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.     

Historical analysis of accidents in seaports

A study has been carried out of accidents occurring in seaports. A total of 471 accidents occurring between the beginning of the twentieth century and October 2002 have been analysed. The results obtained show a significant increase in the frequency of accidents over time: 83% of the accidents occurred in the last 20 years and 59% in the past decade. The most frequent accidents were releases (51%), followed by fires (29%), explosions (17%) and gas clouds (3%). More than half the accidents occurred during transport: loading/unloading operations, storage and process plants also make a large contribution to the total. The various causes of the accidents have also been analysed, as have the type of substance involved and the consequences for the population (number of people killed, injured and evacuated). Finally, some conclusions are drawn concerning the need to improve certain safety measures in ports.     

BLEVE: The case of water and a historical survey

After a short update of the current more accepted definition of BLEVE, the special features of water BLEVEs are analyzed. The stronger overpressure wave generated in the case of water as compared to that of other substances is justified in terms of volume change. Through a comparison with liquefied pressurized propane, three possibilities are analyzed: the simultaneous contribution of both the liquid and the preexisting vapor, the contribution of the liquid flash vaporization, and the contribution of the pre-existing vapor. Also a historical survey on a set of 202 BLEVE accidents –the largest sample of BLEVE accidents surveyed until now– is presented. LPG was the most common substances in this set of accidents. However, water and LNG (11% of water and 4% of LNG in the studied cases) have also been involved. Impact failure (44.8%) and human factor (30.3%) were the most common causes of BLEVEs. Transport, storage, process plants, and transfer were the activities in which more accidents occurred.     

永安火电厂人为继电保护不正确动作事故分析及预防对策

通过历年来永安火电厂继电保护人为不正确动作事故情况,进行原因分析,并采取一系列措施,取得了较好效果。     

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.     

Carbon dioxide pipelines: A statistical analysis of historical accidents

Carbon dioxide pipeline is an essential carrier in carbon capture, utilization, and storage (CCUS). Statistically revealing the accident rate and risk of carbon dioxide pipelines is conducive to integrity management. Based on 112 accident records collected from Pipeline & Hazardous Materials Safety Administration, this work analyzes the frequency, rate, and risk of accidents. In addition, the impact of relevant factors on risk is further discussed. Some primary conclusions are as follows: (1) For carbon dioxide pipelines, the leak is the leading form of accident. Most carbon emissions are generated in the form of leakage, but economic losses are mainly generated in other forms. (2) The pipelines that have been in service for 0–10 years have the highest frequency of accidents and the highest proportion of carbon emissions, but the pipelines that have been in service for 11–20 years have caused the most economic losses. (3) Among the accident causes, the number of accidents caused by equipment failure is the highest, while the economic loss caused by natural force damage is the highest, and the carbon emission caused by material failure is the highest.     

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.     

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.     

Analysis of equipment failures as contributors to chemical process accidents

A database study of chemical process accident cases was carried out. The objective of the study is was to identify the reasons for equipment based accidents. The most frequent accident causing equipment were piping (25%), reactors and storage tanks (both 14%) and process vessels (10% of equipment accidents). The six most accident-prone equipment is process related involve nearly 80% of accidents.78% of equipment accident contributors are technically oriented including design and human/technical interface faults. Purely human and organizational reasons are the most common accident contributors for storage tanks (33%), piping (18%) and heat transfer equipment (16% of causes). For other equipment the technical accident causes are most common.The accident contributors were divided to main and sub-contributors. On average process equipment failures have 2.2 contributors. The contributors, which frequent and act often as main contributors, should be focused. These risky contributors were identified for several equipment types. Also a deeper analysis of the accident causes and their interconnections was made. Based on the analysis a checklist of main risk factors was created for hazard identification on different types of equipment.     

Revising HFACS for SMEs in the chemical industry: HFACS-CSMEs

Chemical accidents have occurred frequently in recent years, and most have occurred in small and medium-sized enterprises (SMEs). SMEs in the chemical industry face greater challenges than large enterprises with regard to accident prevention. However, SMEs have been unable to effectively learn from accidents due to the limited resources. The accident causation model is an effective tool to help the analyst learn from accidents. As a systematic accident causation model, the causes classification in the human factors analysis and classification system (HFACS) can match the characteristics of SMEs, but the cause of chemical accidents can be ineffectively identified by HFACS. In this study, HFACS was revised for the SMEs in the chemical industry, mainly consisting of three parts. First, based on the definition of factors in the original HFACS, the extended HFACS framework was obtained, which include 78 manifestations with the characteristics of the chemical accidents. Second, 101 accidents occurring in a SME in the chemical industry from 2012 to 2016 were analyzed though the extended HFACS framework. Finally, a new model, known as the HFACS-CSMEs, was obtained by further revising the manifestations and causes classification according to the statistical results of the accident analysis. HFACS-CSMEs consists of 15 cause factors and 56 manifestations, which can effectually identify and distinguish the causes in chemical accidents. Moreover, the easy-to-understand and statistically acceptable features of HFACS-CSMEs can cater to the SMEs regarding accident analysis. HFACS-CSMEs solves the problem that HFACS cannot be directly applied to chemical accidents and provides new ideas about preventing accidents in SMEs in the chemical industry.     

Characteristics of direct causes and human factors in major gas explosion accidents in Chinese coal mines: Case study spanning the years 1980–2010

Major accidents from gas explosions have a high rate of occurrence in Chinese coal mines. The frequency of major gas explosion accidents between the years 1980–2000, and the years 2001–2010 was reviewed. Case studies were also compared. The study of direct causes indicates that during the period 2001–2010 the proportion of accidents caused by deliberate violation was reduced by 31.13% compared with data from 1980 to 2000. However the proportion of accidents caused by mismanagement rose by 32.38% during this period. Direct causes of high occurrence rate accidents include deliberate violations such as illegal blasting, conducting maintenance with the power on, and mismanagement behaviors such as chaotic electromechanical management and chaotic ventilation management. The study of environmental characteristics shows that the proportion of accidents occurring in the heading faces increased by 27.18%. The study of human factors indicates that deliberate violation behaviors showed a high utility–high cost factor. Mismanagement behaviors showed strong correlation with responsibility awareness and weak correlation with technological ability.     

Agricultural accidents in north eastern region of India

An investigation was conducted to characterize the agricultural accidents, their magnitude, causes, severity and economic consequences in one of the states of north eastern region of India, Arunachal Pradesh. The accident data for 6 years between years 2000 and 2005 were collected by conducting a survey and personal interview of the victims in 42 selected villages of 4 districts. Agricultural accident incident rate was 6.39 per 1000 workers/year. All the accidents were non-fatal. Farm implement-related accidents accounted for 40% of the accidents. Slashing of shrubs accounted for one-third of the accidents causing cut and hit injuries of moderate severity. Twenty-five per cent of the accidents occurred on the way to or from the field leading to severe or serious injuries. Two-third of the accidents occurred within 4 h of start of work. Thirty-three per cent of the victims were 40–49 years of age. Based on the analysis, both passive and active measures have been suggested to minimize or prevent the occurrence of agricultural accidents.     

Fatal workplace accidents in outsourced operations in the manufacturing industry

Several studies have indicated that outsourcing increases the risk of accidents and presented some explanations for this phenomenon. For example, higher accident proneness of external employees has been presented, but the common causes of accidents have not been reviewed in depth. This paper provides information about typical accidents, the contributing factors, and preventive measures of fatal occupational accidents that occurred in outsourced manufacturing tasks. This paper also compares whether these factors differ from accidents that occurred when tasks were performed in-house in the manufacturing industry. The focus is on operations executed in the factory area for or by an organization operating in the manufacturing business. The accident analysis is based on information gathered from accident reports for fatal workplace accidents that occurred in Finland during 1999–2008. At outsourced operations in manufacturing, accidents occur most commonly when installations or work preparations are being performed. According to the reports, dangerous work practices and insufficient hazard identification most frequently contributed to accidents. In order to prevent typical accidents, e.g., occupational instructional and guidance, hazard identification, work practices, supervision, and task planning should be improved. Statistical differences between outsourced and in-house operations were also found, mainly within the contributing factors. Therefore, the safety of outsourced manufacturing operations should be considered in detail in order to prevent accidents and ensure occupational safety also when operated with other performers.     

Fired equipment combustion chamber accidents: A historical survey

A historical analysis was carried out on 189 accidents that occurred in gas and oil fuel fired equipment. The variation of frequency as a function of time, the main causes leading to a fire or an explosion, as well as the consequences of the accidents were studied. Explosion was the most frequent accident, followed by fire; in a few cases the final outcome was a release. Accidents in gas fired combustion equipment were significantly more frequent than those in the liquid fired ones. The main causes were tube rupture and/or error in ignition/reignition sequences, followed by loss of flame in the combustion chamber and, with a minor frequency, entrance of non-expected fuel and presence of non-combusted materials. The consequences on people were much more important in case of explosions than in case of fires. Even though the equipment involving combustion chambers can be considered essentially safe, this historical analysis has shown that accidents continue to occur with certain frequency because the number of existing units is quite high and the possibility of human error during its operation and maintenance is still significant.     

Technical note on the contribution of sociotechnical factors to accidents notified to MARS

Not least due to the new `Seveso II Directive', Safety Management Systems (SMS) have become a hot topic in the `safety business'. To reveal in a structured way how organisations manage safety at their plants, classification schemes can be applied to identify plant-specific precautions on different hierarchical levels, e.g. from `top level' equipment reliability to `bottom level' safety climate. In this paper, such a model is used to classify the accidents reported to the European Commission's Major Accident Reporting System (MARS) according to the levels on which failures resulting in actual accidents did occur, and to cross-compare the levels of causation with the overall `severity' of the accidents. It is analytically shown that ∼66% of the accidents are caused by latent SMS failures, and that especially those accidents which are caused by failures in the `deepest layers of latency' have significantly higher `severities' than accidents caused by more `immediate' failures. In other words, it is quite likely that the deeper the underlying causes of an accident, the more `severe' its consequences. Implementing SMS is thus worth the effort.     

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.     

Major accidents in process industries and an analysis of causes and consequences

This paper briefly recapitulates some of the major accidents in chemical process industries which occurred during 1926–1997. These case studies have been analysed with a view to understand the damage potential of various types of accidents, and the common causes or errors which have led to disasters. An analysis of different types of accidental events such as fire, explosion and toxic release has also been done to assess the damage potential of such events. It is revealed that vapour cloud explosion (VCE) poses the greatest risk of damage. The study highlights the need for risk assessment in chemical process industries.     

危化品储罐区多灾种耦合效应风险分析

基于危化品储罐区内发生的多米诺效应，以单灾种引发的多米诺事故研究为基础，根据物理学中的触发器原理解释多灾种耦合引发储罐区其他罐体失效的场景，并提出基于物理学理论的多灾种耦合效应模型；基于一储罐区实例分别建立在火灾、爆炸情况下罐区的灾害扩展网络图，并通过无量纲化处理得到综合灾害扩展网络图；分析储罐区在多储罐受灾情况下的灾害扩展情形，得到当D1，D2发生灾害时，D4，D5灾害扩展概率最大；当D1，D8发生灾害时，D4灾害扩展概率最大，建立了多灾种耦合效应的关联图。研究结果对化工园区多灾种耦合的后果预测评估具有指导意义，有助于减少危化品储罐区多米诺效应的发生以及强化危化品储存的安全基础。     

1992-2017年近25年硫化氢中毒事故统计分析研究

为系统掌握硫化氢中毒事故特征及规律,预防事故与灾害发生,本文统计分析了1992年1月至2017年12月间275起硫化氢中毒事故发生时间、区域、行业类别、企业经济类型及事故原因等。结果表明:1992—2015年我国硫化氢中毒事故总起数和死亡人数呈明显增长趋势,2005—2017年事故总起数和死亡人数呈下降趋势;硫化氢中毒事故中一般事故占45.82%,较大事故占53.45%;5、6、7、8月份是事故的高发月份;浙江、山东、上海、江苏、新疆等省份是事故多发区;事故发生主要集中在制造业行业,占事故总数的59%;主要事故经济类型是有限责任公司,占事故总数的50%;29.8%的事故因违反操作规程或劳动纪律导致,15.6%的事故因教育培训不够、缺乏安全操作知识导致。     

基于特征源与环境特征的中国煤矿重大事故研究

通过对中国煤矿1980—2000年20年间发生的重大事故的分析显示,在中国煤矿重大事故的直接原因中,人因事故(含故意违章、管理失误、设计缺陷)所占比率高达97.67%以上,从而使人们对中国煤矿重大事故的致因有了新的认识。笔者从重大事故发生的特征源与环境特征角度,对中国煤矿重大事故及事故中的不安全行为进行研究,无论在理论层面,还是实践层面,对遏止煤矿重大事故都极具价值,意义重大。