate techniques for any circumstance and the choice has become more a matter of taste. In this paper, we examine the risk analysis tools used by 24 chemical plants in Belgium, mainly located in the port of Antwerp, the second largest chemical cluster in the world after Houston, TX, USA. The aim of this paper is to identify the current practice in the chemical industry subject to European Seveso legislation and to examine how the present methods can be integrated to improve safety policy, especially towards preventing major accidents. Moreover, conclusions on the prevention of catastrophic external domino accidents involving several companies are formulated. This paper also gives impulse to investigating cross-company management implementations concerning external domino accident prevention.     

电气伤亡事故的主客体场景指标设计及统计规律

为合理预防控制电气伤亡事故的发生提供依据，通过检索查阅国内外相关文献和政府网站公布的电气伤亡事故和案例情况描述，选取105起典型电气伤亡事故案例进行统计与分析；针对电气伤亡事故涉及的主客体场景要素，对其进行筛选、分类、排序及指标设计，形成系统的电气伤亡事故指标体系；结合现实情况对统计结果进行原因分析，根据统计结果，得到电气伤亡事故发生的一般规律，据此提出安全管理中需要关注与重视之处，以此来预防电气伤亡事故的发生。     

考虑结构特性的化工事故关键致因网络分析*

为揭示化工事故发生机理,考虑事故链中因素的因果关系与事故网络的结构特性,基于复杂网络研究化工事故的关键致因因素,以事故案例中因素与结果为网络节点,因素间的因果关系为边,建立化工事故网络模型,分析网络中节点的度值、结构洞,构建化工事故凝聚网络,分析凝聚节点之间的因果关系。结果表明:在化工事故网络中存在8种致因因素,人的不安全行为与环境的不安全状态占比高达87.5%。通过结构洞分析可有效找出网络中具有较强影响力的潜在致因因素;通过凝聚网络分析,人的不安全行为致使设备的不安全状态与环境的不安全状态连接比例高达29%,存在显著的因果关系。     

基于HFACS的化工企业火灾爆炸事故人因分析*

为研究化工企业火灾爆炸事故的主要人为因素，以63起火灾爆炸事故案例为样本，构建人为因素分析与分类系统（HFACS）模型，进行火灾爆炸事故人为因素分类统计与分析，并利用卡方检验和比值比分析HFACS模型上下层级间的因果关系。结果表明:HFACS模型中上下层级人为因素间存在显著的因果关系，层级1中的“不良的组织氛围”及“组织过程漏洞”和层级2中“监督不充分”在HFACS模型中可以显著增大事故发生的可能性，且“资源管理漏洞”、“不良的组织氛围”、“组织过程漏洞”→“监督不充分”→“人员因素”→“违规”是引发事故的关键路径，并根据HFACS模型中引发事故的关键路径及其人为因素的主要表现形式，提出针对性的化工企业火灾爆炸事故预防措施。     

The significance of domino effect in chemical accidents

A historical survey was performed on 330 accidents involving domino effect, occurred in process/storage plants and in the transportation of hazardous materials; only accidents occurred after 1st-January-1961 have been considered. The main features – geographical location, type of accident, materials involved, origin and causes, consequences, domino sequences – were analyzed, with special consideration to the situation in the developing countries and compared to those from other previous surveys. Among the involved substances, LPG was the most frequent one, followed by liquid hydrocarbons. Process plants (38.5% of cases) and storage areas (33%) were the most common settings; 10.6% of past domino accidents occurred in transfer operations. The ratio between “two-step” and “three-step” domino accidents was found to be 6. A specific analysis of the accidents (84) occurred in the 21st century was performed, comparing them with the total set of accidents. Finally, a set of specific recommendations inferred from the results is provided.     

Analysis of the circumstances of accidents and impact of transformations on the accidents in a beverage delivery company

The aim of the study was to analyze the narratives in accident files to document the circumstances of accidents in a beverage delivery company, in particular, in regard with the activities performed at the time of the accident and the deviations reported. A second aim was to understand the impact of the transformations introduced by the company on accident patterns. Narrative material from 546 files covering a 7-year period was analyzed. Special attention was given to collecting information on the activities conducted at the time of the accident, including location, foot support base, operation, and material involved. The analysis allowed specifying elements that have good potential for improving handling situations and decreasing accident risks. Three categories of deviation were analyzed: situations reported as particular or difficult, unforeseen events, and dysfunction reported in the activity itself. Results show that several external factors play an important role in the occurrence of accidents. Most of these factors are beyond risk analysis of handling situations. The impact of the transformations on the number, seriousness, and causes of accidents was dramatic. Analysis shows that current investigative risk tools are insufficient in helping management predict how decisions will affect safety. The discussion situates the results within the various theories of musculoskeletal mechanisms of injury.     

跨界水污染事故危害实时判定方法的建立

针对跨界突发性水污染事故特点,基于压力-状态-响应模型(PSR)构建了跨界水污染事故预警指标体系,并确立了各指标的分级标准。采用AHP(层次分析法)-综合模糊评价法建立了事故危害实时判定方法。     

Applying linear analysis methods to GIS-supported procedures for preventing traffic accidents: Case study of Konya

This study develops methods to obtain maps to determine traffic Hot Spots in Konya, Turkey, by applying linear analysis supported by Geographical Information Systems (GIS).Hot Spot analysis is known method but the study differs from former researches at the point of determining of risky zones, classification and illustration of them on the maps with the different accident parameters. The aim is not to contribute another Hot Spot analysis using a number of statistical methods, but to determine the Highest Potential Hot Spots (HPHS), which are inter-sectional clusters, and to use different parameters, such as number of accidents, number of fatalities and injured, and number of accidents with only financial loss.In addition, apart from classical illustrational techniques, Hot Pieces (HPCS) on roads divided into 1 km segments are shown by their grading according to their numerical values. Hence, thematic illustration distinguishes them from others.Another aspect of this study is that, besides investigation of Hot Spots by means of data of accidents of previous years’, Probable Hot Spots (PRHS) were illustrated and highly potential Hot Spots were determined. These latter are candidates for Hot Spots in the near future. Thus, premature accidents can be anticipated easily.The main intention of this study is to emphasize the importance of using criteria, other than total accident number, to illustrate intersection Hot Spots and to constitute a model of accident severity and variety. It is anticipated that the results obtained from highway accidents data will guide improvement of the route segments.     

Exploring the management of industrial hazardous waste based on recent accidents

Three accidents occurred in east China's Jiangsu Province in March and April 2019. These accidents sounded the safety alarm for the management of industrial hazardous waste in the “heavy industry” era. This paper explored the internal causes of these accidents through the current situation of the generation, disposal and comprehensive utilization of industrial hazardous waste in China. The results of the analysis showed that the enterprises management systems of hazardous waste had serious problems at the current stage, leading to many potential risks. The chief problem resided in the fact that these systems failed to take full account of safety and environmental protection. Finally, suggestions for improvement were proposed concerning the above problems.