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.     

Risk management of cost consequences in natural gas transmission and distribution infrastructures

A critical aspect of risk management in energy systems is minimizing pipeline incidents that can potentially affect life, property and economic well-being. Risk measures and scenarios are developed in this paper in order to better understand how consequences of pipeline failures are linked to causes and other incident characteristics. An important risk measure for decision-makers in this field is the association between incident cause and cost consequences. Data from the Office of Pipeline Safety (OPS) on natural gas transmission and distribution pipeline incidents are used to analyze the association between various characteristics of the incidents and product loss cost and property damage cost. The data for natural gas transmission incidents are for the period 2002 through May 2009 and include 959 incidents. In the case of natural gas distribution incidents the data include 823 incidents that took place during the period 2004 through May 2009. A two-step approach is used in the statistical analyses to model the consequences and the costs associated with pipeline incidents. In the first step the probability that there is a nonzero consequence associated with an incident is estimated as a function of the characteristics of the incident. In the second step the magnitudes of the consequence measures, given that there is a nonzero outcome, are evaluated as a function of the characteristics of the incidents. It is found that the important characteristics of an incident for risk management can be quite different depending on whether the incident involves a transmission or distribution pipeline, and the type of cost consequence being modeled. The application of this methodology could allow decision-makers in the energy industry to construct scenarios to gain a better understanding of how cost consequence measures vary depending on factors such as incident cause and incident type.     

Migrating an incident reporting system to a CCPS process safety metrics model

A major chemical company established a formal incident investigation and reporting system several years ago. The original system focused heavily on worker-related injuries, illnesses, and near-misses and was used primarily to track statistics reportable to the Occupational Safety and Health Administration (OSHA). This Occupational Injury and Illness (OII) approach has been recognized to be an ineffective tool for measuring, predicting, and preventing process safety incidents. The Center for Chemical Process Safety (CCPS) recently published guidelines on how to establish safety metrics for the measurement and reduction of process safety incidents. The process safety metrics approach relies upon leading and lagging metrics to improve organization process safety. This paper is a case study of the analysis of one organization’s incident database, which represents approximately five years of data from over a dozen facilities. The aim of this investigation was to extract useful process safety metrics from the incident investigation and reporting system, which would be pertinent to the types of process units and process functions at these facilities. This paper will discuss the approach taken to extract process incident information from an OII-based database and present the difficulties of performing an analysis on such a database. This paper provides guidance on how to migrate an existing OII-based reporting system to a program that includes process safety metrics in accordance with industry best practices.     

Cultural influences on risks and risk management: six case studies

Ever since the accident at the Three Mile Island nuclear power plant on 28 March 1979, the term ‘safety culture’ has been a hot topic for both researchers and organisations. Both the content and causes of a poor safety culture have been the focus of numerous research projects, but also its consequences on an organisation's safety performance and the way organisations should be ‘designed’ to facilitate a ‘good’ safety culture. Since others in this issue focus on the content and causes of safety culture, this article focuses on its consequences from two different but inter-related angles. In the first place, the cultural influences on incident causation are considered. In the second place, the cultural influences on risk management, or specifically incident reporting and analysis, are considered. Both angles are supported by empirical incident data collected in the Dutch steel industry and the medical domain. To collect this data, a risk management approach called PRISMA was used. Further, cultural differences between the domains investigated are highlighted and discussed.     

Incident reduction and risk migration

In 2002 an incident trend in Air Traffic Management in a European Centre was analysed from a Human Factors perspective, and a single solution was developed, which stopped the incidents occurring. Three years later a new incident trend appeared, which upon analysis appeared to be a more complex version of the former pattern. This required a more comprehensive analysis as well as a more co-ordinated and systemic approach to reduction. In the end, nine recommendations were made, of which more than half were implemented. The incidents stopped. This case study is used to highlight the issue of risk migration in the context of incident analysis and reduction.     

Developing a process equipment failure knowledge base using ontology approach for process equipment related incident investigations

Process equipment failures (PEFs) are one of the most important causes of process incidents occurrences. To investigate and prevent the PEFs, in addition to having the previous data, it is necessary to have some resources of the PEFs domain knowledge. Nowadays, PEFs data are usually retrieved from existent databases. Customary databases present only previously stored data of equipment failures but, for carrying out a comprehensive PEFs management it is necessary to have access to the PEFs desired knowledge and not only stored data. This paper aims to offer a knowledge base for the PEFs through adopting an ontological approach and then to use the proposed knowledge base for further applications particularly, process incident investigation activities. Through adding semantic search capability, the proposed knowledge base could upgrade the data presenting feature of the common databases into a knowledge presenting feature. Using this approach, the user would be able to extract the desired knowledge of the PEFs along the virtual stored data of occurred cases. The knowledge extraction process and the data mining of occurred incidents are both necessary for the PEFs investigation.     

含硫气田井喷事故行动计划(IAP)编制研究

本文对国内外事故行动计划的研究进展进行了系统性总结,分析了含硫气田井喷事故发生的原因以及特点.结合我国现行的事故应急工作体系,将事故行动计划应用在含硫气田井喷事故应急工作中,提出了针对含硫气田井喷事故的事故行动计划编制方法,建立了包括现状分析、设立事故目标、确定应急组织体系和职责、制定应急处置措施、调配应急资源、开展评估与监控在内的含硫气田井喷事故行动计划编制技术体系.事故行动计划的制定与实施,可有效提高含硫气田应急工作的针对性和指导性,对含硫气田井喷事故应急工作具有重要作用.     

Modelling of BP Texas City refinery accident using dynamic risk assessment approach

Process industries involve handling of hazardous substances which on release may potentially cause catastrophic consequences in terms of assets lost, human fatalities or injuries and loss of public confidence of the company. In spite of using endless end-of-the-pipe safety systems, tragic accidents such as BP Texas City refinery still occur. One of the main reasons of such rare but catastrophic events is lack of effective monitoring and modelling approaches that provide early warnings and help to prevent such event. To develop a predictive model one has to rely on past occurrence data, as such events are rare, enough data are usually not available to better understand and model such behavior. In such situations, it is advisable to use near misses and incident data to predict system performance and estimate accident likelihood. This paper is an attempt to demonstrate testing and validation of one such approach, dynamic risk assessment, using data from the BP Texas City refinery incident.Dynamic risk assessment is a novel approach which integrates Bayesian failure updating mechanism with the consequence assessment. The implementation of this methodology to the BP Texas City incident proves that the approach has the ability to learn from near misses, incident, past accidents and predict event occurrence likelihood in the next time interval.     

打造零事故的建筑安全文化

在研讨安全文化和建筑安全文化内涵,分析国内外建筑安全文化研究与国内实施现状的基础上,研究了5家国际建筑企业的安全创新活动,包括:企业背景、方案、实施过程等。结合利害关系者原理、风险管理和安全知识管理,笔者提出:要实现安全行为,应注重塑造员工的安全信念、态度和承诺;应有高层管理人员强有力的支持,将整个建筑业供应链的利害关系者都纳入到安全管理中,风险管理和安全知识管理的运用可促进零事故安全文化的形成。同时提出构建在我国实现零事故的建筑安全文化的流程,即承认-启动-执行-监督-更新的步骤,给出了一种提高员工安全知识、坚定员工安全信念、塑造员工安全态度、形成安全行为并最终打造健全安全文化的整体策略。     

中国民航行业可接受的安全水平研究

中国民航局提出持续安全理念,并正在制定国家航空安全方案,推动行业安全管理由目前基于规章符合性的安全监管逐渐转向规章符合性基础上的安全绩效监管,其中一项重要的工作是设定中国民航业可接受的安全水平,来衡量民航业是否满足持续改进安全的目标的要求。本文根据国际民航组织对可接受安全水平的设定指南,同时参考国外民航常用的事故指标,设计了一套中国民航行业可接受安全水平的指标体系,该指标体系包括安全评估指标、安全绩效评估指标和安全指数三层,并对该指标体系内事故率指标和事故征候率指标设定了未来10年的目标值。该指标体系及其目标值的设定不仅可作为衡量民航是否持续安全的标准,也可为航空运输企业设定自身的安全绩效考核指标提供参考。     

Using game theory to describe strategy selection for environmental risk and carbon emissions reduction in the green supply chain

This paper provides an approach in the context of green supply chain management, using game theory to analyze the strategies selected by manufacturers to reduce life cycle environmental risk of materials and carbon emissions. Through the application of the ‘tolerability of risk’ concept, a basis for determining the extent of environmental risk and carbon emissions reduction has been established. Currently, scant attention is given to holistic supervision of the supply chain with respect to carbon emissions by governments, and thus the starting hypothesis here is that the default strategy that manufacturers will adopt is only to reduce carbon emissions, and thereby environmental risk, in so far as this is compatible with the aim of increasing revenue. Moreover, we further hypothesize that, once necessary governmental policy has been established in the supply chain management, the strategic choices of the manufacturers would be influenced by government penalties or incentives. A case example is provided to demonstrate the insight that indicates the application of game theory. The limitations of the game model and analysis are discussed, laying a foundation for further work.     

重大事故应急处置基本原则与程序

提高重大事故的风险意识和应急处置能力,对坚持以人为本,建设和谐社会和保护人民群众生命财产安全有重要意义。本文论述了重大事故应急管理基本认识,应急处置过程应遵循的主要原则,论述了适用于各类突发公共事件的应急响应通用程序,并提出其应成为应急管理标准化的一个主要内容。     

Modeling of BP Texas City refinery incident

This paper presents detailed modeling results of the BP Texas City refinery incident. Three different approaches and explosion modeling tools were used to study the event. The results predicted by all three approaches are similar and all approaches identified a hazard potential comparable to what was witnessed on March 23, 2005. This confirms that quantitative risk assessment (QRA) has the ability to model a realistic scenario, and is therefore useful in safety measure design and emergency preparedness decision making to improve overall safety performance. Had QRA been conducted during a management of change (MOC) decision-making process, personnel trailers likely would not have been sited in such close proximity to the process units. The resulting severe consequences would then not have occurred. This work also aims to emphasize the importance of QRA in process safety management.

The paper presents the authors’ perception of the sequence of events involved in the incident based on the published literature available at the time of writing. It also assesses potential consequences for the perceived sequence of events using a variety of consequence assessment tools. In doing so, the analysis illustrates how this incident could have been prevented in spite of many operational difficulties. The observations and commentary presented in this paper are intended solely for the purpose of process safety enhancement on the basis of the lessons learned. BP has published its own detailed report; the incident is also the subject of a recent investigation by the US Chemical Safety and Hazard Investigation Board, with the CSB's final report being available at http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=52 (as of April 2007).     

石油钻井工业事故统计分析

石油钻井工业每年发生大量的事故,造成人员伤亡,环境污染和经济损失。本文通过对中东某采油区13年间3008起各类事故进行统计分析,找出不同因素影响下钻井事故发生的分布规律,为安全管理提供依据。统计结果表明,在炎热的季节,事故发生较为集中,在气候宜人的季节,事故相对较少;斋月所在的月份,事故数量明显增多,与斋月相邻的两个月事故数量明显减少;各类事故按其严重程度呈现金字塔形分布;手脚受伤在LTI中占据相当高的比例;HSE管理质量和承包商的变更对事故的分布有显著的影响。     

Safety management in different high-risk domains – All the same?

In view of safety management being introduced in more and more industries, the aim of this paper is to discuss what different high-risk industries can learn from each other and what limits for generalizing safety management methods within and across industries exist. After presenting core components of safety management, three attributes crucial to any organization’s functioning are described, which also affect the way safety management systems should be designed, run, and assessed. These attributes are (1) the kinds of safety to be managed, (2) the general approach to managing uncertainty as a hallmark of organizations that manage safety, and (3) the regulatory regime within which safety is managed. By discussing safety management in the context of these three attributes, contingencies are outlined that can help decision-makers in companies to tailor safety management to their own situation and support regulators in drawing up and evaluating safety management requirements for different industries while also promoting learning between different high-risk domains. Standards and procedures, safety training, incident reporting and investigation, and safety culture are taken as examples to illustrate why and how different aspects of organizational functioning should be taken into account when designing and evaluating safety management systems or elements thereof.     

机场运行安全规划中安全指标体系的构建

通过对机场运行安全规划中安全指标体系定位的分析,遵循可接受、可实施、可量化、可调控的原则,以结果和过程管理思想为指导,结合风险管理理论,构建机场运行安全规划中的安全指标体系。这个体系包括3个子体系,它们分别涉及运行安全的结果、运行安全的业务过程和运行安全管理绩效3个方面。其中,有关运行安全结果的子指标体系包括事故、事故征候、其他不安全事件3个维度11项指标;有关运行安全业务过程的子指标体系包括飞行区管理、机坪运行管理等7个维度20项指标;有关安全管理绩效的子指标体系包括安全政策与目标、风险管理等4个维度7项指标。     

The prevention of occupational injuries in two industrial plants using an incident reporting scheme

INTRODUCTION: The aim of this study was to examine whether the introduction of an incident reporting scheme with feedback in two industrial plants had an effect on the number of major incidents. METHOD: An intervention design with measurements before the implementation of the incident reporting scheme and two years later was used to examine the relationship between incident rates, safety climate, the willingness to report incidents and perceived management commitment to safety. RESULTS: The results showed that a successful implementation of an incident reporting scheme was followed by a decline in the incidence of major incidents at a Danish metal plant. A key factor in implementing the scheme was top management commitment, which was lacking at another plant, where the implementation of a similar scheme failed. CONCLUSION: Although the study shows some encouraging results concerning the use of incident reporting schemes to prevent occupational accidents, the possibility to draw causal conclusions is limited in the present study, and further studies are needed before the effectiveness of such schemes can be evaluated with certainty.     

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.     

近十年中国民航事故及事故征候的统计分析

对1996—2005年我国民航发生的32起事故及1147起事故征候进行统计分析,其结果表明:我国民航事故和事故征候的万架次率及万时率均呈下降态势,机组、机械和机务原因是我国民航事故和事故征候的主要原因,事故征候的主要类型是鸟击、空中停车、偏出/冲出跑道/场外接地,事故征候发生阶段依次为巡航、起飞、着陆、爬升和进近。该研究成果有助于寻找事故和事故征候成因和规律。明确安全管理重点和难点;采取有效的预警和预控对策。