Handling data uncertainties in event tree analysis

Event tree analysis (ETA) is an established risk analysis technique to assess likelihood (in a probabilistic context) of an accident. The objective data available to estimate the likelihood is often missing (or sparse), and even if available, is subject to incompleteness (partial ignorance) and imprecision (vagueness). Without addressing incompleteness and imprecision in the available data, ETA and subsequent risk analysis give a false impression of precision and correctness that undermines the overall credibility of the process. This paper explores two approaches to address data uncertainties, namely, fuzzy sets and evidence theory, and compares the results with Monte Carlo simulations. A fuzzy-based approach is used for handling imprecision and subjectivity, whereas evidence theory is used for handling inconsistent, incomplete and conflicting data. Application of these approaches in ETA is demonstrated using the example of an LPG release near a processing facility.     

生活事件分析法在煤矿企业中的应用

我国煤矿一再的发生事故,绝大部分原因是人为失误.根据人为失误的发生机理,本文提出了生活事件分析方法,并研制了其配套应用程序,对某煤矿企业的人因事故危险性进行了实际评价.该方法可方便地应用于煤矿企业人为事故的预防工作中.     

Crash data analysis: collective vs. individual crash level approach

INTRODUCTION: Traffic safety literature has traditionally focused on identification of location profiles where "more crashes are likely to occur" over a period of time. The analysis involves estimation of crash frequency and/or rate (i.e., frequency normalized based on some measure of exposure) with geometric design features (e.g., number of lanes) and traffic characteristics (e.g., Average Annual Daily Traffic [AADT]) of the roadway location. In the recent past, a new category of traffic safety studies has emerged, which attempts to identify locations where a "crash is more likely to occur." The distinction between the two groups of studies is that the latter group of locations would change based on the varying traffic patterns over the course of the day or even within the hour. METHOD: Hence, instead of estimation of crash frequency over a period of time, the objective becomes real-time estimation of crash likelihood. The estimation of real-time crash likelihood has a traffic management component as well. It is a proactive extension to the traditional approach of incident detection, which involves analysis of traffic data recorded immediately after the incident. The units of analysis used in these studies are individual crashes rather than counts of crashes. RESULTS: In this paper, crash data analysis based on the two approaches, collective and at individual crash level, is discussed along with the advantages and shortcomings of the two approaches.     

基于可靠性理论的事件树分析方法研究

事件树分析过程中事件树的编制和分析方法缺乏系统性,导致实际运用中事件树的编制缺乏可操作性。从目标系统的选择、环节事件逻辑关系的确定、定量分析中基本数据的来源和确定方法等三个问题进行了系统研究,并以可靠性的相关理论为基础,提出"从控制和影响初始事件发展演化的角度,调查分析对初始事件做出响应的安全功能,按系统工作原理对目标系统进行重构,构建目标系统的功能结构图,画出系统的可靠性框图"入手,对"传统的事件树绘制程序"进行修正,解决了事件树分析过程中目标系统的选择、环节事件逻辑关系的确定以及定量分析基本数据的确定方法等问题。修正后的方案对实现事件树的正确编制和系统分析逻辑更清晰,操作指导性更强。     

突发公共事件信息解读机制的社会学分析

有效的危机管理是建立在公共安全预警决策分析机制的充分准备基础之上的，结合我国公共安全预警决策分析机制的要求，必须开展公共安全系统模型研究和风险预测研究；建立突发公共事件预警应急与对策分析系统；发挥Avaya应急呼叫中心集成解决方案作用；重视依靠专家力量把握平战结合的信息管理。     

计算机辅助故障模式影响分析与事件序列图综合分析方法研究

故障模式影响分析(Failure Mode Effect Analysis, FMEA)和事件序列图(Event Sequence Diagram, ESD)是分析系统故障因果关系的两种常用技术,在分别独立应用时,既有各自的优点,也存在着一定的缺陷和不足,主要体现为: FMEA不能展示故障模式到故障后果的推演过程; ESD模型的合理性很大程度上取决于初始事件的确定,而该方法本身不能实现这一功能.本文综合FMEA与ESD的优点,阐述了复杂动态系统FMEA与ESD综合分析的思路,对现有FMEA进行了一定的改进,并进一步分析计算机辅助FMEA和ESD综合方法建模的原理和实现技术.     

Subjective theories of organizing and learning from events

The present paper outlines potential shortcomings of analyzing events in high hazard systems. We argue that the efficiency of organizational learning within high hazard systems is at least partially undermined by the subjective theories of organizing held by their members. These subjective theories basically reflect an “engineering” understanding of “how a system and its components perform”, and are assumed to involve (social-) psychological blind spots when applied to the analysis of events. More specifically, we argue that they neglect individual motives and goals that critically drive work performance and social interactions in high hazard systems. First, we focus on the process of identifying the causes of failed organizing within the course of an event analysis. Our analysis reveals a mismatch between the basic functional assumptions of the event analyst on the motives of social actors involved in an event and on the other hand, the perspective held by the social actors themselves. Second, we discuss the process of correcting failed social system performance after events. Thereby we draw on blind spots that emerge from the direct application of technical safety principles (i.e., standardization and redundancy) to the organization of social systems. Finally, we propose some future research strategies for developing event analysis methods which are aimed at improving an organization’s learning potential.     

用沙坝断层滑移型微震事件群活动特征分析

提出利用空间聚类算法DBSCAN与S波、P波能量比(ES/EP)相结合的方法,识别得到开磷用沙坝矿2014年3—5月IMS微震监测系统数据库中F310断层附近的断层滑移型微震事件群。对微震事件群区域的微震事件活动率与时间分布特征、视体积与施密特数、b等特征进行分析。结果表明:微震事件主要集中在每天的12时到14时,震级大于-0.5级的微震事件主要发生在每天的11时到16时;4月3—10日、5月2—9日和5月16—23日3个时间段内微震事件活动频繁,而且都具有施密特数时间序列曲线斜率增大、累积视体积曲线急剧下降、b出现下降的特性,表明这3个时间段断层区域岩体不稳定,发生危险事故的可能性较大。相比于同等能量的爆破事件,断层滑移型微震事件更能诱发顶板冒落和矿柱坍塌甚至岩爆等灾害,分析其活动特征可为分析断层活动趋势提供有效的预判信息。     

Lessons learnt from a crisis event: How to foster a sound safety culture

Recent events in the nuclear industry have blamed a declining safety culture both on the utility and regulatory side as the major responsible. Confidence in the nuclear industry can be dramatically affected by such events. In this context, the present paper analyses a recent crisis event that involved a research reactor. It shows the time history of the event and how its escalation brought to a temporary shut down of the reactor. In-depth analysis of the event pointed out safety culture deficiencies within the organization. The paper presents the key elements in the ensuing organizational change process and describes the different phases (short and long term approaches), players and measures involved in the process that the organisation set up to address deficiencies and improve safety culture. The case represents an interesting example from which important lessons can be learnt. In particular, staff motivation in terms of involvement in improvement activities is considered central in managing safety.     

A framework for learning from incidents in the workplace

Learning from Incidents (LFI) in the workplace has been gaining increasing importance in the Health, Safety and Environment context. Although organisations adopt a variety of LFI initiatives, it is often unclear what learning approaches are the most appropriate and the most effective for different types of incidents across a range of contexts. The aim of the paper is to surface factors that are important for effective Learning from Incidents (LFI). The paper builds on a conceptual framework for learning from incidents, developed through an earlier study. This conceptual framework was validated through empirical data collected at two multinational corporations in the energy sector. From this data a refined framework for learning from incidents was devised with five factors important for LFI: participants of learning, type of incidents, learning process, type of knowledge and learning context. This framework can be used as an evaluation tool and as a guidance tool to develop holistic, organisational learning approaches.     

Safety in fishing — learning from experience

This article critically examines the level of safety in some sections of the UK fishing industry not only by looking at the available statistics but also by examining actual recent case histories.In 1989 the UK Department of Transport established the Marine Accident Investigation Branch (MAIB). Case histories published by MAIB have been taken as the basis for the article in order to illustrate and draw lessons from incidents that occur in fishing.Fishing will always be a high risk profession but there are ways in which risks can be diminished. Many of the problems are due to vessels being built below the 12 m threshold at which the 1975 Safety Rules currently apply. Some of the vessels lack adequate reserve stability to withstand capsize in the dynamic situation and there are deficiences in design and safety equipment. The training programmes introduced by Seafish for Survival, Fire Fighting and First Aid are now mandatory for all new entrants and these have almost certainly resulted in the saving of lives. However, there needs to be a much greater awareness of accident prevention and the article makes a plea for this to be given more attention.Each case study is probably unique or there are some specific circumstances as to why the accident happened. Nevertheless, there are always underlying lessons to be learnt from every incident of this type, even if there is no loss of life or serious injury.     

建筑工人不安全行为的模仿与学习的调查与分析

为了控制不安全行为在建筑工人中的传播和流行,基于社会学习理论,通过行为调查、理论分析和案例研究,对建筑工人不安全行为的模仿与学习的方式、过程和影响因素进行了研究,提出了控制不安全行为传播的策略。结果表明:模仿与学习是建筑工人不安全行为复制和传播的重要方式和途径,对新不安全行为产生起着联系和催化作用。建筑工人不安全行为的模仿与学习的方式有视听式、想象式和参与式,其中视听式是最主要方式。建筑工人不安全行为的模仿与学习的影响因素涵盖榜样及其行为、模仿者和模仿学习过程。其中,榜样的权威性和影响力是最重要的增强因素,不安全行为后果的威慑力是最重要的抑制因素。     

Retraction statement: Authentically leading groups: The mediating role of collective psychological capital and trust

The following article from the Journal of Organizational Behavior, Authentically leading groups: The mediating role of collective psychological capital and trust by Fred O. Walumbwa, Fred Luthans, James B. Avey and Adegoke Oke, published online on 1st September 2009 in Wiley Online Library ( www.wileyonlinelibrary.com ) and in Volume 32, Issue 1, January 2011, Pages 4‐24, has been retracted by the journal's Editor in Chief, Neal M. Ashkanasy, and John Wiley & Sons Ltd. The retraction is on the grounds of the authors' advice that they made an error in relation to the level of analysis used. As a result of this error, the authors incorrectly calculated key fit statistics. When correctly estimated, the fit statistics do not provide an acceptable level of support for the hypothesized model, rendering the authors' conclusions, as stated in the article, unsustainable.     

A posteriori hazard analysis and feedback information of an accidental event in the grains storage of an agrochemical product

The present study concerns a hazardous event which occurred in an industrial storage tank of a ground insecticide. A preliminary post-accident approach of the hazard evaluation is performed. The rapid report of the presence of an unstable functional group in the active product and of its potential thermal instability (CHETAH indices) has led to complete this examination by an experimental study of thermal analysis using isotherm exposition measurement (DTA) or with temperature programming by differential scanning calorimetry (DSC) and oxidability tests (BAM). The apparent kinetics of decomposition of the active matter of the ground insecticide has been represented by a global Arrhenius law.

A model designed for the simulation of heterogeneous thermal runaways based on the numerical solution of the transient mass and energy balances has been further applied to define the critical conditions of the storage and simulate its behavior.

The results obtained during this analysis with the experienced feedback allowed us on one side to explain the hazardous event and especially on the other side to modify the operating protocol of the conditions of formulation of the active matter on the inert mineral support.     

航天器总装事故原因事件重要度分析

为解决传统安全性定量分析方法不能描述航天器总装这一复杂人-机-环系统的失效数据波动性和非严格逻辑关系的问题,结合生产实际,采用问卷调查的方法找出影响总装事故的风险因素,即导致事故的事件发生可能性、输入事件对输出事件的影响程度等。在验证调查数据的有效性之后,应用基于模糊数的模糊因果图(FCD),计算某航天器与支架车连接作业的事故风险可能性。提出原因事件重要度的计算方法。通过计算发现,人员注意力和发动机保护罩作用是导致发动机损伤的关键事件。与模糊事故树(FFT)、贝叶斯网络(BN)重要度计算结果对比表明,模糊重要度计算结果能反映事故发生可能性对原因事件发生可能性值的增减的敏感度。     

Management of the UK HSE failure rate and event data

The UK Health and Safety Executive (HSE) requires failure rate data for the assessment of COMAH safety reports and in the implementation of its statutory functions relating to land use planning in the vicinity of major hazard sites. Many of the existing failure rates used by HSE were derived over 20 years ago, but have been subject to periodic review to ensure that they remain appropriate for modern planning enquiries or quantified risk assessments. HSE needs to be assured that its sources of data and their application continue to be fit to support its statutory duties.HSE has implemented a programme of work to be carried out by the Health and Safety Laboratory (HSL). This includes the development and maintenance of a single source of quality assured failure rate data, ideally accessible from the Internet, bringing together and updating existing failure rate data sources and reviewing new sources not previously available to HSE.A review of HSE’s current failure rate values is being carried out and this will be used to generate a single source of publically available failure rate data for use by both HSE and the public. This would help industry and HSE move toward a common position or understanding on failure rates. It would also help ensure that HSE professional advice is defensible and transparent.This paper will detail the progress made to date on the programme of work. It will also discuss the issues that arise as a consequence of changing failure rates and how HSE deals with these issues.     

体育馆中人员安全疏散的仿真分析

针对现今公共活动中的人群踩踏事故频发问题,应用计算机仿真技术研究紧急情况下建筑物中人群逃生规律及设施优化方法。设置人员体质、移动余值、出口逃生条件等因素,扩展元胞自动机(CA)行人流模型。利用Matlab语言实现可视化模拟。对莱阳市某体育馆进行人流疏散模拟,分析得到其安全设施的最佳设定参数,实现优化目的。结果表明:该体育馆仿真疏散完成总时间为103.5 s,可引发踩踏事故的疏散危险期长达49.0 s,疏散危险期长度为判断踩踏事故发生可能性的重要指标;出口宽度、数量均与疏散时间呈负相关,且均存在疏散能力饱和点。据此提出将宽度改建为2.5 m、数量增加到6个的优化方案,此方案疏散危险期为9.0 s,疏散总时间缩短到33.5 s。