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.     

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.     

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.     

基于突变理论的非常规突发事件下个体行为状态研究

针对非常规突发事件下个体行为状态,考虑物质环境、社会环境和个体属性等因素,建立评价影响个体行为状态的3级指标体系;在分析非常规突发事件下个体行为状态突变特征的基础上,建立非常规突发事件下个体行为状态的尖点突变模型;采用突变级数法对4类非常规突发事件进行实例分析,得到4类突发事件下个体行为状态的影响度。实例表明,不同类型非常规突发事件下个体行为状态的影响度不同;重大自然灾害和公共卫生类型突发事件中个体行为所受影响最大,社会安全事件次之,事故灾难突发事件中最小。     

Improving situational awareness through the design of offshore installations

Maintaining the situational awareness of control room operators on offshore installations contributes to the timely diagnosis of conditions and making appropriate decisions. This is particularly important when dealing with events and incidents. Recent initiatives aimed at reducing operators’ exposure to the hazards of working on offshore installations may have a negative impact upon situational awareness within the control room environment.This paper discusses mitigation of the negative impact through the design and operation of the installation and control system; either by improving the general level of situational awareness or by specifically targeting the areas affected by these initiatives.     

Performance evaluation of process industries resilience: Risk-based with a network approach

Risk management can be defined as coordinated activities to conduct and control an organization with consideration of risk. Recently, risk management strategies have been developed to change the approach to hazards and risks. Resilience as a safety management theory considers the technical and social aspects of systems simultaneously. Resilience in process industries, as a socio-technical system, has four aspects of early detection, error-tolerant design, flexibility, and recoverability. Meanwhile, process industries' resilience has three phases: avoidance, survival, and recovery, determining the transition between normal state, process upset event, and catastrophic event. There may be various technical and social failures such as regulatory and human or organizational items that can lead to upset or catastrophic events. In the avoidance phase, the upset event is predicted, and thus, the system remains in a normal state. For the survival phase, the system state is assumed to be an upset process event, and the system tries to survive through the unhealthy process conditions or remains in the same state, probably with low performance. In the recovery phase, the system is supposed to be catastrophic, and the emergency barriers are prioritized to show the severity of the consequences and response time, leading to a resumption of a normal state. Therefore, a resilience-based network can be designed for process industries to show its inherent dynamic transition in nature. In this study, network data envelopment analysis (DEA), as a mathematical model, is used to evaluate the relative efficiency of the process industries regarding a network transition approach based on the system's internal structure. First, a resilience-based network is designed to consist of three states of normal, upset, and catastrophic events. Then, the efficiency of each industrial department, which is defined as decision-making units (DMUs), is evaluated using network DEA. As a case study, a refinery that is considered a critical process industry is assessed. Using the proposed model shows the efficient and inefficient DMUs in each of three states of normal, upset, and catastrophic events of the process and the projection onto efficient frontiers. Besides calculating the network efficiency, the performance of each state is extracted to precisely differentiate between DMUs. The results of this study, which is one of the fewest cases in the area of performance evaluation of process industries with a network approach, indicated a robust viewpoint for monitoring and assessment of risks.     

Learning from incidents – A method for assessing the effectiveness of the learning cycle

This paper describes a method for assessing the effectiveness in the steps of the learning cycle: the 1st loop with reporting – analysis – decision – implementation – follow-up, and the 2nd loop on an aggregated basis. For each step, the dimensions considered the most relevant for the learning process (scope, quality, timing and information distribution) and for each dimension the most relevant aspects (e.g. completeness and detail) were defined. A method for a semi-quantitative assessment of the effectiveness of the learning cycle was developed using these dimensions and aspects and scales for rating. The method will give clear indications of areas for improvement when applied. The results of the method can also be used for correlation with other safety parameters, e.g. results from safety audits and safety climate inquiries. The method is intended to be used on a sample of the broad range of incidents normally seen in process industry companies. The method was tested on a two-year incident reporting material from six companies from various types of process industries. It was found that the method and the tools worked very well in practice. The results gave interesting insights into the effectiveness of learning from the incidents.     

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.     

Harnessing database resources for understanding the profile of chemical process industry incidents

Analyzing historical databases can provide valuable information on the incident occurrences and their consequences for assessing the safety of the chemical process industry. In this study, the RMP and HSEES databases were utilized to understand the patterns and the factors influencing chemical process industry incidents. Frequency exceedance curves were generated by utilizing the different incident consequences from the databases to understand the profile of societal loss from reported incidents. Understanding the statistics and trends of the historical incidents could serve as important lagging indicators in order to assess the probable proximity to major consequences from the low-probability/high-consequence incidents. To this regard, the safety pyramids were also generated to better understand the relationship between the different consequences of the reported incidents. Furthermore, the safety pyramids were analyzed in comparison with the traditional safety pyramid proposed by Heinrich to understand the US process industry incident occurrence trends.     

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.     

Accident investigation in the Norwegian petroleum industry - Common features and future challenges

In their regulations, the Petroleum Safety Authority Norway (PSA) states that the companies responsible for oil and gas exploration and production activities in Norway shall record and investigate accidents and serious incidents. This paper introduces a general model for the accident investigation process in the Norwegian petroleum industry, and presents some results derived from a comparative study of causal factors identified in offshore accident investigation reports from 2002 to 2006. The paper also offers a discussion of the improvement potential in the use of investigation methods. Finally, a discussion of future challenges in accident investigations is provided.     

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.     

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.     

Investigation of the Jahn Foundry and CTA Acoustics dust explosions: similarities and differences

The Jahn Foundry in Springfield, Massachusetts and CTA Acoustics in Corbin, Kentucky experienced devastating dust explosions in 1999 and 2003, respectively. At the time, Jahn Foundry was a gray iron casting facility that used phenolic resin powder as a binder for sand molds. CTA Acoustics was a manufacturer of thermal acoustic insulation that used phenolic resin powder as a binder for fiberglass mats. In both facilities the phenolic resin was able to migrate from the process, accumulate in the facility, and fuel catastrophic dust explosions.In this paper we review Exponent's investigation of the two incidents and identify root causes of the incidents and applicable standards that, if followed, could have prevented or mitigated the incidents. Throughout the paper we identify similarities and differences between the two facilities. For instance, in both facilities hazardous levels of dust had been allowed to accumulate due, in part, to inadequate housekeeping. However, a significant difference between the two facilities was that Jahn Foundry had no dust collection systems while the CTA Acoustics facility had dust collection systems designed to minimize the release of dust into the plant. The paper summarizes lessons learned from these two incidents that should be remembered when designing new facilities and analyzing hazards at existing facilities.     

Trends in accidents,disasters and risk sources in Europe

Most of the adverse impacts on man and/or the environment result from routine human activities such as the process industry, electricity generation and use, transport and agriculture (hazards, i.e. sources of risk). Apart from such essentially technological hazards, possibly resulting in “accidents”, human health and the environment can also be affected by natural hazards, possibly resulting in “disasters”, such as earthquakes or floods. This paper examines current trends in the risk sources and occurrences of four classes of such types of undesired events, entailing largely involuntary risk (e.g. neither car-driving nor smoking):

• •major accidents at fixed installations in the process industry,
• •incidents/accidents at nuclear installations,
• •marine transport and offshore installation accidents,
• •disasters caused by natural hazards and their potential exacerbation by human activities.

It aims to provide an integrated overview of such events in Europe (≡ 15 EU Member States, 4 EFTA, 13 PHARE, 7 TACIS and 5 other South and South Eastern European countries) during the last decade, estimating and interpreting trends in the number of risk sources and accidental events. For each type of event, specific “accident” definitions are given, illustrating the differences in the perception of the respective risk.     

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.     

Insight from hindsight: A practitioner’s perspective on a causal approach to performance improvement

The petrochemical industry works relentlessly on many fronts to improve performance and to create desired performance outcomes. Companies’ approaches vary widely; yet despite best efforts, the industry continues to experience periods of undesirable performance outcomes in product quality, reliability, process safety, environmental, and personal injury. The industry continues to search for better methods, techniques, and technology that are assumed to be missing, but the causes of incidents illustrate that what is in the way of improving performance may not be what is missing but rather what already exists.This paper provides an alternative perspective of performance problems viewed from underlying causes and patterns of causes of incidents in these so-called “high hazard industries” (Carroll, 2004) across several years and geographic regions. The perspective includes two distinct insights.

First, although problems can have a wide range of outcomes and impact, the underlying causal patterns are relatively few in number. These few represent essential elements that are repeatedly discovered in various forms under many unrelated problems.

Second, several common obstacles within organizations often inhibit the ability to find the causes, learn from the causes and to effectively address the causes of performance problems.

The conclusion is that when these repeating patterns are combined with a limited ability to effectively find, learn, and eliminate the causes, organizations are left with repeating periods of performance problems despite well-intended efforts to improve.