Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

我国近年来桥梁事故发生的原因与教训

回顾1998—2006年我国桥梁事故发生的典型案例,从设计、施工、营运管理、水文地质和自然灾害等方面分析事故发生的原因;归纳和总结了事故带来的教训:认识的错位是引发桥梁事故的思想根源,法制的缺陷是造成桥梁事故的重要因素,科学规范的违背是酿成桥梁事故的主要根源、历史的欠账是发生桥梁事故的先天隐患、腐败的黑洞是导致桥梁事故的罪魁祸首。从培训教育、严格科技规范、健全法规制度、保障资金投入、加强维护等方面提出预防桥梁事故发生的对策,得出一切桥梁事故都是可以预防的结论。     

Learning lessons from tunnel accidents – Recommendations in support of the implementation of Article 15 on Reporting of the EU Directive 2004/54/EC

Tunnels in the trans-European road network (TEN) facilitate the transport of persons and goods on European roads. Following a series of major tunnel accidents European Union Directive 2004/54/EC was adopted to support the achievement of uniform and high tunnel safety levels. With future accident prevention and mitigation in mind and in support of the effective implementation of Article 15 on Reporting of the Directive we outline a procedure for learning lessons and discuss every step in the process with specific regard for its implications on Article 15. This includes accident investigation, reporting, data collection and analysis, learning lessons and their implementation. The realization that validated information on tunnel accidents is not easily available or accessible, or suffers from a lack of detail or accuracy fed into the development of a data-collection template. By its very nature the template development also guided the formulation of key recommendations for accident investigation and reporting as the main information source. In addition, key recommendations on data analysis, learning lessons and implementation were also made to assist the actors responsible for reporting or sharing information under the EU Directive.     

生产安全事故事件资源化利用措施研究

本文旨在实现对事故事件资源的最大化利用,以丰富日常安全监管方式,避免同类事故事件再次发生。通过系统分析决定生产安全事故事件可资源化利用的3个有利因素,提出以事故事件教训实施培训教育、根据事故事件发生原因制定管理措施和依据事故事件分布规律进行预警提示等3项措施,表明:事故事件案例对安全管理是一种重要资源,对实现安全生产具有极为重要、有效的作用。     

Comparison of techniques for accident scenario analysis in hazardous systems

In this paper, three accident scenario analysis techniques are presented and compared regarding their efficiency vs. the demanded resources. The complexity of modern industrial systems has prompted the development of accident analysis techniques that should thoroughly investigate accidents. The idea of criteria classification to fulfill this requirement has been proposed by other researchers and is examined here too. The comparison is done through the application of Event Tree analysis, Fault Tree analysis and Petri Nets technique—two relatively simple and a more demanding methodology—on the same hazardous chemical facility in view of analyzing an accident scenario of a hazardous transfer procedure. Accident scenario analysis techniques are essential not only in learning lessons from unfortunate events in the chemical industry but also in preventing the occurrence of such events in the future and in communicating risk more efficiently.     

Prerequisites for learning from accident investigations – A cross-country comparison of national accident investigation boards

In this paper railway accident investigation reports issued by the national accident investigation boards in three Scandinavian countries during a 2-year period have been systematically studied. Content analysis of attributed causes in these reports reveals a considerable emphasis on physical processes, actor activities and equipment (the microlevel). Much less attention is paid to organisational factors (the mesolevel) and conditions related to regulators, associations and government (the macrolevel). This means that lessons will primarily be learned about aspects at the lower of these levels. Interviews show that the factors emphasised in investigation reports typically reflect the competences and experiences of the investigators, i.e. they are inclined to focus on areas of their own expertise. Since failures at the microlevel in many cases merely are symptoms of trouble at higher levels, it is argued that competence among investigators that supplements entirely technical or operational backgrounds are necessary for enabling deeper understanding of the factors leading to accidents. One possible way for achieving this is the creation of multi-modal investigation boards that provide a number of potential advantages, such as increased access to specialist competences that are shared between different sectors. Although a multi-modal approach to some degree has been adopted in all three countries, interviews reveal that these positive effects do not emerge automatically. It can therefore be concluded that multi-modal investigation boards offer a number of possible advantages, but only when these synergies are fully exploited can they provide a potential for more effective learning from accidents.     

基于粗糙集理论的路段交通事故多发点成因分析

交通事故多为多种原因综合造成且具有不确定性。判别各因素对于引发交通事故的影响程度存在困难,因此,需要引入不确定性分析方法。基于粗糙集理论具有处理不精确、不确定与不完全数据的优势,是一种先进的并处于不断发展的不确定性分析和推理方法。笔者提出路段上交通事故成因分析的模型和方法。具体做法是,根据该路段事故多发点的统计数据建立基于粗糙集理论的决策表,再利用粗糙集模型的简约算法求出各个因素的重要性,从而判断各因素对交通事故的影响程度大小,为决策提供依据。以算例说明模型和方法的可用性。     

Learning lessons from incidents: A paradigm shift is overdue

Drawing on historical data we show that the international community of process engineers has not been good at learning lessons from their past accidents. We call for a paradigm change in the way we approach this and the creation of a single new, multi-national, multilingual accident database that is free at the point of use and that includes immediate and underlying causes as well as “lessons learned”. It must be user-friendly and provide links to key source documents. The purpose of this paper is to challenge those in authority, and with the power to do so, to make this happen. We give some preliminary views on what may be required. In countries that so choose this could include an element of compulsion to consult the database in specific circumstances and a sign-off procedure to verify that this has been done.     

森工企业伐木作业事故成因分析与预防措施

以森工企业伐木作业三起事故为案例,对造成事故的原因进行了分析,根据事故成因提出了相对应的事故预防措施.     

城市油气管道泄漏爆炸重大案例应急管理对比研究

青岛东黄输油管道泄漏爆炸特别重大事故,引起公众对城市油气管道安全的普遍关注。近年来,城市油气管道事故频繁发生,反映出我国在城市地下管道安全管理方面存在较大问题。基于国内外管道相似事故调研,选取墨西哥瓜达拉哈拉管道泄漏爆炸事故和青岛东黄输油管道泄漏爆炸事故进行对比分析。基于事故致因理论,探究事故发展模式,建立事故链模型。结合应急管理思想,从预警预控、应急处置、评估恢复角度分析事故应急管理过程的共性失误。最后,针对应急管理各阶段共性失误提出防范措施,对提高类似事故的应急管理能力具有一定的参考意义     

盐酸装置爆炸事故分析及预防措施

我厂“三合一”盐酸新生产线,新来连续发生5次爆炸事故,经分析事故原因。发现爆炸原因与诸多刊物上发表文章所述类似事故的起因不同,经技术改造后,达到了预防爆炸的功效。     

Study of Major Accidents Involving Chemical Reactive Substances: Analysis and Lessons Learned

The objective of this paper is to present the results of the analysis performed on a selection of accidents included in the MARS database. This is a database of past accidents that occurred in Europe maintained by the European Commission, in order to help the Member States to meet the requirements of the Seveso and Seveso II directives. The study is focused on those accidents that involve reactions between chemical substances, whether wanted or unwanted, that generated a hazardous situation by loss of control of such reactions. Runaway reactions are known to be especially dangerous, given that many times they are unexpected, or their possible consequences underestimated, so sometimes chemical industries are not ready to cope with the effects of loss of control of reactive processes. The aim of the analysis is to obtain lessons learned from past accidents in order to prevent similar situations in the future, or to reduce their consequences. Understanding the causes of past accidents, including equipment failures, deviations in the expected course of a reaction, or deficiencies in process operations performed, can help to a better understanding of similar processes. Industries working with potentially dangerous chemicals should consider introducing lessons learned into their safety management systems.     

有限空间作业中毒窒息事故的预防

中毒窒息事故是有限空间危险作业的常发事故之一,多发生在封闭或半封闭设备,地上有限空间和地下有限空间,施害物主要为硫化氢、一氧化碳、二氧化碳、氨和甲烷(沼气)等。在我国,随着经济的迅猛发展,一大批农民转变成产业工人,由于新工人群体的总体文化素质低,自身的安全意识、安全知识和安全技能的缺乏,一些管理者对中毒窒息危险危害认识始终存在盲区,导致同类职业中毒事故悲剧不断重演,使农民工、临时工或新工人成为中毒窒息事故的主要受害对象。为有效防止类似事故再次发生,笔者结合几起中毒窒息典型案例,阐述发生中毒窒息的5点原因以及从中汲取的2个教训,即必须按照规章作业和施救必须以自身安全为前提,总结中毒窒息场所安全作业要求,提出了一系列的防范措施。     

油库火灾原因分析

油库火灾爆炸事故除易造成人员中毒、伤亡、经济损失巨大外,还会导致环境污染严重。近十年来油罐单罐面积越来越大,油库火灾爆炸发生的次数和损失与2000年以前相比急剧增长,特别是对环境的污染日益引起人们的重视。通过对23起油库火灾爆炸事故案例进行分析,发现静电是引发油库火灾爆炸几率最大的火源,输、卸油是最易引发油库火灾的操作工艺,人为的操作失误是油库发生火灾爆炸事故的主要原因。探索油库火灾爆炸事故发生的原因,对减少、避免同类事故的发生具有重要价值和意义。     

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.     

我国危险化学品事故统计分析及对策研究

基于2005—2008年我国发生的1565起危险化学品事故,从事故发生时间、发生地点、发生环节等方面分析事故的致因、特点以及规律,可以发现:近3年来我国危险化学品事故呈逐渐下降趋势;石化产业大省是危险化学品事故高发省份;每年3—8月是危险化学品事故高发时期;每天上午10点和下午3点是危险化学品事故高发时间;生产、运输、储存是危险化学品产业链六大环节中的事故高发环节。根据统计结果分析,指出我国危险化学品安全管理存在的问题,并提出预防和减少危险化学品事故的对策。     

Building urban gas process safety management (UG-PSM) system: Based on root cause analysis with 160 urban gas accidents in China

Urban safety is significantly impacted by the complexity of urban gas accidents. Although China has put forward the goal of “zero fatalities in accidents” for urban gas, unfortunately, the root causes of the unsound safety culture and imperfect safety management system of urban gas enterprises remain unresolved. Therefore, statistical analysis and 24Model analysis of 160 urban gas accidents in mainland China were performed to investigate the proximate causes of the accidents and the current situation of urban gas safety. The CCPS's risk-based process safety elements were used to identify potential deficiencies in the current urban gas process safety management (UG-PSM). During the analysis, it was observed that insufficient implementation of concealed danger investigation and rectification accounted for 76%, which is the primary proximate cause of urban gas accidents. Stakeholder outreach is the most under-represented competency in urban gas safety management. Based on the results, a novel framework for the UG-PSM system was constructed, and the theory of urban gas safety management was further improved. Furthermore, we evaluated the matching degree between UG-PSM elements and the existing measures of the government, urban gas associations, third-party organizations, and urban gas enterprises. Finally, we analyzed the feasibility, challenges, and development directions of the UG-PSM system. This study establishes a foundation for researchers and practitioners in the future research and practice of urban gas process safety and provides theoretical guidance for preventing high-incidence accidents of urban gas in China.     

Causes and lessons of five explosion accidents

This paper describes five disastrous explosion accidents that occurred in recent years that had serious consequences for lives and property. The five explosions were: 1) The explosion at a TNT workshop of a chemical factory, Liaoning province, on February 9, 1991 in which 17 employees died and 107 were injured; 2) The nitro-amine explosive production workshop of a chemical factory in Hubei province on June 27, 1992, which led to the deaths of 22 employees and 13 injuries; 3) An explosion in storage warehouses containing dangerous goods in Shenzhen City on August 5, 1993, where 141 were injured; 4) A explosion of a truck loaded with 1.05 million detonators on October 23, 1994 causing 5 deaths and 95 injuries; and 5) An RDX explosive accident in Hunan province on January 31, 1996 in which 134 people died and 17 were injured. In this paper, the causes of these accidents are described and the lessons to be learned from these accidents are summarized.Great changes and significant achievements have taken place and the national economy has been developing at high speed since China reform and open policy. But as far as safety in production is concerned, catastrophic explosion accidents have occurred in recent times and some of them have been exceptionally serious. The author has participated in the investigation of many explosion accidents, which brought about heavy casualties and great economic losses. The bitter experiences have given us many beneficial lessons written in blood from which we must try to avoid such similar unnecessary accidents. In this paper, the causes of five disastrous explosion accidents are analyzed and lessons learned from these accidents are summarized. Proposals for safety production are also put forward.