A study of maintenance-related major accident cases in the 21st century

This paper is based on a review of 183 detailed, major accident investigation and analysis reports related to the handling, processing and storage of hydrocarbons and hazardous chemicals over a decade from 2000 to 2011. The reports cover technical, human and organizational factors. In this paper, the Work and Accident Process (WAP) classification scheme is applied to the accident reports with the intention of investigating to what extent maintenance has been a cause of major accidents and what maintenance-related causes have been the most frequent.The main objectives are: (1) to present more current overall statistics of maintenance-related major accidents, (2) to investigate the trend of maintenance-related major accidents over time, and (3) to investigate which maintenance-related major accident causes are the most frequent, requiring the most attention in the drive for improvement.The paper presents statistical analysis and interpretation of maintenance-related major accidents’ moving averages as well as data related to the types of facility, hazardous substances, major accidents and causes. This is based on a thorough review of accident investigation reports.It is found that out of 183 major accidents in the US and Europe, maintenance was linked to 80 (44%) and that the accident trend is decreasing. The results also show that “lack of barrier maintenance” (50%), “deficient design, organization and resource management” (85%) and “deficient planning/scheduling/fault diagnosis” (69%) are the most frequent causes in terms of the active accident process, the latent accident process and the work process respectively.     

Global process industry initiatives to reduce major accident hazards

In the past 10 years, the vapor cloud explosion at Texas City, the ammonium nitrate explosion in Toulouse, a pipeline disaster in Belgium, and three near total loss events in Norway have highlighted that major accident process safety is still a serious issue. Hopes that PSM or Safety Case regulations would reduce process events by 80% have not proven true. The Baker Panel, convened after Texas City developed a series of recommendations, mainly around leadership, incentives, safety culture and more effective implementation of PSM systems. Many US-based companies are working hard to implement the Baker recommendations. In Europe, an approach built around safety barriers, especially relating to technical safety systems, is being widely adopted.The author’s company has carried out a global survey of process industry initiatives, for both upstream and downstream activities, to identify what the industry itself is planning to enhance process safety in the next 5-10 years. This paper presents a summary of some of the major programs and initiatives as apply to traditional oil majors, newer national oil companies, and the chemical industry. These are a mixture of Baker recommendations, barrier approaches and tighter integration of process safety and asset integrity. While the factor of 10 improvement achieved in occupational safety over the past 20 years seems unattainable for process safety, a factor of 3-4 improvement in the next 20 years does seem possible. This would call for significant effort on the part of operators, but the benefits fully justify the effort.     

Challenges and proposals for managing major accident risk through the planning process

Major accidents are characterized by complex causal patterns with many factors influencing the occurrence of such accidents. The causes can be found not just in the execution of the work, but also in the preparations and planning before performing the work. In this paper, we have identified a set of challenges related to planning that may influence major accident risk. The basis is theoretical and partly empirical. The theoretical part is from a study of major accident theories. The empirical part includes studies of investigation reports, interviews and a workshop. The challenges identified can be grouped into four main topics including inadequate plan, inadequate planning, inadequate shared overview and understanding and late risk identification. The challenges have subsequently been addressed through a set of proposed improvements, which are aimed at improving the planning process to better manage major accident risk.     

Maintenance-related major accidents: Classification of causes and case study

The potential for major accidents is inherent in most industries that handle or store hazardous substances, for e.g. the hydrocarbon and chemical process industries. Several major accidents have been experienced over the past three decades. Flixborough Disaster (1974), Seveso Disaster (1976), Alexander Kielland Disaster (1980), Bhopal Gas Tragedy (1984), Sandoz Chemical Spill (1986), Piper Alpha Disaster (1988), Philips 66 Disaster (1989), Esso Longford Gas Explosion (1998), Texas City Refinery Explosion (2005), and most recently the Macondo Blowout (2010) are a few examples of accidents with devastating consequences.Causes are being exposed over time, but in recent years maintenance influence tends to be given less attention. However, given that some major accidents are maintenance-related, we intend to concentrate on classifying them to give a better insight into the underlying and contributing causes.High degree of technological and organizational complexity are attributes of these industries, and in order to control the risk, it is common to deploy multiple and independent safety barriers whose integrity cannot be maintained without adequate level of maintenance. However, maintenance may have a negative effect on barrier performance if the execution is incorrect, insufficient, delayed, or excessive. Maintenance can also be the triggering event.The objectives of this article are: (1) To investigate how maintenance impacts the occurrence of major accidents, and (2) To develop classification schemes for causes of maintenance-related major accidents.The paper builds primarily on model-based and empirical approaches, the latter being applied to reports on accident investigation and analysis. Based on this, the Work and Accident Process (WAP) classification scheme was proposed in the paper.     

生产安全事故风险分级与分级监察研究

针对我国安全生产形势严峻现状，为进一步提高安全生产监察效率和质量，强化行政执法力度，提出了在我国建立生产安全事故风险分级与分级监察系统，其方法是首先确定行业相对风险度，再计算企业职业伤害风险系数，据此对企业风险进行分级，根据监察力量和监察计划对不同风险级别的企业进行分级监察，为实行集约型安全生产监察工作提供参考。     

Korean experience of process safety management (PSM) regulation for chemical industry

From the 1960s, Korean industries have been encouraged by the government to nurture heavy and chemical industry and to modernize the economics and industrial structures. The development of chemical industry particularly became the turning point in industrial development, and played a major role in the construction of a new industrialized country. However, the process systems in the chemical industry have become more complex and larger, and the inventories of dangerous chemicals that are produced or consumed have continuously increased. Therefore, the hazards from potential accidents such as fire and explosion or release of toxic chemicals have also increased. In fact, from the end of 1980s to the beginning of 1990s in Korea, a number of major industrial accidents such as ABS extruder explosion, TDI release and dryer explosion, etc. Occurred and caused many fatalities. As the chemical companies recognized the importance of preventing major hazards, PSM system, the prevention of major industrial accidents, was introduced in January 1995 by amending Industrial Safety and Health Act, and it has been enforced from January 1, 1996. According to the law, the business owner of a workplace with hazardous or dangerous equipment shall submit a process safety report to the Government to prevent any accidents, which could inflict an immediate damage on workers or on areas in the vicinity of the workplaces. As a result of PSM implementation for 19 years, chemical accident prevention system has been stabilized and various kinds of effectiveness and desirable customer satisfaction have been made.     

Overcoming the blame game to learn from major accidents: A systemic analysis of an Anhydrous Ammonia leakage accident

This article aims to demonstrate the need for changing the methods with which accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the sociotechnical principle of understanding the real operating conditions in which accidents take place. In order to demonstrate the benefits of the theoretical framework, we compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic approach. The results favor the latter since it tends to be more reliable and offering useful recommendations to safety management processes, thus helping to prevent accidents, especially in complex systems.     

基于FDA事故致因模型的铁路行车安全管理研究

为了从安全信息视角深入分析铁路行车事故原因,基于信息学、管理科学和行为科学等相关理论知识,结合铁路行车事故致因原理,构建铁路行车FDA(Forecast-Decision-Action)事故致因模型。该模型由行车人员、铁路运输企业和国家铁路局3条事故致因子链和1条事故致因主链构成,进一步归纳总结出3条子事故域、1条总事故域及各阶段正常运行所需要的安全信息。研究结果表明:破坏事故致因主链或破坏3条事故致因子链,防止不安全物态,可以有效预防铁路行车事故发生。以"4·28胶济铁路特别重大交通事故"为例论证模型具有实用性。     

A criterion for developing credible accident scenarios for risk assessment

Maximum credible accident analysis is one of the most widely used concepts in risk assessment of chemical process industries. Central to this concept is the aspect of ‘credibility’ of envisaged accident scenarios. However, thus far the term credibility is mostly treated qualitatively, based on the subjective judgement of the concerned analysts. This causes wide variation in the results of the studies conducted on the same industrial unit by different analysts.

This paper presents an attempt to develop a criterion using which credible accident scenarios may be identified from among a large number of possibilities. The credible scenarios thus identified may then be processed for detailed consequence analysis. This would help in reducing the cost of the analysis and prevent undue emphasis on less credible scenarios at the expense of more credible ones.     

基于模糊评价法的建筑安全事故预测模型

针对建筑工程安全领域中许多对象具有"内涵明确,外延不明确"的特点,本文利用模糊数学对建筑安全事故影响因素进行度量,通过层次分析法确定各影响因素权重,提出了一种基于模糊评价法的建筑安全事故预测模型,解决了建筑生产中安全事故的即时预测,并通过实例给予说明,说明了模型在建筑安全事故预测中的有效性和实用性.     

基于熵理论的重大事故复杂链式演化机理及其建模

为完善重大事故演化的本质规律和探究事故后果累积放大原理,从安全物质学的视角提出事故链定义和形成机理,并解析其内涵;通过物质、能量和信息表征事故链演化过程的载体反映;基于物质流、能量流和信息流构建事故链式演化概念模型;基于熵理论和耗散结构理论论述事故阶段演化特性;在此基础上,提炼事故预防与控制策略框架。研究结果丰富了事故链式演化理论,可为事故预防与控制提供更深层次的理论基础。     

重大危险源辨识与监控是企业建立事故应急体系的基础

本文简要介绍了重大工业事故预防控制体系要素和国家法律、法规与政策对企业重大危险源监控与应急体系建设的要求,论述了重大危险源辨识、监控是企业建立事故应急体系和重大事故预防控制体系的基础和前提,对企业重大危险源监控和应急预案编制要求提出了建议.     

基于监管的化工园区事故免疫系统构建

为探索完善化工园区安全生产监管体系,借鉴生物免疫系统抵御疾病的机理,构建了在组织、功能、机制等方面与生物免疫系统相似的化工园区事故免疫系统;从化工园区安全生产监管的角度出发,阐述了化工园区事故免疫系统组织、功能和机制的具体构建方法。结果表明,生物免疫系统和化工园区安全生产监管体系具有共性、完善的组织是化工园区事故免疫系统预防事故的首要条件、化工园区事故免疫系统可为完善化工园区安全生产监管提供策略和方法。     

基于事故演化网络的旅游安全及风险防控研究

为做好旅游活动的安全管理和风险防控,构建旅游安全事故演化网络,从旅游事故演化的角度分析旅游中常见的事故类型及其演化过程;根据旅游事故发生的时序和相关程度将旅游安全事故分为4级,从事故节点的出入度、子网节点数和支链数进行分析,判断不同旅游事故的风险大小;此外,从不同结构演化链的角度,总结旅游事故演化的特征.结果表明:旅游...     

Factors in offshore planning that affect the risk for major accidents

The purpose of this paper is to systematically analyse a typical planning process in the offshore industry from the perspective of causes of major accidents, with the ultimate aim of identifying factors that affect the risk for major accidents occurring. We first study and describe a typical planning process for offshore oil and gas operations in Norway. Then we analyse a number of theories of major accidents, to see how the different theories and their explanations of causes and contributing factors can be of relevance for future plans and planning processes. Finally, we review accident investigations to search for evidence of how weaknesses in planning processes can contribute to major accidents through the above identified factors. Also, we try to identify any additional factors that have not been recognised through the theoretical review. This provides empirical support for the theoretical basis. Thirteen factors which directly or indirectly can influence the planning process causing a major accident potential are identified. These are exemplified through a review of investigation reports. The paper suggests that planning process should focus more on increasing quality in the plans at an early phase, with examples from incidents, and illustrate the relation between planning quality and potential for major accidents.     

低概率重大事故风险与定量风险评价

论述应用定量风险评价(QRA)对评价、控制低概率重大事故风险的重要意义.介绍了低概率重大风险范畴与主要来源,QRA技术的主要用途与基本方法,研发与使用QRA计算重大风险的主要技术程序.提出了在应用QRA评价重大风险时应注意的几个主要技术问题.     

基于风险防御的机场跑道事故风险控制研究

在风险管理程序中,风险辨识和风险评估是风险管理的基础,而风险控制才是风险管理的最终目标。只有通过风险控制才能实现降低风险水平的目的,才能体现风险管理的全部意义。跑道运行涉及的人员、设备众多,是航空地面事故的多发环节,因而对跑道事故风险进行控制是具有一定意义的。在对现有风险控制方法分析的基础上,提出了基于风险防御的跑道事故风险控制,构建了跑道事故风险防御体系,指出了风险控制的思想重在事故发生前的预防。从技术研究(从具体的事故影响因素角度出发)和组织支持措施(从机场安全管理全局的角度出发)两方面进行跑道事故风险的控制。最后,对风险防御技术进行了研究。从风险控制的角度,为预防跑道事故的发生提供理论依据和指导。     

重大事故应急预案评审技术研究

重大事故应急预案评审是重大事故应急预案管理中的一个重要环节,为了进一步提高应急预案的针对性、实用性和可操作性,完善重大事故应急预案体系,应进行重大事故应急预案的评审。本文主要介绍重大事故应急预案评审的目的及原则,重大事故应急预案评审应遵循的基本准则,以及重大事故应急预案评审的基本方法和内容要求。     

石化企业平面布局安全设计中事故场景的选择研究

基于安全性能思想的设计方法是石化行业平面布局安全设计的一个重要发展方向,文章对这种设计方法中目前存在的主要不确定因素——事故场景的选择问题进行了研究。对《石油化工企业设计防火规范》等指令性规范中各级别平面布局安全设计的依据进行了统计分析,给出了各级别布局设计中主要的安全考虑和大致的安全间距范围,并对目前安全考虑中存在的模糊性进行了分析,给出了导致其存在的原因主要为＂事故场景考虑不同＂和＂‘相互影响’的含义不同＂;由此,结合事故伤害理论,对石化行业常见的9种19类常见事故场景的后果分析估算,得到了各事故场景对目标设施造成不同程度＂影响＂的范围,并以之为依据,分析给出了各级别布局安全设计中适合考虑的事故场景及适当的安全设计目标。