A framework for human error risk analysis of coal mine emergency evacuation in China

Evacuation from underground coal mine in emergency as soon as possible makes the difference between life and death. Human factors have an important impact on a successful evacuation, but literature review shows that there is a lack of consideration of human error risk during coal mine emergency evacuation in China. To address the above problems, in this paper, we established a framework for human error risk analysis of coal mine emergency evacuation, consisting of scenario and task analysis, risk assessment and risk reduction. A general evacuation procedure which is applicable for different causes is detailed through the scenario and task analysis. A new method based on expert judgment, named OGI-Model, is proposed to evaluate the reliability of human safety barrier. In this new approach, human safety barrier is divided into three sub-barriers, i.e., organization safety sub-barrier (OSSB), group safety sub-barrier (GSSB), and individual safety sub-barrier (ISSB). Each sub-barrier consists of a series of concrete measures against specific evacuation actions. An example is provided in this paper to demonstrate the use of this framework and its effectiveness.     

Development of a risk-based maintenance strategy using FMEA for a continuous catalytic reforming plant

Petrochemical facilities and plants require essential ongoing maintenance to ensure high levels of reliability and safety. A risk-based maintenance (RBM) strategy is a useful tool to design a cost-effective maintenance schedule; its objective is to reduce overall risk in the operating facility. In risk assessment of a failure scenario, consequences often have three key features: personnel safety effect, environmental threat and economic loss. In this paper, to quantify the severity of personnel injury and environmental pollution, a failure modes and effects analysis (FMEA) method is developed using subjective information derived from domain experts. On the basis of failure probability and consequence analysis, the risk is calculated and compared against the known acceptable risk criteria. To facilitate the comparison, a risk index is introduced, and weight factors are determined by an analytic hierarchy process. Finally, the appropriate maintenance tasks are scheduled under the risk constraints. A case study of a continuous catalytic reforming plant is used to illustrate the proposed approach. The results indicate that FMEA is helpful to identify critical facilities; the RBM strategy can increase the reliability of high-risk facilities, and corrective maintenance is the preferred approach for low-risk facilities to reduce maintenance expenditure.     

安全阀失效模糊综合评价方法的研究

针对安全阀在实际使用过程中的失效涉及诸多因素影响的特点,运用模糊综合评价的数学模型,将安全阀失效的相关影响因素作为因素集,把可能产生故障的元件作为评价集,按照权重的大小对安全阀的故障进行综合评价,以提高维修人员对安全阀故障的判断能力和综合检修能力,达到设备稳定运行的目的。     

城市管道系统风险分析及闭环管理研究

为了探索构建城市管道系统安全及可靠性风险管理体系,基于FMECA,FTA&ETA及FRACAS等技术,建立涵盖故障模式辨识、影响及危害度分析、纠正措施执行等内容,且遵循闭环管理原则的科学、完整的风险闭环管理模式。针对城市管道安全及可靠性研究存在的局限性,引入FCE改进的FMECA和模糊灰关联FTA等定量计算方法,克服统计信息匮乏、数据模糊等瓶颈。研究结果表明:基于改进“3F”一体化技术的系统风险闭环管理体系契合城市管道风险管控需求,为多态、多要素耦合、不确定性复杂系统整体风险分析研究提供新思路。     

Comprehensive alarm information processing technology with application in petrochemical plant

During the abnormal plant conditions, too much information is produced due to momentary plant excursions above alarm limits. This flood of information impedes correct interpretation and correction of plant conditions by the operator. Existing techniques for the design of alarm systems mostly have weak ability to handle complex hazard scenarios and increase the probability of larger safety issues. In this paper, a comprehensive alarm information processing (AIP) technology is introduced, called multi-round alarm management system (MRAMS), including several processing strategies: AIP based on single sensor, AIP based on sensor group, root cause diagnosis based on Bayesian network, sensor fault judgment method and false alarm inhibition method. In case studies, both simulation experiment and pilot application on a real petrochemical plant are presented. Results indicate the MRAMS is helpful in improving the accuracy of correctly diagnosing the root causes and hence avoiding false and redundant alarms. By adopting this new technology, the safe and reliable operation of the plant can be achieved, and the economic loss brought by improper alarms can be reduced.     

行为安全研究进展追溯与述评

为推动行为安全研究的发展和应用,通过文献综述方法,确定广义行为安全研究对象,从理论和管理2个维度来解析行为安全研究进展。在理论层面,通过分析行为机理来阐述行为安全理论基础,提炼行为影响因素并探究因素间作用关系;在管理层面,追溯行为安全管理在不同阶段、不同行业的应用现状,提出改进方案。结果表明:行为安全理论基础和影响因素分析2方面的研究较为深入,但是仍需夯实相关模型并引入先进的研究方法,而行为安全管理应用的时效性和针对性较差,需要在组织因素和个体因素结合、干预的效果、信息技术应用等方面进行改进。     

An integrated approach to the analysis of incident causes

Root cause analysis (RCA) is a well-established method for the determination of incident causes. However, the application of the method, especially for accidents in complex socio-technical systems, encounters limitations. It cannot identify some types of causes. This article finds ways to deal with the limitations, and integrates them into the RCA procedure. It results in the proposal of the Integrated Procedure of Incident Cause Analysis (IPICA). The integrated approach is based on the integration of assumptions about the structure of safety management in the investigated process into a comprehensive picture. It offers an integrated view of various types of causes. To a necessary extent, it integrates a non-linear incident model into the RCA procedure. The example – an analysis of the Walkerton tragedy from 2000 – illustrates the application of the integrated approach. IPICA is shown to be more universal than RCA, just as effective, and not excessively complicated.     

危化品物流运输企业安全管理能力模型构建

为了明晰危化品物流运输企业安全管理能力要素的相互关系和结构属性,提出了 一种层次分析法和DEMATEL法耦合的安全管理能力分析方法。首先,在现有安全管理能 力研究的基础上建立考虑涌现性的危化品物流运输企业安全管理能力概念模型并确定危 化品物流运输企业安全管理能力的构成要素;然后针对传统DEMATEL方法的不足,构建 了基于层次分析法的改进DEMATEL方法;最后,通过问卷调研获取危化品物流运输企业 安全管理能力影响因素重要度判断矩阵,并通过中心度和原因度确定能力要素相互关系 。研究结果表明,所建立的方法可以用于分析危化品物流运输企业安全管理能力并构建 其结构模型。     

Subsea pipelines incidents prevention: A case study in Brazil

There are more than 4000 subsea pipelines in Brazil. These pipes include umbilicals, drilling risers, flexible risers, rigid risers, hybrid risers, flowlines, and export pipelines. Despite all standards, regulations, guides, and risk management tools designed to avoid events, subsea pipeline incidents still occur, revealing possible failures in companies' risk control. Identifying similarities between different subsea pipeline failure events is crucial to improving the design, risk management practices, and regulation requirements, besides promoting accident prevention. This paper proposes applying the life cycle and management practices combined to analyze subsea pipeline incidents from the RDI (Detailed Incident Report) and investigations reported to ANP (Brazilian National Agency of Petroleum, Gas, and Biofuels), the Brazilian safety regulatory agency. Furthermore, subsea pipeline incidents data were analyzed: correlated circumstances, consequences, and causes. The results show that most riser and flowlines causal factors are related to equipment failures, and recurrent root causes are design errors and integrity control. Based on the proposed approach, it was possible to identify gaps in most riser and flowlines accident investigations since there are few causal factors, root causes, and the absence of riser and flowlines failure mode and mechanisms. Therefore, the development of accident recommendations can be compromised. Thus, this paper proposes improvements to current Brazilian regulations to clarify the minimal subsea pipeline accident investigation requirements.     

多因素耦合的加工车间关键风险因素定量分析

为了准确分析加工车间关键风险因素,考虑多风险因子交互影响的情境,提出了一种基于模糊决策实验室分析法的加工车间关键风险因素定量分析方法。首先,从人员、设备、环境、物料和管理因素等5个维度辨识加工车间风险因素并建立风险因素集;基于此,采用三角模糊数对专家判断语义进行表征,然后运用DEMATEL法计算多因素耦合下的风险重要度,从而确定加工车间的关键风险因素。最后,以安徽省某机械加工车间为例,说明所提出方法的应用过程。结果表明,加强对安全制度和安全文化建设等关键风险因素的控制,有助于加工车间的风险控制,改善车间生产安全。     

基于模糊层次分析法的民用机场安全风险管理

以某一民用机场为例,基于"人-机-环境-管理"的系统工程理论,分析该机场影响飞行安全的各影响因素。利用三角模糊数来表征专家判断信息,构造三角模糊数互补判断矩阵。依据模糊层次分析法,对各影响因素进行单排序和总排序,得到其重要性的排序。模糊层次分析法可以更加客观地描述专家判断的模糊性,并且计算过程简单。基于模糊层次分析法的安全风险管理不仅能够客观地评估民航的安全状态,而且对于有重点地改善民用机场安全有着积极的作用。     

Managing safety in hydropower projects in emerging markets – Experiences in developing from a reactive to a proactive approach

International companies investing in emerging markets need to address the management of safety under varying conditions. The paper presents an evaluation of the approaches taken by an international hydropower company in two different construction projects, one in India and one in the Philippines. In the first project, the company had to intervene as a reaction to poor safety and overall performance. Based on previous experiences, the company selected a proactive approach in the second project, involving use of the contracting process to ensure adequate conditions from the start of construction and onwards. The paper accounts for the safety performance results in the two projects and interprets them in relationship to external and internal influencing factors in the respective project. It is concluded that a proactive approach has the potential of delivering satisfactory safety results at moderate costs for follow-up. A reactive approach risks exposing the company to ethical and reputation risks due to a poor safety performance before the corrective actions have taken full effect. It is also resource demanding. Results demonstrate the feasibility of turning around a project’s safety performance also when preconditions are challenging.     

Experts,Bayesian Belief Networks,rare events and aviation risk estimates

Bayesian Belief Networks (BBN) are conceptually sensible models for aviation risk assessment. The aim here is to examine the ability of BBN-based techniques to make accurate aviation risk predictions. BBNs consist of a framework of causal factors linked by conditional probabilities. BBN conditional probabilities are elicited from aviation experts. The issue is that experts are not being asked about their expertise but about others’ failure rates. A simple model of expertise, which incorporates the main features proposed by researchers, implies that a best-expert’s estimates of failure rates are based on accessible quantitative data on accidents, incidents, etc. Best-expert estimates will use the best available and accessible data. Depending on the frequency of occurrence, this will be data on similar events, on similar types of event, or general mental rules about event frequencies. These considerations, plus the need to be cautious about statistical fluctuations, limit the accuracy of conditional probability estimates. The BBN framework assumes what is known as the Causal Markov Condition. In the present context, this assumes that there are no hidden common causes for sequences of failure events. Examples are given from safety regulation comparisons and serious accident investigations to indicate that common causes may be frequent occurrences in aviation. This is because some States/airlines have safety cultures that do not meet ‘best practice’. BBN accuracy might be improved by using data from controlled experiments. Aviation risk assessment is now very difficult, so further work on resilience engineering could be a better way of achieving safety improvements.     

Railway safety climate: a study on organizational development

The safety climate of an organization is considered a leading indicator of potential risk for railway organizations. This study adopts the perceptual measurement–individual attribute approach to investigate the safety climate of a railway organization. The railway safety climate attributes are evaluated from the perspective of railway system staff. We identify four safety climate dimensions from exploratory factor analysis, namely safety communication, safety training, safety management and subjectively evaluated safety performance. Analytical results indicate that the safety climate differs at vertical and horizontal organizational levels. This study contributes to the literature by providing empirical evidence of the multilevel safety climate in a railway organization, presents possible causes of the differences under various cultural contexts and differentiates between safety climate scales for diverse workgroups within the railway organization. This information can be used to improve the safety sustainability of railway organizations and to conduct safety supervisions for the government.     

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.     

Inherent safety in offshore oil and gas activities: a review of the present status and future directions

Inherent safety is a proactive approach for hazard/risk management during process plant design and operation. It has been proven that, considering the lifetime costs of a process and its operation, an inherently safer approach is a cost-optimal option. Inherent safety can be incorporated at any stage of design and operation; however, its application at the earliest possible stages of process design (such as process selection and conceptual design) yields the best results.Although it is an attractive and cost-effective approach to hazard/risk management, inherent safety has not been used as widely as other techniques such as HAZOP and quantitative risk assessment. There are many reasons responsible for this; key among them are a lack of awareness and the non-availability of a systematic methodology and tools.The inherent safety approach is the best option for hazard/risk management in offshore oil and gas activities. In the past, it has been applied to several aspects of offshore process design and operation. However, its use is still limited. This article attempts to present a complete picture of inherent safety application in offshore oil and gas activities. It discuses the use of available technology for implementation of inherent safety principles in various offshore activities, both current and planned for the future.     

Safety investment optimization in process industry: A risk-based approach

Process plant safety is a critical indicator of organizational performance. Adequate investment into safety practices to avoid future accident cost is therefore a beneficial strategy. The current approach to such investments in the process industry is driven largely by simple risk-based heuristics, insurance market premiums, organizational culture and management judgment. There is, however, an absence of an overarching methodology to assist such an effort. Therefore, there is a need for developing a robust decision-making framework for enabling systematic and optimal allocation of financial resources across all significant risk elements within a process plant.The present work proposes a safety investment optimization (SIO) framework for a typical process plant. Such an optimization approach targets maximal reduction of risk values across all potential hazards within the constraint of a given safety investment budget at the incipient stage of establishing a plant such that it saves future cost to company by reducing the risk from accidents. At the same time the framework takes into account the need to comply with the regulatory requirements imposed by the government. Additionally, access to insurance market as a strategy to transfer risk is also integrated. Finally, the residual risks are managed through investments in selective safeguards while ensuring that the benefits over-weigh the cost of such an exercise. For illustrating the application of the framework, a representative process plant with a select number of risk scenarios is chosen and all steps suggested by the framework are demonstrated quantitatively. It is anticipated that the proposed SIO framework will help optimal resource allocation for managing the risks implicit in a typical process plant.     

HAZOP-FTA综合分析方法在煤化工装置中的应用

为提高煤化工生产工艺安全水平,降低事故发生的可能性和严重程度,有必要对其工艺过程中的危害因素进行全面系统的辨识分析。以某甲醇公司煤制甲醇气化装置为例,运用HAZOP方法准确识别工艺偏差危害因素,定性分析偏差产生的可能原因、后果及现有安全措施;在此基础上,运用FTA方法,获得顶上事件发生概率值和基本事件重要度结果,实现工艺设备设施危害因素的定性与定量分析,提出有针对性的建议安全措施。两种方法的综合应用,给予煤化工企业系统安全分析一种新的思路,使其得到更加科学准确的危险性分析结果,为企业开展危害因素的分级管理,有效预防和减少事故的发生提供了理论支撑。     

谈职业健康安全管理体系审核的有效性

笔者从审核人日、抽样的合理性、审核员能力、审核过程的有效性等4个方面讨论了职业健康安全管理体系(OHSMS)审核的有效性。从要素的角度,介绍国家标准GB/T28001—2001中“对危险源辨识,风险评价和风险控制的策划”,“法律法规及其他要求”,“职业健康安全管理方案”,“结构和职责”,“运行控制”,“绩效测量与监测”,“事故事件,不符合,纠正与预防措施”等7个要素审核过程的有效性。可为认可认证机构判断OHSMS审核的有效性提供一定的参考。     

Focus on mission success: Process safety for the Atychiphobist

Modern process plants are complex engineering systems. While thorough reviews of system safeguards are performed, catastrophic events continue to occur, often unfolding in unforeseen ways. Success in process safety demands safe processes, and understanding rare, high consequence events is central to the traditional process safety approach. This philosophy is common to all high-hazard industries, offering the potential for sharing approaches, experience, and lessons learned. The problem, however, is that people (and organizations and entire industries) who fear failure (atychiphobia) sometimes obsess about failure so much that they miss opportunities to succeed.This paper examines selected risk management practices in the power generation and aerospace industries and how those practices have led to improved performance. Risk informed decision making (RIDM) has had widespread application in the nuclear and aerospace industries, and is undergoing enhancements to become a key framework for risk management. Additionally, rather than focusing on avoidance of loss, there are emerging approaches supporting achievement of success. This approach provides a more direct link of risk to business and operational objectives, but does challenge conventional risk approaches founded in a loss prevention-centric view. The paper reflects upon risk informed decision making and success modeling, and suggests how these methods may be applied in the field of process safety. Specific examples are drawn from the defense in depth approach from the nuclear power industry and mission success concepts developed for NASA.