Challenges and proposals for managing major accident risk through the planning process

Major accidents are characterized by complex causal patterns with many factors influencing the occurrence of such accidents. The causes can be found not just in the execution of the work, but also in the preparations and planning before performing the work. In this paper, we have identified a set of challenges related to planning that may influence major accident risk. The basis is theoretical and partly empirical. The theoretical part is from a study of major accident theories. The empirical part includes studies of investigation reports, interviews and a workshop. The challenges identified can be grouped into four main topics including inadequate plan, inadequate planning, inadequate shared overview and understanding and late risk identification. The challenges have subsequently been addressed through a set of proposed improvements, which are aimed at improving the planning process to better manage major accident risk.     

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.     

Allocation of performance shaping factors in the risk assessment of an offshore installation

Offshore oil production is one of the most important human productive activities. There are many risks associated with the process of constructing a subsea well, pumping oil to the platform, and transporting it to refineries via underwater pipes or oil tankers. All actions performed by workers in those operations are influenced by specific working conditions, involving the use of complex systems. Contextual factors such as high noise, low and high temperatures and hazardous chemicals are considered to be contributors to unsafe human actions in accident analysis and also give a basis for assessing human factors in safety analysis. Some failure modes are particularly dangerous and can result in severe accidents and damage to humans, the environment and material assets. Fires and explosions on oil rigs are some of the most devastating types of offshore accidents and can result in long-term consequences. The most typical root causes related to accidents include equipment failure, human error, environmental factors, work organization, training and, communication, among others. The principal objective of this study is to propose a methodological framework to identify the factors that affect the performance of operators of an offshore unit for oil processing and treatment. In this phase, an ergonomics approach based on operators' work analysis is used as a supporting tool. After identification of factors that affect the performance of operators, a decision-making model based on AHP (analytic hierarchy process) is applied to rank and weight the principal performance shaping factors (PSFs) that influence safe operations. The next step involves the use of the SHELLO model to group the main PSFs in elements named software, hardware, environment, liveware and organization. In the last phase, a relevant accident that occurred aboard a floating production storage and offloading (FPSO) vessel is analyzed. The allocation process of the factors that affect the operator's performance in risk assessment was developed through fuzzy logic and the ISO 17776 standard.     

基于最优尺度Logit模型的交通事故形态致因分析

为剖析典型交通事故形态致因,在利用最优尺度分析法诊断交通事故形态致因共线性的基础上,筛选关键影响因素,构建无序多分类Logit交通事故致因模型并对模型进行参数标定,并选择100个交通事故样本对模型进行精度验证,该模型相对误差仅为4.0％,能够较为准确地分析典型交通事故形态致因.研究结果表明:路侧及中央隔离设施、照明是事...     

基于STAMP模型的丰城坍塌事故原因分析

为了系统地分析建筑施工事故原因、有效预防同类事故,运用STAMP模型从控制角度详细分析了一起特别重大坍塌事故,分别从物理过程及环境因素、基层操作原因以及管理层原因3方面分析了导致事故的控制缺陷,并且根据分析结果,提出事故控制措施及建议。结果表明:STAMP模型不仅可以分析各个层级的原因,还可以找出层级之间以及层级内不同组织之间的交互影响原因;建设方、施工方、监理方以及承包方对项目管理内容交叉与重叠,且沟通与协调缺失是导致错误决策和不恰当控制动作产生的主要因素;基层不安全控制动作直接导致事故发生,但取决于管理因素,管理层的原因是预防同类事故的重点。     

基于动态风险平衡的海洋平台事故连锁风险研究

针对海洋平台事故风险特点,提出动态风险平衡概念,以此建立事故动力模型,并将该模型运用到墨西哥湾"深水地平线"井喷事故。动态风险平衡表征事故动力与事故阻力之间的动态平衡状态,具有动态性和暂时稳定性。事故动力模型以海洋平台可能发生的重大事故为研究对象,从工艺、技术和管理等角度分析事故可能致因和事故发展可能影响因素。该模型首先分析对象的初始事故动力,建立事故连锁风险图,然后计算初始动力发生情况下,传递动力和传递阻力的概率分布,最后提出相应风险控制措施。实例分析表明,基于动态风险平衡建立的事故动力模型能有效分析海洋平台事故连锁风险。     

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.     

重大事故应急预案评审技术研究

重大事故应急预案评审是重大事故应急预案管理中的一个重要环节，为了进一步提高应急预案的针对性、实用性和可操作性，完善重大事故应急预案体系，应进行重大事故应急预案的评审。本文主要介绍重大事故应急预案评审的目的及原则，重大事故应急预案评审应遵循的基本准则，以及重大事故应急预案评审的基本方法和内容要求。     

海上平台事故应急演练评估方法研究

针对目前我国海上平台事故应急演练缺乏有效评估体系的现状,结合海上平台事故应急演练典型示例,运用“事故应急指挥系统（ICS）”基本理念,对整个应急演练过程进行系统分析,从人员安全、资产保护、环境保护、企业声誉等4个方面搭建应急演练评估框架。采用层次分析法构建计算模型,合理设置评估指标权重,最终建立了1套具有海洋石油行业特点的应急演练评估指标体系,并选取国内1个海上平台事故应急演练进行了应用分析。研究结果表明:构建的演练评估指标体系及评估方法能较好地应用于海上平台事故应急演练过程,进而在演练评估结果的基础上,实现应急演练的持续改进。     

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。     

基于多米诺效应的输油管道重大事故后果分析

针对近年来不断发生的输油管道重大事故,引入多米诺效应理论分析输油管道事故后果。首先依据多米诺效应机理,建立输油管道重大事故多米诺效应模型,然后采用PHAST软件确定初始事故影响范围,运用设备损坏概率和人员伤亡概率模型计算初始事故对周围设备和个体的影响概率,从而可以从设备损坏、人员伤亡和事故影响范围三个方面定量分析输油管道的事故后果。研究结果对制定输油管道重大事故应急抢险方案,避免事故影响范围进一步扩大具有理论指导意义。     

基于生物免疫的化工园区事故发生机理研究

基于生物免疫系统抵御疾病(抗原)的原理,从事故致因、事故演化过程和事故发展规律出发,分析化工园区事故发生机理。结果表明,安全生产免疫系统的免疫力持续低于抗原系统的抗原强度是化工园区事故发生的根本原因;化工园区事故演化过程包括潜伏期、萌芽期、暴露期和恢复期,各个时期的形成是安全生产系统的免疫力和抗原系统的抗原强度之间的差异决定的;化工园区事故发生具有周期性,每个事故发展周期内都包含安全生产免疫系统→免疫力过低的免疫因子→事故触发免疫因子和安全生产抗原系统→抗原强度过大的抗原因子→事故触发抗原因子的变化过程。     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

Applicability of accident analysis methods to Chinese construction accidents

IntroductionIt is necessary to clearly understand construction accidents for preventing a rise in Chinese construction accidents and deaths. Better analysis methods are required for Chinese construction sector accidents.MethodsChoosing and analyzing a typical construction accident based on four popular contemporary accident causation models: STAMP, AcciMap, HFACS, and the 2-4 Model. Then we evaluated the models' applicability to construction accidents, including their usability, reliability, and validity.ResultsSTAMP addressed how complexity within the accident system influenced the accident development, and its output makes the responsibilities clearer for the accident. AcciMap described the entire system's failure, the entire accident's trajectory, and the relationship between them. AcciMap showed that the accident was a dynamic developing process, and this method has a high usability. The taxonomic nature of HFACS is an important feature that provides it with a high reliability. In the accident reviewed here, we found that poor management was a critical factor rather than the individual factor in the accident. The 2-4 Model provided detailed causes of the accident and established the relationship among the accident causes, the safety management system, and the safety culture. It also avoided capturing all of the complexity in the large sociotechnical system and revealed a dynamic analysis and developing process. We confirmed that it has a high usability and validity. Therefore, the 2-4Model is recommended for future Chinese construction accident analysis efforts.Practical ApplicationsThe study provides a useful, reliable, and effective analysis method for Chinese construction accidents.     

基于危化品事故案例的决策规则提取算法研究*

为充分解析文本形式的危化品事故案例,探讨事故类型与大量事故致因间的因果关联,从化工行业入手,通过扎根理论对175起危化品事故案例进行因素提取,共确定5个子系统、19个因素、80个子因素,提出基于事故生命周期的事故致因框架;在此基础上,提出改进的Gra Apriori算法,以解决经典的Apriori无法考虑属性类别关系的问题,最终获得14个以事故类型为决策属性的规则。结果表明:这些规则从不同事故阶段细致地剖析了危化品事故所遵循的规律,重现事故的演变过程,为危化品事故风险管理提供准确可靠的预防策略和决策支持。     

Industrial accidents in spray dryer plants for dairy products in Europe

Despite the fact that the information about past accidents is an integral part of accident prevention, the information about industrial accidents is not commonly available in food and agricultural sectors. Spray dryer plants for dairy products are not an exception. The aim of this paper is the creation of the representative database for industrial spray drying accidents in order to identify their major causes. The paper is divided into 8 chapters. The first two chapters deal with the general information about technology of spray drying of dairy products. The third chapter provides the outputs from the authors' database containing records of 25 accidents in milk drying facilities in Europe. These accidents took place between 1999 and 2019 in six European countries. Based on the accident database, the most common causes of accidents were identified. Processes that can cause a fire, an explosion, or damage to environment are described in the fourth, fifth and sixth chapter. The seventh chapter deals with process, technical and organizational measures; these were discussed using literature research and the results of the accident database. The eighth chapter is the conclusion with a focus on further improvement of process safety through newly developed protective tools.     

Multilevel learning from accidents – Case studies in transport

Substantial efforts have been devoted to accident investigations, but do we gain a reasonable benefit from these efforts? The current study explores multilevel (individual, company, sector/trade, authorities) learning from major accidents and serious incidents. Specifically, this involves identifying a set of learning criteria, i.e. factors or indicators that potentially support and contribute to multilevel learning processes. Identifying such criteria is based on: (i) the accident investigation process, (ii) the follow-up efforts, and (iii) contextual aspects. Three Norwegian accident investigations in transportation (aviation, marine, rail) represent the empirical foundation for the study. Learning criteria were derived by both document analyses from the accidents (e.g. investigation reports) and literature reviews on organizational learning. These were the basis for a workshop regarding learning from accidents, with participants from the aviation, marine, and rail sector. Key results from this workshop are presented and discussed. The study concludes by presenting a set of criteria for learning from accidents.     

Method for identifying contributors to chemical process accidents

The paper presents a new method for identifying contributors to chemical process accidents by exploiting knowledge on causes of past accident cases. Accident reports from the Failure Knowledge Database were analyzed and utilized for hazard identification. The accident information gathered was used as a basis to develop an accidents ranking and points-to-look-for approach for the safe design and operation of chemical process equipment. In the method, accident contributors including technical, design and operation errors of major process equipment types and piping are identified. The method is applicable throughout the process lifecycle, even for process changes in the early design stages. The Bhopal tragedy is used as a case study to demonstrate and test the method. The proposed method can predict on average up to 85% of accident causes and design and operation errors.     

我国涉水旅游安全事故的时空分布及成因研究*

为探究我国涉水旅游安全事故的时空分布特征及事故成因机制，提升旅游目的地安全管理水平。以2010—2018年我国旅行社责任险平台的1 752起涉水旅游安全事故保险案例为数据源，利用社会网络分析方法，并结合Ucinet可视化分析技术构建事故时空分布模型及事故成因模型。结果表明:在时空分布规律上，我国涉水旅游安全事故具有较强的时间导向性和空间异质性；在事故成因规律上，游览环境因素和游客自身因素是导致事故发生的主要原因，同时不同影响因素之间具有较强的关联性。研究结果有助于深化旅游者及安全管理人员对涉水旅游安全风险认知，为相关旅游目的地安全管理工作提供理论依据。     

矿工不安全行为研究综述

我国30年间煤矿重大事故统计数据显示,人因事故占到事故总数的90%以上。为 了更好地评述近16年间有关煤矿人因事故研究的成果,运用统计分析法,对文献计量中 关键词频率较高的事故、原因、测量方法及措施四个方面进行了综述。研究发现,矿工 的不安全行为是各类事故产生的直接原因,且矿工的行为失误占主要因素。不安全行为 的研究热点体现在对其产生原因的分析上,包括矿工的心理及生理因素分析、设备因素 、文化因素、环境因素及管理因素。在对不安全行为的防范措施分析中,主要是依据其 产生的原因进行针对性的管控。说明矿工不安全行为的研究已自成体系,并越来越向系 统化和综合化方向发展,这对降低矿难事故的发生有着深远意义。