What can the trove of CSB incident investigations teach us? A detailed analysis of information characteristics among chemical process incidents investigated by the CSB

Understanding the commonalities among previous chemical process incidents can help mitigate recurring incidents in the chemical process industry and will be useful background knowledge for designers intending to foster inherent safety. The U.S. Chemical Safety and Hazard Investigation Board (CSB) reports provide detailed and vital incident information that can be used to identify possible commonalities. This study aims to develop a systematic approach for extracting data from the CSB reports with the objective of establishing these commonalities. Data were extracted based on three categories: attributed incident causes, scenarios, and consequences. Seventeen causal factors were classified as chemical indicators or process indicators. Twelve chemical indicators are associated with the hazards of the chemicals involved in the incidents, whereas five process indicators account for the hazards presented by process conditions at the time of the incident. Seven scenario factors represent incident sequences, equipment types, operating modes, process units, domino effects, detonation likelihood for explosion incidents, and population densities. Finally, three consequence factors were selected based on types of chemical incidents, casualties, population densities, and economic losses. Data from 87 CSB reports covering 94 incidents were extracted and analyzed according to the proposed approach. Based on these findings, the study proposes guidelines for future collection of information to provide valuable resources for prediction and risk reduction of future incidents.     

On the need for system-theoretic hazard analysis in the process industries

Most process hazard analysis (PHA) studies today are conducted using traditional methods such as the hazard and operability study (HAZOP). Traditional methods are based on a chain-of-events model of accident causality. Current models of accident causality are based on systems theory and provide a more complete representation of the causal factors involved in accidents. Consequently, it is logical to expect that PHA methods should reflect these models, that is, system-theoretic hazard analysis (STHA) should be used. Indeed, system-theoretic process analysis (STPA) has been developed as such a method. STPA has been used in a variety of industries but, at this time, it has not gained acceptance by the process industries. This article explores the reasons for this situation. Expectations for PHA in the process industries are examined and issues for the application of STPA in the process industries are discussed. It is concluded that a variety of matters must be addressed before STPA can be considered as a viable PHA method for the process industries and the case for the use of STHA in the process industries is not yet proven.     

Improved management practice and process hazard analysis techniques for minimizing likelihood of process safety incidents in Taiwan

In Taiwan, process safety accidents often occur despite the prior implementation of process hazard analysis (PHA). One of the main reasons for this is the poor quality of the PHA process; with the main hazards not being properly identified, or properly controlled. Accordingly, based on the findings of 86 process safety management (PSM) audits, dozens of post-accident site resumption review meetings, and hundreds of PSM review sessions, this study examines the main deficiencies of management practice and PHA implementation in Taiwan, and presents several recommendations for improved PHA assessment techniques and procedures. The study additionally examines the feasibility for using PSM-related information, such as process safety information and process incident information, as a tool for further enhancing the PHA quality. Overall, the study suggests that, in addition to following the basic rules of PHA and requirements of OSHA (1992),management in Taiwan should also provide training in the enhanced assessment techniques proposed herein and take active steps to incorporate PSM information into the PHA framework in order to improve the general quality of PHA and reduce the likelihood of process safety accidents accordingly.     

Insights into process safety incidents from an analysis of CSB investigations

Many incidents have helped to define and develop process safety. Each has provided valuable learning opportunities. However, it is even more important to identify insights that can be obtained from an analysis of a large set of incidents that represents those that typically occur. This larger picture illuminates trends and commonalities and provides learning opportunities that are even more important than the causes of any one individual incident.The Chemical Safety Board has published the results of over 60 investigations of process safety incidents. These data have been analyzed to identify commonalities and trends so that measures to help protect against future incidents can be developed. Recommendations are made to address key issues identified.     

The INDICATE safety program: evaluation of a method to proactively improve airline safety performance

A number of recent and highly publicised fatal aircraft accidents, within the Australian regional airline industry, has highlighted the need for operators of regular public transport aircraft to be more proactive in identifying and addressing aviation safety hazards. Despite this need, there are currently few proactive safety management programs that are practical, simple, cost effective and which reliably demonstrate improvements in airline safety performance. This paper outlines a new proactive airline safety program called INDICATE (Identifying Needed Defences In the Civil Aviation Transport Environment) that has been applied within the Australian regional airline industry. To evaluate the INDICATE program, a major Australian regional airline agreed to implement the program in one of its operational bases while another base was used as a control group. Five evaluation criteria were applied to determine whether the program would have a positive influence on the airline's safety performance. These criteria included airline safety culture, staff risk perception of aviation safety hazards, willingness of staff to report safety hazards, action taken on identified safety hazards and staff comments about safety management within the airline. Results from the trial suggest that the program can have a positive influence on airline safety performance, specifically: improving staff confidence in how safety is managed, increasing staff willingness to report safety hazards and incidents, improving organisational safety culture and reducing staff perceptions of the severity and likelihood of safety hazards occurring within the airline. The success of the trial has resulted in a number of Australian and International airlines adopting the program.     

Investigation of the Jahn Foundry and CTA Acoustics dust explosions: similarities and differences

The Jahn Foundry in Springfield, Massachusetts and CTA Acoustics in Corbin, Kentucky experienced devastating dust explosions in 1999 and 2003, respectively. At the time, Jahn Foundry was a gray iron casting facility that used phenolic resin powder as a binder for sand molds. CTA Acoustics was a manufacturer of thermal acoustic insulation that used phenolic resin powder as a binder for fiberglass mats. In both facilities the phenolic resin was able to migrate from the process, accumulate in the facility, and fuel catastrophic dust explosions.In this paper we review Exponent's investigation of the two incidents and identify root causes of the incidents and applicable standards that, if followed, could have prevented or mitigated the incidents. Throughout the paper we identify similarities and differences between the two facilities. For instance, in both facilities hazardous levels of dust had been allowed to accumulate due, in part, to inadequate housekeeping. However, a significant difference between the two facilities was that Jahn Foundry had no dust collection systems while the CTA Acoustics facility had dust collection systems designed to minimize the release of dust into the plant. The paper summarizes lessons learned from these two incidents that should be remembered when designing new facilities and analyzing hazards at existing facilities.     

Aerial lift fall injuries: a surveillance and evaluation approach for targeting prevention activities

PROBLEM: Work on aerial lift platforms exposes workers to fall hazards. The objective of this study was to identify the most common injury scenarios and determine current research gaps for addressing fall incidents associated with aerial lifts. METHODS: Three databases were searched: Census of Fatal Occupational Injuries (CFOI), NIOSH Fatality Assessment and Control Evaluation (FACE) reports, and OSHA Incident Investigation Records. RESULTS: The majority of falls/collapses/tipovers were within the height-category of 10-29 feet. Tipovers comprised 44-46% of boom-lift falls and 56-59% of scissor-lift falls. Constructing and repairing activities were most commonly associated with fall/collapse/tipover incidents. DISCUSSION: CFOI and OSHA/FACE show convergent data, suggesting similar scenarios for aerial lift tipovers. IMPACT ON INDUSTRY: The analysis provides the aerial lift industry information to prioritize their efforts on aerial lift design.     

The role of people and human factors in performing process hazard analysis and layers of protection analysis

Process hazard analysis (PHA) and Layers of Protection Analysis (LOPA) studies address human failures in operating and maintaining processes and the human factors that influence them, amongst other types of failures. People perform PHA and LOPA studies and, therefore, such studies themselves are subject to various possible human failures. Much less attention has been paid to the human factors that influence the performance of PHA and LOPA studies than human factors that influence hazard scenarios. Human failures in the performance of PHA and LOPA studies should be of significant concern to practitioners as such studies are difficult and time-consuming activities that place significant demands on participants, which increases the chance that errors will be made. Human factors such as willingness to rely on the unsubstantiated opinions of others, groupthink, underestimation of the frequencies of low-probability, high-consequence events, and allowing a false sense of accomplishment to distract from implementing study results must be recognized and addressed.This paper identifies and discusses various human factor issues that can influence the quality of PHA and LOPA studies covering preparing for, conducting, recording, documenting, and following-up on studies. Guidelines are provided to help minimize the extent to which these human factor issues may impair study quality.     

基于模糊评判人工神经网络的重大危险源辨识研究

国家已经制定了重大危险源辨识标准,辨识依据是危险物质的数量,主要适用于化工行业.本文对于国家重大危险源辨识标准不适合的行业,结合各行业发生事故的特点和工艺特征,综合利用模糊评判法和人工神经网络,辨识企业内存在的重大危险源.在某化工厂进行了检验,实践证明了方法的科学性和合理性.     

作业场所职业危害分级监管模式及其实施

作业场所职业危害分级监管工作涉及到监管决策、监管实施以及分级监管配套规章制度的建设等多个环节。本文从上述几个方面对如何有效实施作业场所职业危害分级监管工作进行了探讨,提出了综合监管决策、现场监管实施与制度建设等内容的基于作业场所职业危害风险评价分级的监管模式。其中,监管决策应当考虑确定区域、作业场所的监管优先顺序、监管资源与技术服务资源的合理配置,并对不同职业危害风险等级企业具体主体责任的落实提出要求;现场监管应在分析与掌握现状的基础上,通过风险评估实施分级管理,分级监管有关制度建设应当确定分级监管原则并包含上述有关内容。     

Historical analysis of U.S. onshore hazardous liquid pipeline accidents triggered by natural hazards

Incidents at U.S. onshore hazardous liquid pipeline systems were analyzed with an emphasis on natural hazards. Incidents triggered by natural hazards (natechs) were identified by keyword-based data mining and expert review supplemented by various data sources. The analysis covered about 7000 incidents in 1986–2012, 3800 of which were regarded as significant based on their consequences. 5.5% of all and 6.2% of the significant incidents were found to be natechs that resulted in a total hazardous substance release of 317,700 bbl. Although there is no trend in the long-term yearly occurrence of significant natechs, importance is found to be increasing due to the overall decreasing trend of the incidents. Meteorological hazards triggered 36% of the significant natechs, followed by geological and climatic hazards with 26% and 24%. While they occurred less frequently, hydrological hazards caused the highest amount of release which is about 102,000 bbl. The total economic cost of significant natechs was 597 million USD, corresponding to about 18% of all incident costs in the same period. More than 50% of this cost was due to meteorological hazards, mainly tropical cyclones. Natech vulnerabilities of the system parts vary notably with respect to natural hazard types. For some natural hazards damage is limited possibly due to implemented protection measures. The geographical distribution of the natechs indicated that they occurred more in some states, such as Texas, Oklahoma, and Louisiana. About 50% of the releases was to the ground, followed by water bodies with 28%. Significant consequences to human health were not observed although more than 20% of the incidents resulted in fires. In general, the study indicated that natural hazards are a non-negligible threat to the onshore hazardous liquid pipeline network in the U.S. It also highlighted problems such as underreporting of natural hazards as incident causes, data completeness, and explicit data limitations.     

Worker-centered investigation of issues with procedural systems: Findings from interviews with a representative sample of workers in high-risk process industries

Issues related to procedural systems have been found to contribute to incidents in many high-risk industries such as petrochemical, oil and gas, etc. While previous research has focused on understanding issues with procedural systems from the perspective of the workers (who are the end-users of procedures), most of this research suffers from samples that only include companies with programs focused on improving safety by improving procedures. These companies may have inherent differences in their safety practices and thus the experiences of these workers may not completely represent all workers’ experiences in this domain. The purpose of this study is to gain insights into the thoughts and perceptions from a representative and broad sample of workers concerning procedure use and purpose. To improve the generalizability of previous findings, interviews were conducted with workers from a broad range of high-risk process industries to investigate issues related to procedure adherence that may be present in companies not currently implementing. Findings from a qualitative data analysis provide support for the generalizability of issues previously discovered, such as: more experience workers being more likely to deviate; procedure quality being inconsistent; and the procedure revision process being problematic. However additional prominent issues were found as well. Most importantly, this study found that adherence to procedures is often motivated by potential liability issues instead of genuine concerns for safety in organizations and many deviations from procedures were due to pressure from immediate supervisors. These findings suggest a relationship between the effectiveness/quality of procedural systems and the safety climate of the organization or work unit.     

Pilot sample risk analysis for underground coal mine fires and explosions using MSHA citation data

After three decades of sustained continuous improvement of mine safety performances in the US, mine disasters in 2006 and 2007 compromised an excellent record and presented new challenges and vulnerabilities for the underground coal mining industry. In the aftermath of the incidents, formal investigations and new scrutiny of mine safety by the US Congress and expert study groups followed. The US Congress passed the Mine Improvement and New Emergency Response Act of 2006 (MINER Act), which mandated new laws to address the issues, including those related to mine fires and explosions from which miners must be protected. The National Mining Association-sponsored Mine Safety Technology and Training Commission report highlighted the role of risk analysis and management in identifying and controlling major hazards, such as fires and explosions. In this paper an approach is given for analyzing the risks for fires and explosions based on the Mine Safety and Health Administration citation database. Using 2006 citation data and focusing on subsystem failures, the methodology is applied to a database for a pilot sample of underground coal mines stratified by mine size and state.     

Process safety management lessons learned from a fire and explosion accident caused by a liquefied petroleum gas leak in an aromatics reforming unit in Taiwan

A severe fire and explosion accident was caused by a liquefied petroleum gas leak in Taiwan in 2019. This accident resulted in the loss of approximately US$3.5 billion in output value due to a one-and-a-half-year shutdown after the accident; however, no casualties were recorded at the accident scene. An analysis of the accident pipelines demonstrated that the pipeline leak had been caused by hydrochloric acid corrosion. Cause analysis based on the accident timeline, fault tree analysis, and causal factor charting indicated inadequacies in five elements of process safety management (PSM) namely mechanical integrity (MI), management of change, emergency planning and response, process hazard analysis (PHA), and process safety information (PSI) as the root causes of the accident. Furthermore, insufficient PSI (i.e., a lack of comprehensive understanding regarding corrosion mechanisms) was deemed to have been the core problem leading to the accident. This accident revealed common shortcomings that are often overlooked in PSM implementation in Taiwan; thus, the present research can serve as a vital reference for improving PSM programs in Taiwan.     

The legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

Hazards from carbon dioxide capture, transport and storage

Carbon capture and storage (CCS) is a developing technology which raises a number of issues in terms of safety. CCS involves a chain of processes comprising capture of carbon dioxide, transport and injection into underground storage. In work carried out for the IEA Greenhouse Gas R&D Programme, a number of high-level hazard identification (HAZID) studies have been performed with the help of industry experts. The HAZIDs considered a carbon capture and storage chain involving capture, pipeline transport and injection. HAZID has been performed at a high-level for such a CCS chain with three types of capture technology and using pipeline transport. It is hoped that the results of the HAZID studies will be of use to those carrying out CCS projects, but should not be a substitute for them carrying out a full suite of integrated hazard management processes. A number of example hazards have been described to raise awareness of the range of hazards in a CCS process and to identify barriers which could prevent, minimise, control or mitigate CCS hazards. Bow-tie diagrams have been produced to record the information from this study and to organise it in a systematic way so that it is far less likely that contributors to and mitigators of hazards will be missed. The diagrams are available in Excel spreadsheet format so that they can be used as the starting point for development by specific CCS projects. CCS technology is still advancing and a number of knowledge gaps in terms of safety have been identified which require further development.     

国外化工企业工艺安全技术管理概述

国外化工企业工艺安全技术管理范畴主要包括PHA、MOC、RA/RM、事故调查、其他工艺安全管理工具等。本文主要介绍了国外化工企业常规工艺安全技术管理MOC———变更管理的概念、流程,临时MOC、MSR、PSSR等概念及流程。PHA———工艺危险性分析是国外化工企业工艺安全技术管理核心,主要应用于大型或复杂项目,重点详述了工艺危险性分析的流程、步骤以及四种常用的危险识别方法———HAZOP、SCA、What-If、FEMA的概念、主要步骤、分析过程及主要优点。一旦工艺危险被分析识别后,阐述了如何运用风险评估和风险管理（RA/RM）步骤、后果等级、频率评价、风险等级矩阵和风险降低的主要方法,如何采用故障树FTA和事件树ETA两种不同的方法测算各种事件或故障发生的概率以及事故的后果等级,最后介绍了故障树FTA和事件树ETA的主要步骤和方法。     

Wet bench reactive hazards of cleaning stages in semiconductor manufacturing processes

According to the research from FM Global (Factory Mutual Insurance Company), most of the incidents that have occurred in semiconductor plants in the past two decades were reported as “Fire Cases”. They claim that the fires in wet chemical cleaning processes were mainly caused by heater failure. However, depending on the process conditions, electrical heaters are designed to turn off automatically when the temperature reaches a set point. Therefore, a thorough study of the situations related to possible fires in wet chemical cleaning processes is necessary.

This study focused on the incompatible behaviors of cleaning materials used in the wet bench stage. These results can be applied to determine the causes of fires in the wet bench stage from using reactive chemicals for cleaning purposes.

Another purpose of this study was to investigate the potential hazards of widely used chemicals (hydrogen peroxide, concentrated sulfuric acid, hydrochloric acid and isopropyl alcohol) within similar processes in semiconductor plants. Experimental data were also verified in order to establish a concentration triangular diagram, which could be used to identify a combustion, deflagration or even detonation zone. Finally, this study can provide basic design data for an inherently safer process to avoid potential hazards caused by dangerous mixtures, which may result in large property loss in semiconductor plants.     

Safety related questions for computer-controlled plants: derivation, organisation and application

The use of computers in process control has improved productivity and product quality but has also caused a number of accidents. If we learn from these accidents we may be able to prevent them from happening again. This paper advocates a systematic approach to deriving and organising safety-related questions from past incidents and then applying the questions to consider the safety issues related to the whole life-cycle of computer-controlled plants. Over 170 questions were derived from 300 incident reports provided by two major organisations. The questions are organised into a structured framework so that relevant questions can be located easily when considering different aspects of a computer-controlled plant. Examples illustrating the application of the questions are given. The whole set of questions is listed in the Appendix.     

Qualitative Assessment for Inherently Safer Design (QAISD) at preliminary design stage

Conventional hazard evaluation techniques such as what-if checklist and hazard and operability (HAZOP) studies are often used to recognise potential hazards and recommend possible solutions. They are used to reduce any potential incidents in the process plant to as low as reasonably practicable (ALARP) level. Nevertheless, the suggested risk reduction alternatives merely focus on added passive and active safety systems rather than preventing or minimising the inherent hazards at source through application of inherently safer design (ISD) concept. One of the attributed reasons could be the shortage of techniques or tools to support implementation of the concept. Thus, this paper proposes a qualitative methodology that integrates ISD concept with hazard review technique to identify inherent hazards and generate ISD options at early stage of design as proactive measures to produce inherently safer plant. A modified theory of inventive problem solving (TRIZ) hazard review method is used in this work to identify inherent hazards, whereby an extended inherent safety heuristics tool is developed based on established ISD principles to create potential ISD options. The developed method namely Qualitative Assessment for Inherently Safer Design (QAISD) could be applied during preliminary design stage and the information required to apply the method would be based on common process and safety database of the studied process. However, user experiences and understanding of inherent safety concept are crucial for effective utilisation of the QAISD. This qualitative methodology is applied to a typical batch reactor of toluene nitration as a case study. The results show several ISD strategies that could be considered at early stage of design in order to prevent and minimise the potential of thermal runaway in the nitration process.