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.     

Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Factors contributing to US chemical plant process safety incidents from 2010 to 2020

Process safety incidents can result in injuries, fatalities, environmental impacts, facility damage, downtime & lost production, as well as impacts on a company's and industry's reputation. This study is focused on an analysis of the most commonly reported contributing factors to process safety incidents in the US chemical manufacturing industry. The database for the study contained 79 incidents from 2010 to 2019, partly investigated by the Chemical Safety Board (CSB). To be included in the study, the CSB archive of incident investigations were parsed to include only incidents which occurred at a company classified as 325 in the North American Industry Classification System (NAICS), assigned to businesses that participate in chemical manufacturing. For each incident, all of the identified contributing factors were catalogued in the database. From this list of identified contributing factors, it was possible to name the ‘top three’ contributing factors. The top three contributing factors cited for the chemical manufacturing industry were found to be: design; preventive maintenance; and safeguards, controls & layers of protection. The relationship between these top contributing factors and the most common OSHA citations was investigated as well. The investigation and citation history for NAICS 325 companies in the Occupational Safety & Health Administration (OSHA) citations database was then analysed to assess whether there was any overlap between the top reported contributing factors to process safety events and the top OSHA citations recorded for the industry. A database consisting of the inspection and citation history for the chemical manufacturing industry identified by NAICS code 325 was assembled for inspections occurring between 2010 and 2020 (August). The analysis of the citation history for the chemical manufacturing industry specifically, identified that the list of the top contributing factors to process safety incidents overlapped with the most common OSHA violations. This finding is relevant to industry stakeholders who are considering how to strategically invest resources for achieving maximum benefit – reducing process safety risk and simultaneously improving OSHA citation history.     

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.     

Do industrial incidents in the chemical sector create equity market contagion?

IntroductionThis paper examines a number of US chemical industry incidents and their effect on equity prices of the incident company. Furthermore, this paper then examines the contagion effect of this incident on direct competitors.MethodEvent study methodology is used to assess the impact of chemical incidents on both incident and competitor companies.ResultsThis paper finds that the incident company experiences deeper negative abnormal returns as the number of injuries and fatalities as a result of the incident increases. The equity value of the competitor companies suffer substantial losses stemming from contagion effects when disasters that occur cause ten or more injuries and fatalities, but benefit from the incident through increasing equity value when the level of injury and fatality is minor.ConclusionsPresence of contagion suggests collective action may reduce value destruction brought about by safety incidents that result in significant injury or loss of life.Practical ApplicationsThis research can be used as a resource to promote and justify the cost of safety mechanisms within the chemical industry, as incidents have been shown to negatively affect the equity value of the not just the incident company, but also their direct competitors.     

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.     

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.     

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.     

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.     

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.     

Operational risk assessment of chemical industries by exploiting accident databases

Accident databases (NRC, RMP, and others) contain records of incidents (e.g., releases and spills) that have occurred in the USA chemical plants during recent years. For various chemical industries, [Kleindorfer, P. R., Belke, J. C., Elliott, M. R., Lee, K., Lowe, R. A., & Feldman, H. I. (2003). Accident epidemiology and the US chemical industry: Accident history and worst-case data from RMP*Info. Risk Analysis, 23(5), 865–881.] summarize the accident frequencies and severities in the RMP*Info database. Also, [Anand, S., Keren, N., Tretter, M. J., Wang, Y., O’Connor, T. M., & Mannan, M. S. (2006). Harnessing data mining to explore incident databases. Journal of Hazardous Material, 130, 33–41.] use data mining to analyze the NRC database for Harris County, Texas.Classical statistical approaches are ineffective for low frequency, high consequence events because of their rarity. Given this information limitation, this paper uses Bayesian theory to forecast incident frequencies, their relevant causes, equipment involved, and their consequences, in specific chemical plants. Systematic analyses of the databases also help to avoid future accidents, thereby reducing the risk.More specifically, this paper presents dynamic analyses of incidents in the NRC database. The NRC database is exploited to model the rate of occurrence of incidents in various chemical and petrochemical companies using Bayesian theory. Probability density distributions are formulated for their causes (e.g., equipment failures, operator errors, etc.), and associated equipment items utilized within a particular industry. Bayesian techniques provide posterior estimates of the cause and equipment-failure probabilities. Cross-validation techniques are used for checking the modeling, validation, and prediction accuracies. Differences in the plant- and chemical-specific predictions with the overall predictions are demonstrated. Furthermore, extreme value theory is used for consequence modeling of rare events by formulating distributions for events over a threshold value. Finally, the fast-Fourier transform is used to estimate the capital at risk within an industry utilizing the frequency and loss-severity distributions.     

The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.     

Updating the economic cost of large-scale industrial accidents: Application to the historical analysis of accidents

This paper analyses the feasibility of applying different update rates of industrial prices to the economic assessments of accidents with special emphasis on those related to the chemical process industry. The advantages and disadvantages of applying this technique to the historical analysis of accidents are analysed and compared with the results obtained with the five most widely used indexes. The results of a general analysis of the historical evolution of the cost of accidents recorded in two prestigious databases are also presented. Valid data are obtained for decision-making with regard to insurance premiums, revaluation of assets and risk management (administration, safety management of large chemical complexes).     

A violent,episodic vapour cloud explosion assessment: Deflagration-to-detonation transition

A large vapour cloud explosion (VCE) followed by a fire is one of the most dangerous and high consequence events that can occur in petrochemical facilities. The current process of safety practice in the industry in VCE assessment is to assume that all VCEs are deflagration. This assumption has been considered for nearly three decades. In recent years, major fire and VCE incidents in fuel storage depots gained considerable attention in extreme high explosion overpressure due to the transition from Deflagration to Detonation (DDT). Though the possibility of DDTs is lower than deflagrations, they have been identified in some of the most recent large-scale VCE incidents, including Buncefield (UK), 2005, San Juan explosion (US), 2009, and IOCL Jaipur (India), 2009 event. Such an incident established the need to understand not only VCE but also the importance of avoiding the escalation of minor incidents into much more devastating consequences.Despite decades of research, understanding of the fundamental physical mechanisms and governing factors of deflagration-to detonation transition (DDT) transition remains mostly elusive. An extreme multi-scale, multi-physics nature of this process uncertainly makes DDT one of the “Grand Challenge” problems of typical physics, and any significant developments toward its assured insistence would require revolutionary step forward in experiments, theory, and numerical modelling. Under certain circumstances, nevertheless, it is possible for DDT to occur, and this can be followed by a propagating detonation that quickly consumes the remaining detonable cloud. In a detonable cloud, a detonation creates the worst accident that can happen. Because detonation overpressures are much higher than those in a deflagration and continue through the entire detonable cloud, the damage from a DDT event is more severe. The consideration of detonation in hazard and risk assessment would identify new escalation potentials and recognize critical buildings impacted. This knowledge will allow more effective management of this hazard.The main conclusion from this paper is that detonations did occur in Jaipur accident at least part of the VCE accidents. The vapour cloud explosion could not have been caused by a deflagration alone, given the widespread occurrence of high overpressures and directional indicators in open uncongested areas containing the cloud. Additionally, the major incident has left many safety issues behind, which must be repeatedly addressed. It reveals that adequate safety measures were either underestimated or not accounted for seriously. This article highlights the aftermath of the IOCL Jaipur incident and addresses challenges put forward by it.     

Challenges and needs for process safety in the new millennium

Process industries have made quite a bit of progress in process safety since the tragic night of December 2, 1984 in Bhopal. Nonetheless, incidents continue to occur on a regular basis due to insufficient understanding of the urgency to identify best practices and drive for process safety improvements in the organization. This paper addresses some of the critical challenges in implementing effective safety programs: (a) failure to learn from past incidents and to capture those lessons into process design, procedures, training, maintenance, and other programs, (b) insufficient attention to leading indicators, and (c) an increase in complexity of process operations and lack of communication. In the presence of these challenges, there is a great need to develop better solutions by utilizing good science based approaches and best practice studies. Potential research areas include, but are not limited to, incident database analysis, reactive chemicals, inherently safer design, combustible dust explosion, facility siting, and the flammability of fuel mixtures and aerosols. In addition, an example was presented on LNG industry safety to illustrate that science-based research is needed to ensure the safe operation and to avoid or mitigate unintended consequences.     

Lessons learned from recent incidents: Facility siting, atmospheric venting, and operator information systems

Recent incidents have focused attention on a number of technical and management systems that need to be addressed by industry. A multiple layer of protection approach is essential for the prevention of incidents and/or reduction of consequences. Safety culture and operational discipline are the overall embracing factors that influence the safety performance of a facility. However, as recent events have indicated, there are a number of technical and engineering issues that must also be developed and implemented appropriately. Some of these issues that could lead to incidents with catastrophic consequences include facility siting and atmospheric relief venting. Impact of operator information systems on the prevention of releases of hazardous materials from their containment is also another significant factor that should be given appropriate attention.

This paper describes these three topics based on the findings from recent incidents and historical data. Engineering standards, regulatory requirements, and industry practices are discussed for facility siting, atmospheric relief venting, and operator information systems. Finally, a summary of gaps and needs in technology, standards, and practices is presented.     

Modeling the effects of production pressure on safety performance in construction projects using system dynamics

Introduction: Construction incidents occur due to system failures, not due to a single factor such as unsafe behavior or condition. Therefore, construction safety should be investigated using a systematic view capable of illustrating the complex nature of incidents. Construction projects are also often behind their planned schedule and suffer from various pressures caused by contractual deadlines or clients. Previous studies demonstrated that such pressures negatively affect safety performance; however, the process of how production pressure influences safety performance is not fully investigated. Method: The present research aimed to understand the feedback mechanism of how production pressure interactively affects safety performance and safety-related managerial components in a construction project. Ground theory method (GTM) is used to create a conceptual causal loop diagram that shows the relationship between incident rate and other variables such as labor hour, actual and planned progress, safety climate, rework, and safety training. Moreover, a power plant construction project was used as a case study to practically investigate the conceptual model; a case study is employed to build a System Dynamics (SD) model. The simulation model was then validated using behavior reproduction and sensitivity analysis. Results: The results of the inequality statistics show that the simulation model can be used to forecast trends in the incident rate.     

Method for evaluating learning from incidents using the idea of “level of learning”

Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be questioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.