An integrated framework to the predictive error analysis in emergency situation

This paper introduces an analysis framework and procedure to predictively analyze human errors in performing emergency tasks, which are mostly composed of cognitive activities, in nuclear power plants. The framework focuses on the cognitive errors and provides a new perspective in the utilization of context factors into cognitive error prediction. The basic viewpoint on the occurrence of cognitive error taken in this paper is that the cognitive function failures occur from the mismatch between operator's cognitive capability and the requirements of a given task and situational condition. In accordance with this viewpoint, performance influencing factors that influence the occurrence of human errors are classified into three groups, i.e. Performance Assisting Factors (PAF), Task Characteristic Factors (TCF), and Situational Factors (SF). This classification helps analysts view the overall task context in an integrative way by considering the level of PAF with the requirements of TCF and SF to predict the possibility of cognitive function failures. Further, it enables analysts to draw specific error reduction strategies. The framework suggested was applied to the analysis of cognitive error potential for the bleed and feed operation of emergency tasks in nuclear power plants.     

ABC干粉灭火器爆炸事故原因分析

通过化学分析、模拟试验和理论计算分析ABC干粉灭火器爆炸事故发生的原因.研究事故灭火器充装的ABC干粉灭火剂的性能、碳酸盐含量、生成气体种类、化学反应机理和爆破压力.结果表明,以磷酸铵盐为主料的ABC干粉灭火剂含有碳酸氢钠和碳酸钙,同时ABC干粉灭火剂存在含水率超标、吸湿性和斥水性不合格等质量问题.贮存期间,ABC干粉灭火剂中的磷酸铵盐可与碳酸氢钠、碳酸钙发生非预期化学反应,产生CO2,使灭火器筒体内压力升高,直至超过灭火器爆破压力,这是造成灭火器爆炸事故的根本原因.因此,生产实践中应科学配方、确保原材料质量、严格遵守生产工艺,以有效控制ABC干粉灭火剂质量和避免类似事故发生.     

我国工业爆炸事故原因分析

为了控制工业爆炸事故的发生 ,我们详细分析了近年来我国发生的特大、重大工业爆炸事故 4 0多例 ,占近年来特大、重大工业爆炸事故案例总数 2 / 3以上。虽然事故发生的后果是随机的 ,即受偶然性因素的影响 ;但事故致因则不是随机的 ,而是系统性因素即非偶然性因素的影响结果。因此 ,这 4 0多例事故的致因对于我国近年来全部工业爆炸事故的致因来说 ,具有合理的代表性。1　瓦斯爆炸事故1.1　直接原因1.1.1　瓦斯浓度超限的原因　　ａ .停电造成停风　　ｂ .停风　　———局扇被违章关停 (包括对临时停工的地点停风 ) ;　　———局扇故障或…     

浅析工伤事故的原因及预防措施

通过对工伤事故原因的分析 ,剖析了安全管理的缺陷 ,提出了预防事故的措施     

习惯性违章行为导致事故的潜在性原因分析

1 习惯性违章行为导致事故的案例 2009年1月24日12时40分,某公司烧结车间中控通知该班作业长有4台烧结机白煤槽位下降快,该作业长马上组织人员破料.在和小修作业长处理皮带打滑过程中,小修作业长说通知气焊进行处理,并在皮带机头部研究方案.这时该作业长急于追槽位,便到皮带尾部取下撞锤上的三角带,打开北侧防护栏,将三角带塞进皮带尾轮滚筒后,便通知中控起车(皮带带速0.7 m/s),在靠近一步观察效果时不慎踩在三角带上,左脚被三角带勒在机架间隙里,导致左小腿骨折.经调查,确定事故原因是:     

Fire incident at a refinery in West Malaysia: the causes and lessons learned

Refineries are major hazard installations (MHI) which possess large quantities of hazardous substances. Refineries are characterized by high complexity and tight-coupled organization. Due to the high complexity and level of interaction among subsystems, designers and operators are unable to predict failures at the refinery units. The world has seen many incidents in refineries through leakage, fire and explosions. The consequences of the accidents sometimes extend beyond the boundary of the property and reach the neighboring residents. This paper reviews refinery incidents worldwide and also outlines the causes of a fire incident at a refinery in West Malaysia and the lessons learned.     

An integrated approach to assessing the environmental and health impacts of pollution in the urban environment: Methodology and a case study

This paper presents a new decision-support methodology and software tool for sustainable management of urban pollution. A number of different methods and tools are integrated within the same platform, including GIS, LCA, fate and transport modelling, health impact assessment and multi-criteria decision analysis. The application of the framework is illustrated on a case study which investigates the environmental and health impacts of pollution arising from different industrial, domestic and transport sources in a city. The example city chosen for the study is Sheffield, UK, and the main pollutants considered are NO_x, SO₂ and PM10. The results suggest that the absence of the current large industrial sources in the city would lead to a 90% reduction of the SO₂ and 70% of the NO₂ ground concentrations, consequently preventing 27 deaths and 18 respiratory hospital admissions per annum for a population of 500,000. Based on the total annual mortality and hospital admissions in Sheffield for the year of the assessment, this means that 0.53% of premature deaths and 0.49% of respiratory hospital admissions would be prevented by the estimated reduction in air pollution.     

An integrated quantitative risk analysis method for natural gas pipeline network

Natural gas industry is developing rapidly, and its accidents are threatening the urban safety. Risk management through quantitative assessment has become an important way to improve the safety performance of the natural gas supply system. In this paper, an integrated quantitative risk analysis method for natural gas pipeline network is proposed. This method is composed of the probability assessment of accidents, the analysis of consequences and the evaluation of risk. It is noteworthy that the consequences analyzed here include those of the outside and inside gas pipelines. The analysis of consequences of the outside pipelines focuses on the individual risk and societal risk caused by different accidents, while those of the inside pipelines concerns about the risk of the economic loss because of the pressure re-distribution. Risk of a sample urban gas pipeline network is analyzed to demonstrate the presented method. The results show that this presented integrated quantitative risk analysis method for natural gas pipeline network can be used in practical application.     

Agent-based analysis and support for incident management

This paper presents an agent-based approach for error detection in incident management organizations. The approach consists of several parts. First, a formal approach for the specification and hierarchical verification of both traces and properties. Incomplete traces are enriched by enrichment rules. Furthermore, a classification mechanism is presented for the different properties in incident management that is based on psychological literature. Classification of errors provides insight in the functioning of the agents involved with respect to their roles. This insight enables the provision of dedicated training sessions and allows software support to give appropriate warning messages during incident management.     

一种基于层次分析法的危险化学品源安全评价综合模型

危险化学品源的安全评价是安全生产管理中的一项重要内容.目前用于危险化学品源安全评价与分级的常用方法有后果分析法、道指数法、蒙德指数法以及使用临界系数判别重大危险源的方法等.在实际应用中,单独使用某一方法时,由于存在各种片面性问题而得不到满意的评价结果; 几种方法同时使用时,其评价指标、评价结果以及结果的形式又会互相冲突.为解决上述问题,建立了基于层次分析法的综合评价模型.首先,根据安全评价要求构建3层次的评价体系,在各层次中构造判断矩阵,并计算4种常用方法相对综合评价模型的置信度; 其次,对各方法统一危险分级标准,均采用危险分数划定危险级别,并取各危险分数的加权平均值--综合危险分数作为综合评价模型下的危险源分级标准.采用综合评价模型可消除单一方法进行评价时的片面性和偏差,同时,评价结果的一致化使得判断危险化学品源的危险级别以及由此采取相应级别的管理措施成为可能,将更有利于实际安全生产管理指导.     

An extended HAZOP analysis approach with dynamic fault tree

An extended hazard and operability (HAZOP) analysis approach with dynamic fault tree is proposed to identify potential hazards in chemical plants. First, the conventional HAZOP analysis is used to identify the possible fault causes and consequences of abnormal conditions, which are called deviations. Based on HAZOP analysis results, hazard scenario models are built to explicitly represent the propagation pathway of faults. With the quantitative analysis requirements of HAZOP analysis and the time-dependent behavior of real failure events considered, the dynamic fault tree (DFT) analysis approach is then introduced to extend HAZOP analysis. To simplify the quantitative calculation, the DFT model is solved with modularization approach in which a binary decision diagram (BDD) and Markov chain approach are applied to solve static and dynamic subtrees, respectively. Subsequently, the occurrence probability of the top event and the probability importance of each basic event with respect to the top event are determined. Finally, a case study is performed to verify the effectiveness of the approach. Results indicate that compared with the conventional HAZOP approach, the proposed approach does not only identify effectively possible fault root causes but also quantitatively determines occurrence probability of the top event and the most likely fault causes. The approach can provide a reliable basis to improve process safety.     

毒气泄漏事故避难场所避难效果分析

有毒气体泄漏时,疏散和就地避难都是保护人员安全的有效行动。当疏散行动无效时,此时可考虑进行就地避难,应急决策者必须准确认识就地避难的可靠性。文中模拟分析了渗透吸附作用、换气次数、避难室空间体积、有效吸附面积对避难室内浓度的影响。结果表明,渗透吸附作用的存在明显降低了室内浓度,且强度越大浓度越低;换气次数越小,浓度越低;避难室空间越大,浓度越低,但影响不明显;吸附面积与空间体积之比越大,浓度下降越明显;毒负荷指数越大,规定暴露时间内避难室内毒负荷上升越缓慢。最后确定了特定场景下避难室最佳换气次数。     

冗余系统应用于安全管理的探讨

利用故障树方法证明了系统中增加有效的冗余件能大大增加系统的安全性，提高设备的本质安全化的水平，加强了安全管理的效果，同时对冗余系统的插入方式进行了分类，列举了应用实例。     

线路板废水处理工艺的探讨

简要介绍了线路板工业的发展状况，对线路板废水的来源、处理工艺、主要设计参数、 操作要点等问题进行了详细的论述。     

企业外用工安全管理探讨

企业用工制度改革后,外用工越来越多,给企业安全管理带来了许多新的问题。叙述了对外用工安全管理中存在的问题,提出了改进措施。     

An integrated EDIB model for probabilistic risk analysis of natural gas pipeline leakage accidents

Natural gas pipeline construction is developing rapidly worldwide to meet the needs of international and domestic energy transportation. Meanwhile, leakage accidents occur to natural gas pipelines frequently due to mechanical failure, personal operation errors, etc., and induce huge economic property loss, environmental damages, and even casualties. However, few models have been developed to describe the evolution process of natural gas pipeline leakage accidents (NGPLA) and assess their corresponding consequences and influencing factors quantitatively. Therefore, this study aims to propose a comprehensive risk analysis model, named EDIB (ET-DEMATEL-ISM-BN) model, which can be employed to analyze the accident evolution process of NGPLA and conduct probabilistic risk assessments of NGPLA with the consideration of multiple influencing factors. In the proposed integrated model, event tree analysis (ET) is employed to analyze the evolution process of NGPLA before the influencing factors of accident evolution can be identified with the help of accident reports. Then, the combination of DEMATEL (Decision-making Trial and Evaluation Laboratory) and ISM (Interpretative Structural Modeling) is used to determine the relationship among accident evolution events of NGPLA and obtain a hierarchical network, which can be employed to support the construction of a Bayesian network (BN) model. The prior conditional probabilities of the BN model were determined based on the data analysis of 773 accident reports or expert judgment with the help of the Dempster-Shafer evidence theory. Finally, the developed BN model was used to conduct accident evolution scenario analysis and influencing factor sensitivity analysis with respect to secondary accidents (fire, vapor cloud explosion, and asphyxia or poisoning). The results show that ignition is the most critical influencing factor leading to secondary accidents. The occurrence time and occurrence location of NGPLA mainly affect the efficiency of emergency response and further influence the accident consequence. Meanwhile, the weight ranking of economic loss, environmental influence, and casualties on social influence is determined with respect to NGPLAs.     

An innovative and comprehensive approach for the consequence analysis of liquid hydrogen vessel explosions

Hydrogen is one of the most suitable solutions to replace hydrocarbons in the future. Hydrogen consumption is expected to grow in the next years. Hydrogen liquefaction is one of the processes that allows for increase of hydrogen density and it is suggested when a large amount of substance must be stored or transported. Despite being a clean fuel, its chemical and physical properties often arise concerns about the safety of the hydrogen technologies. A potentially critical scenario for the liquid hydrogen (LH₂) tanks is the catastrophic rupture causing a consequent boiling liquid expanding vapour explosion (BLEVE), with consequent overpressure, fragments projection and eventually a fireball. In this work, all the BLEVE consequence typologies are evaluated through theoretical and analytical models. These models are validated with the experimental results provided by the BMW care manufacturer safety tests conducted during the 1990's. After the validation, the most suitable methods are selected to perform a blind prediction study of the forthcoming LH₂ BLEVE experiments of the Safe Hydrogen fuel handling and Use for Efficient Implementation (SH₂IFT) project. The models drawbacks together with the uncertainties and the knowledge gap in LH₂ physical explosions are highlighted. Finally, future works on the modelling activity of the LH₂ BLEVE are suggested.     

基于贝叶斯网络的一种事故分析模型

贝叶斯网络被认为是人工智能研究中不确定性知识表示和推理的重要工具。当前在系统安全领域中已开始运用贝叶斯网络技术进行故障诊断分析，然而故障只是诱发事故的因素之一，无法系统的评价事故背后的隐患，对事故后果的预测也甚少涉及。笔者将贝叶斯网络作为一种事故分析手段，在事故致因理论的基础上提出了一种基于危险因素-事故-事故危害的三层贝叶斯网络拓扑模型；阐述了网络模型层次间的因果关联关系、各层次的构成、节点的描述方法以及网络模型的构建方法；最后通过一个天然气球罐的分析案例验证了该模型分析方法的可行性和有效性。