LPG leakage and explosion accident analysis based on a new SAA method

The petrochemical industry has inherently high safety risks. On 5^th June 2017, a liquefied petroleum gas tanker in the storage and transportation department of Linyi Jinyu Petrochemical Co., Ltd. leaked during unloading, causing a major explosion and fire. Ten people were killed and nine were injured. To prevent the recurrence of similar accidents, a retrospective accident analysis was conducted using the system accident analysis method known as ‘24Model’. This analysis proved the coupling relationship between accident causes involving multiple organisations and multiple factors. The analysis results show that the five modules of maintenance and design, that is, loading and unloading valves, emergency training, management of subsidiaries and contractors, multi-level supervision, and task arrangement need to be checked from top to bottom by relevant organisations.In order to verify the reliability of 24Model analysis results, three SAA methods, namely STAMP, FRAM, AcciMap, were used to analyse the accident, and results obtained by the four methods were evaluated qualitatively and quantitatively. The results show that the output of 24Model is reliable and has a more understandable framework, which can be used as reference for the development of other linear accident cause models and application of system accident analysis methods to real applications.     

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors

IntroductionCurrently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs.MethodsA Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry.ResultsOne GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ² test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident.ConclusionsSCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices.Practical applicationsGeneral aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.     

化工行业典型安全事故统计分析

化工行业安全事故的统计分析,是对化工行业安全生产问题进行研究的重要基础性工作。基于事故的随机性,采用数理统计的方法,主要从事故发展趋势、事故类型、事故原因、季节性、工作日和时段等方面,对收集到的114例1974—2010年间的重大伤亡或造成较大影响的化工企业典型安全风险事故案例的系统、全面地分析,揭示化工行业典型安全事故的部分特征和规律,为化工行业安全生产问题的进一步研究提供依据和参考。     

从问责调查到问题调查——基于系统论和系统安全理论的思考与建议

生产安全事故调查处理是安全生产工作的一项重要内容,事故调查的政策和方法等的制度创新对完善我国安全生产工作的体制机制有很大意义。针对当前我国安全生产总体形势和事故调查处理的工作现状,采用对照评估的方法,分析了近三年来我国特大事故发生的态势和原因,总结了事故发生的基本规律和共性问题,基于系统安全的思想,认为安全是系统整体属性,系统脆弱性是导致重特大事故风险和严重损失的主要原因,不应简单把事故仅仅归咎于某些人或某件事的责任。据此,进一步分析生产安全事故调查处理的利弊得失,提出在现有基础上,进一步改革创新生产安全事故调查处理制度,应逐步实现从问责调查向问题调查的转变,并对如何修改《生产安全事故报告和调查处理条例》（国务院令第493号）提出了六条具体建议。     

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.     

高速公路运营安全性评价

系统研究国内外道路运营安全评价先进技术,认为各种安全评价方法有其优缺点,单一方法使用时,难以得到全面、可靠的评价结果。在此基础上,结合我国高速公路运营状况,提出了运用速度协调性分析、事故调查与分析、设计符合性以及运营安全评价清单进行评价的高速公路运营综合安全评价方法。该方法能最大程度地发现事故隐患、预防事故的发生或减轻事故的严重程度。并运用该方法对某改建高速公路进行了运营安全评价,指出了该拟改建高速公路两处事故多发路段和3方面的安全隐患,证实了综合安全评价方法的有效性。     

Accident investigation in the Norwegian petroleum industry - Common features and future challenges

In their regulations, the Petroleum Safety Authority Norway (PSA) states that the companies responsible for oil and gas exploration and production activities in Norway shall record and investigate accidents and serious incidents. This paper introduces a general model for the accident investigation process in the Norwegian petroleum industry, and presents some results derived from a comparative study of causal factors identified in offshore accident investigation reports from 2002 to 2006. The paper also offers a discussion of the improvement potential in the use of investigation methods. Finally, a discussion of future challenges in accident investigations is provided.     

中欧事故报告与调查处理比较研究

事故调查是安全生产工作中的重要环节,是对生产安全事故及时处理、发现问题的重要手段,其目的在于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。从法律依据、事故分级、事故调查程序、事故调查主体、调查组组成、事故调查期限、责任追究、事故调查经费来源、信息公开等方面开展了我国与欧盟的事故报告与事故调查处理对比分析,剖析了我国目前事故报告与调查处理的工作存在的一些问题,研究和借鉴了欧盟的一些先进理念和做法,并提出改进我国事故报告与调查处理的若干对策建议。     

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].     

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。     

基于文本挖掘和复杂网络的事故致因重要度评估方法——以房屋市政较大以上事故为例

为充分挖掘事故调查报告中的有效信息,明确安全管理工作的内容.首先,利用文本挖掘分析事故调查报告,采用最小词频阈值文档频改进信息增益评估函数对分词结果降噪,通过回溯特征项在报告中的具体表述,提取事故致因,再构建同义词词库.然后,引入复杂网络以改进TF-IDF,综合事故致因因素的关联特征评估其重要度.最后,以房屋市政较大及...     

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.     

2006-2010年我国危险化学品事故统计分析研究

本文基于＂十一五＂期间我国危险化学品事故统计数据,从事故类别、事故发生区域、事故发生时间、企业经济类型、危险化学品类别、危险化学品事故发生环节等方面进行分析,结果表明,中毒与窒息事故和爆炸事故占危险化学品事故主要类型,易燃液体、易燃气体、爆炸品和腐蚀性物质是引发危险化学品事故的主要危险物质类型,生产环节是事故发生的主要环节,违反操作规程或劳动纪律与设备设施工具附件有缺陷是导致事故的重要原因。从落实企业安全生产主体责任、提升本质安全化水平、开展重大危险源普查、建立安全监管网络、加强危险化学品产业布局、提高事故应急救援能力等方面提出了预防和控制危险化学品事故的对策建议。     

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.     

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.     

The context and habits of accident investigation practices: A study of 108 Swedish investigators

The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the ‘human factor’ was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices – particularly those conducted as part-time work in organizations.     

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.     

数据挖掘与现场调查结合的电动汽车事故分析

为了解电池热失控引起的电动汽车自燃事故起因,降低事故发生率,统计梳理2020年新能源汽车起火事故概况,并基于动力电池失效机制和车辆运行数据,提出一种融合事故阶段安全参数关联分析、事故现场调查和全生命周期数据一致性分析的事故多维分析方法,采用该方法深入剖析一起电动汽车起火事故.研究结果表明:事故多维分析方法可通过探究事故...     

石油钻井作业的安全葡萄图管理技术

石油钻井作业是一个高风险行业,其风险具有严重性、突发性、隐蔽性、随机性的特点,是石油石化行业中最主要的事故频发区之一.震惊世界的“12.23”事故以后,在国家和企业安全生产的指导与监督下,事故较以前明显减少,但钻井作业的特点决定了其风险因素不会被消除,只能通过人的因素去预防事故发生.安全葡萄图从人的因素考虑,结合了人体生物节律与葡萄图两者的优点,除了具有葡萄图的特点外,还具有预测性、记录性和选拔性,是安全管理方面的一种新方法.安全葡萄图是一种以人为本的安全管理方法,通过加强人员安全管理来减少和消除事故隐患的目的.该方法简单实用,适合于钻井等高风险行业使用.     

基于贝叶斯网络的煤矿事故人因推理

煤矿事故的不可重现性决定了事故原因的调查具有很强的不确定性,如何通过事故发生后的相关信息提高事故深层次原因调查的准确性是非常重要的。将HFACS与贝叶斯网络相结合,以煤矿事故HFACS分析结果为样本,通过卡方检验和让步比分析建立人因的贝叶斯网络因果图,进一步利用最大似然估计算法确定了煤矿事故人因的贝叶斯网络参数。最后,以双柳煤业顶板事故的调查信息为证据推理导致煤矿事故发生的深层次原因,提高事故原因调查的准确性,从而验证模型的有效性。