The Viareggio LPG accident: Lessons learnt

On June 29th, 2009 the derailment of a freight train carrying 14 LPG (Liquefied Petroleum Gas) tank-cars near Viareggio, in Italy, caused a massive LPG release. A gas cloud formed and ignited triggering a flash-fire that resulted in 31 fatalities and in extended damages to residential buildings around the railway line. The vulnerability of the area impacted by the flash-fire emerged as the main factor in determining the severity of the final consequences. Important lessons learnt from the accident concern the need of specific regulations and the possible implementation of safety devices for tank-cars carrying LPG and other liquefied gases under pressure. Integrated tools for consequence assessment of heavy gas releases in urban areas may contribute to robust decision making for mitigation and emergency planning.     

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.     

火灾爆炸事故多米诺效应耦合模型研究

为了评估火灾爆炸事故中相邻储罐由于多米诺效应而引发二次事故的风险,提出了基于热辐射、冲击波超压以及碎片冲击等三种物理效应共同作用下的事故多米诺效应耦合分析模型.模型采用概率组合方法计算事故影响区域内目标对象发生二次事故的最可能组合及概率.研究表明,火灾爆炸事故多米诺效应的产生受到多种因素影响,其中平面布局、防火间距是影响二次事故发生的主要因素.在计算设施失效概率的过程中,考虑了热辐射、爆炸冲击波以及碎片冲击三种物理效应的耦合作用效果,采用影响系数法对二次事故的可能单元组合加以研究.最后,以一储罐区蒸气云爆炸事故为例对可能发生的二次事故进行了模拟,得到了相邻储罐二次事故的单元组合及概率.     

A model for estimating the impact of the domino effect on accident frequencies in quantitative risk assessments of storage facilities

It is well known that the domino effect can have a major impact on accidents in storage facilities, as it can increase the consequences of an initial event considerably. However, quantitative risk assessments (QRAs) do not usually take the domino effect into account in a detailed, systematic way, mostly because of its complexity and the difficulties involved in its incorporation. We have developed a simple method to include the domino effect in QRAs of storage facilities, by estimating the frequency with which new accidents will occur due to this phenomenon. The method has been programmed and implemented in two case studies. The results show that it can indeed be used to include the possibility of domino effect occurrence in a QRA. Furthermore, depending on the design of a facility, the domino effect can have a significant effect on the associated risk.     

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.     

Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP

Three accident causation models, each with their own associated approach to accident analysis, currently dominate the human factors literature. Although the models are in general agreement that accidents represent a complex, systems phenomenon, the subsequent analysis methods prescribed are very different. This paper presents a case study-based comparison of the three methods: Accimap, HFACS and STAMP. Each was used independently by separate analysts to analyse the recent Mangatepopo gorge tragedy in which six students and their teacher drowned while participating in a led gorge walking activity. The outputs were then compared and contrasted, revealing significant differences across the three methods. These differences are discussed in detail, and the implications for accident analysis are articulated. In conclusion, a modified version of the Accimap method, incorporating domain specific taxonomies of failure modes, is recommended for future accident analysis efforts.     

Slip and fall accident prevention: A review of research, practice, and regulations

This paper summarizes current research, practices, and regulations regarding walking/working surface slipperiness and coefficient of friction (COF) measurements. The literature and data are reviewed from three aspects:

1. (a) the biomechanics of walking and psychophysiological factors involved in slips and falls studied by the scientific community,

2. (b) various measuring devices and methods developed in an attempt to quantify the “slipperiness” of walking/working surfaces, and

3. (c) an acceptable quantitative standard for the “slipperiness” of surfaces and the impact of the Americans with Disabilities Act (ADA) on such a standard.

Unresolved issues related to slip-resistance are identified. A multifaceted approach and synergy from researchers, the building industries, standards organizations, and government are needed to obtain concensus on such issues.     

某滑坡事故的诱因分析

从爆破地震安全距离、爆破振动速度及对边坡的影响、空气冲击波安全距离等角度对某滑坡事故的诱因进行分析,得出爆破过程对事故有一定的影响作用,认为事故的产生是边坡开挖、爆破及大降暴雨综合作用的结果。     

Risk homeostasis theory, utility and accident loss in a simulated driving task

The suggestion that utility is logically necessary for behavioural adjustments to be made in response to changes in intrinsic risk is fundamental to risk homeostasis theory (RHT). However, the methodology used to investigate RHT — analysis of road traffic accidents — is ill-suited to the investigation of this assertion. The role of utility and intrinsic risk as possible determinants of behavioural compensation were therefore examined experimentally across 14 specific behaviours using the Aston Driving Simulator. RHT predicts that these two factors act in a multiplicative way to form a statistical interaction. It also predicts that the behavioural pathways through which the effect manifests itself should be reconcilable with the concept of utility. Both predictions received little support in this experiment, suggesting that utility and intrinsic risk operate as independent factors: both factors produced significant main effects across a number of behaviours. This finding, if it can be generalised, implies that, contrary to mathematically-based models of danger compensation and the traditional model of risk homeostasis, utility is not logically necessary for behavioural compensation in response to a change in intrinsic risk.     

Development of a new chemical process-industry accident database to assist in past accident analysis

Past accident analysis (PAA) is one of the most potent and oft-used exercises for gaining insights into the reasons why accidents occur in chemical process industry (CPI) and the damage they cause. PAA provides invaluable ‘wisdom of hindsight’ with which strategies to prevent accidents or cushion the impact of inevitable accidents can be developed.A number of databases maintain record of past accidents in CPI. The most comprehensive of the existing databases include Major Hazard Incident Data Service (MHIDAS), Major Accident Reporting System (MARS), and Failure and Accidents Technical Information Systems (FACTS). But each of these databases have some limitations. For example MHIDAS can be accessed only after paying a substantial fee. Moreover, as detailed in the paper, it is not infallible and has some inaccuracies. Other databases, besides having similar problems, are seldom confined to accidents in chemical process industries but also cover accidents from other domains such as nuclear power plants, construction industry, and natural disasters. This makes them difficult to use for PAA relating to CPI. Operational injuries not related to loss of containment, are also often included. Moreover, the detailing of events doesn’t follow a consistent pattern or classification; a good deal of relevant information is either missing or is misclassified.The present work is an attempt to develop a comprehensive open-source database to assist PAA. To this end, information on about 8000 accidents, available in different open-source clearing houses has been brought into a new database named by us PUPAD (Pondicherry University Process-industry Accident Database). Multiple and overlapping accident records have been carefully eliminated and a search engine has been developed for retrieval of the records on the basis of appropriate classification. PUPAD doesn’t aim to replace or substitute the well established databases such as MHIDAS and MARS but, rather, aims to compliment them.     

某矿一起坠井事故的剖析与对策

对某矿副井发生的一起3名乘罐人员坠井事故进行了分析,并提出了预防措施。     

Evaluating a safety culture campaign: Some lessons from a Norwegian case

The focus of the present study is on the implementation and some of the results of an evaluation of a safety culture campaign that partly was aimed at increasing workmate interventions (care). I focus on three groups either working on or with a Norwegian offshore platform: onshore managers, crane operators and process operators. The research questions are: “Has the safety culture campaign contributed to new safety cultures related to care in the three groups, why/why not and what can we learn from this?”. The study indicates that two of the groups have developed new safety cultures that sensitize them to new hazards, motivate and legitimize new preventive practices. In accordance with the interpretive approach to culture in organizations, these changes are discussed in light of members’ of each group’s negotiation over the meaning and relevance of campaign efforts on workmate interventions. Lessons that can be learned from the study are discussed.     

海氏事故致因论的建筑事故例证与分析

海因里希于1931年在其<工业事故预防-管理手段>*一书中,首次提出了他的事故致因理论,其内容为"事故是由类似于多米诺骨牌一样的因果链所引起的".这个因果链为"人成长的社会环境或遗传因素(第一块骨牌)形成了他本身的某方面的缺欠(第二块骨牌),这个缺欠导致工作时他有不安全行为的和物(如机械设备等)的某方面的不安全状态发生(第三块骨牌),人的不安全行为和物的不安全状态导致事故(第四块骨牌)的发生,事故再最终导致人员发生伤害(第五块骨牌)."     

响水“3·21”事故应急救援处置启示

响水"3·21"特别重大爆炸事故发生之后,江苏省消防救援总队启动重特大灾害跨区域作战预案,一边开展火灾扑救、一边进行人员疏散搜救,并对核心区及半径2千米范围的化工企业进行风险排摸。本文主要介绍响水"3·21"特别重大爆炸事故现场情况、处置情况、灾害特点及技战术措施等。     

Study on mechanics and domino effect of large-scale goaf cave-in

A large area of continuous solid shallow-buried goaf group created by open-stope method, under the influence of space-time effects exerted by slow creep of the pillar-roof system, will wholly collapse driven by partly instability of pillar and roof collapse until the whole mine collapses, showing a domino effect. The dynamic process is ignored in the traditional analysis of mechanical stability. Based on analysis for the domino effect and disaster-relief mechanism in the mining goaf, the mechanical method combined with Voronoi graph method has been adopted to establish the dynamic analysis on the pillar-roof system stability. It seems more in line with the actual situations, and can help to more accurately predict the time and location of disaster. The conclusion is of great value on study of rock mechanics and mining companies’ safety production.     

一例急性苯中毒死亡事故调查

叙述了一例急性苯中毒死亡事故的发生原因和经过 ,对致死原因进行了分析。     

一起化肥厂爆炸事故的原因分析

某县化肥厂合成车间分析室突然发生爆炸,当班的2名化验员当场死亡,经济损失较大.爆炸冲击波将整个钢筋水泥(20m2)的分析室夷为平地,一块重约70kg的砖垛被抛至30m以外;离爆炸中心方圆60m以内的建筑物玻璃全部震碎.     

Occupational injury and accident research: A comprehensive review

In this paper, a comprehensive review of the concepts of occupational injury and accident causation and prevention is presented. Starting with hazard identification, the issues on risk assessment, accident causation, and intervention strategies are discussed progressively. The distinctiveness and overlaps in accident and injury research are highlighted. Both empirical research in terms of hypotheses tested and theoretical research such as accident causation models are compared and contrasted. Finally, based on the critical appraisal of the comprehensive review, future research directions on occupational injury research are delineated.     

Naturalistic teenage driving study: Findings and lessons learned

IntroductionThis paper summarizes the findings on novice teenage driving outcomes (e.g., crashes and risky driving behaviors) from the Naturalistic Teenage Driving Study.MethodSurvey and driving data from a data acquisition system (global positioning system, accelerometers, cameras) were collected from 42 newly licensed teenage drivers and their parents during the first 18 months of teenage licensure; stress responsivity was also measured in teenagers.ResultOverall teenage crash and near-crash (CNC) rates declined over time, but were > 4 times higher among teenagers than adults. Contributing factors to teenage CNC rates included secondary task engagement (e.g., distraction), kinematic risky driving, low stress responsivity, and risky social norms.ConclusionsThe data support the contention that the high novice teenage CNC risk is due both to inexperience and risky driving behavior, particularly kinematic risky driving and secondary task engagement.Practical ApplicationsGraduated driver licensing policy and other prevention efforts should focus on kinematic risky driving, secondary task engagement, and risky social norms.     

从一起桥机起吊事故案例剖折谈起

0引言 桥机起吊工序在不少企业生产中是不可缺少的重要手段,起吊安全事关重要,人命关天.据发生事故资料表明:由于施工组织者安全意识淡薄、操作者存在侥幸心态、单纯凭经验盲目起吊及操作不当引起的人身伤害事故率约占60%以上,给国家、集体的财产造成损失,给个人和家庭带来不幸.通过剖析典型事故案例,针对施工组织者、操作者的工作中普遍存在的问题,我们提出防范、减少发生桥机起吊事故的看法和建议,希望能对遏制桥机起吊事故发生的安全监察工作有所帮助.