Near-Miss定义及管理流程分析

作为事故金字塔的基座,Near-Miss管理在企业HSE管理乃至整个企业管理中起着非常重要的作用。通过消除底部的Near-Miss,可以最大限度地消除隐患,避免顶端意外事件的发生,提升企业HSE业绩,提高企业的运行效率。通过比较分析,可将Near-Miss翻译为"虚惊事件"。一个完整的Near-Miss管理可分解为八个流程,每个流程缺一不可,且前面的流程决定了后面流程的完成情况。通过八个流程的充分运行,可以获得Near-Miss管理效益的最大化,最终提升企业的HSE管理水平。     

Accident prevention approach throughout process design life cycle

The accident rate in the chemical process industry (CPI) has not been decreasing although majority of accident causes have been identified and could have been prevented by using existing knowledge. These recurring accidents show that the existing knowledge has not been used effectively. In this paper, accident knowledge learned from earlier accident analyses are utilized to predict the common design errors during chemical plant design. An accident prevention approach throughout process design life cycle is proposed for a safer design consideration where designers are guided to identify common design errors, accident contributors and critical points to look for. The accident prevention approach has been applied to analyze the BP Texas City Refinery Explosion and Fire tragedy.     

Dynamic risk assessment using failure assessment and Bayesian theory

To ensure the safety of a process system, engineers use different methods to identify the potential hazards that may cause severe consequences. One of the most popular methods used is quantitative risk assessment (QRA) which quantifies the risk associated with a particular process activity. One of QRA's major disadvantages is its inability to update risk during the life of a process. As the process operates, abnormal events will result in incidents and near misses. These events are often called accident precursors. A conventional QRA process is unable to use the accident precursor information to revise the risk profile. To overcome this, a methodology has been proposed based on the work of Meel and Seider (2006). Similar to Meel and Seider (2006) work, this methodology uses Bayesian theory to update the likelihood of the event occurrence and also failure probability of the safety system. In this paper the proposed methodology is outlined and its application is demonstrated using a simple case study. First, potential accident scenarios are identified and represented in terms of an event tree, next, using the event tree and available failure data end-state probabilities are estimated. Subsequently, using the available accident precursor data, safety system failure likelihood and event tree end-state probabilities are revised. The methodology has been simulated using deterministic (point value) as well as probabilistic approach. This Methodology is applied to a case study demonstrating a storage tank containing highly hazardous chemicals. The comparison between conventional QRA and the results from dynamic failure assessment approach shows the significant deviation in system failure frequency throughout the life time of the process unit.     

From a survey on accidents in the downstream oil industry to the development of a detailed near-miss reporting system

A historical analysis with statistical investigation on accidental events in the oil industry from the beginning of the XX century till now, was performed in order to identify historical trend and go deeper into accident causes. The classification methodology was developed referring to three headings, namely plant/process, environment and organization and trying to go deeper into the analysis of the causes of the accidents reported and understand more of what is probably behind the accidents. The accident types and severity were studied, plotting the accumulated frequency–fatality curve for each item. In the subsequent applicative phase, we applied a similar classification approach to near-misses directly collected over nine years observation in a large downstream oil firm. The historical analysis was extended on each section of the refinery, paying a careful attention to all causes and consequences of the event. Data were structured for analyzing trends and identifying possible precursors of unwanted events. According to the step-by-step approach we try to evidence how immediate causes of a near-miss could be linked in some kind of causal chain to underlying causes that should be controlled by middle or higher management, or are part of the corporate safety culture.     

基于有序Probit模型的铁路险兆事件影响因素识别研究*

为识别铁路险兆事件的影响因素,以宜春车务段2017年9月—2017年10月共1 870条数据为样本,以铁路险兆事件等级为因变量,事件原因、环境特征和事件特征为自变量建立有序Probit模型,探究人、设备、环境和管理因素对铁路险兆事件严重影响程度。研究结果表明:设备设施未按规定防护是影响严重性险兆事件发生的主要因素;与其他人为因素相比,未执行相关作业规定对增加险兆事件严重程度有显著作用。研究结果可为铁路管理部门实现事故预控提供依据。     

Modeling the major accident prevention legislation change process within Europe

The factors giving impulse to changing major accident prevention legislation within Europe, the so-called Seveso Directive, have not been thoroughly studied and molded into an understandable model thus far. For example the exact relationship between major industrial accidents and an ever changing legislation is still unexplored. This paper thoroughly investigates the parameters having influenced the change of the 1996 Seveso II Directive into the 2003 Seveso Directive Amendment 2003/105/EC and develops the accompanying legislation change process. The official major accident reports of Baia Mare, Enschede and Toulouse are studied in-depth, as well as many other official EU documents. Furthermore, experts from academia, government and industry who witnessed and/or participated into the legislation change process were interviewed in-depth. More profound insights into the societal debate following a major accident may help private companies to adapt their safety management system and their prevention policies, and may aid the legislator to develop more efficient and effective regulations. This way, the societal demand to change legislation in an ad hoc manner may be unpressurized.     

Route evaluation for hazmat transportation based on total risk - A case of Indian State Highways

Risk-based hazmat transportation route evaluation involves risk calculations taking into consideration the probability of collision related accident occurrence and detailed consequence analysis of various event scenarios. Probabilistic hazmat transportation risk assessment mainly depends on three important factors i.e. accident rate, Average Daily Traffic and population density besides route length which has a definite bearing on it. An effort has been made to estimate the route segment specific (location-specific) accident rate instead of aggregate National or State average values in order to bring specificity into the issue of decision making to avoid routes with higher accident rates. Instead of using default accident rate for different highway types developed with the US data, which are not well-comparable when used in Indian situations; the author used site-specific truck accident data. Subsequently, Loss of Containment (LOC) probabilities and spillage probabilities for different route segments have been computed and compared. Finally, route segment-wise total risk is estimated which is a convenient measure of the average number of persons likely to be exposed from all the possible consequence event scenarios resulting from releases of different hazmats being transported along the studied routes. The present study highlights the route evaluation carried out based on total risk computation, without going through detailed event based consequence analysis on two State Highway routes and one major urban road passing through important industrial corridors of Surat District in western India, to enable routing decisions by local authorities and also for planning emergency mitigation purposes.     

Cost-based fire risk assessment in natural gas industry by means of fuzzy FTA and ETA

Fire is the most prevalent accident in natural gas facilities. In order to assess the risk of fire in a gas processing plant, a fault tree analysis (FTA) and event tree analysis (ETA) has been developed in this paper. By utilizing FTA and ETA, the paths leading to an outcome event would be visually demonstrated. The framework was applied to a case study of processing plant in South Pars gas complex. All major underlying causes of fire accident in a gas processing facility determined through a process hazard analysis (PHA). Fuzzy logic has been employed to derive likelihood of basic events in FTA from uncertain opinion of experts. The outcome events in event tree has been simulated by computer model to evaluate their severity. In the proposed methodology the calculated risk has the unit of cost per year which allows the decision makers to discern the benefit of their investment in safety measures and risk mitigation.     

事故调查分析方法与技术述评

根据事故的原因结果模型、过程模型、能量模型、逻辑树模型、SHE管理模型将事故调查分析技术方法归纳为5大类,介绍了广泛使用的事故调查分析技术方法的特点,并按一定的标准进行分析和比较。分析表明:每种方法都有其不同的应用领域和优缺点,应针对不同领域问题选用合适的分析方法,多种调查技术组合分析适用于复杂事故的调查;考虑事件次序及其影响因素的调查方法,便于提出预防事故再次发生和减少风险的建议,图表阐述有利于鉴别信息缺陷,并使调查组之间的沟通有力;笔者在调查过程中注重于非正常分析方法得出的结果,宜采用更为先进的事故分析技术方法以保证事故调查的客观性。     

Design and evaluation of safety measures using a newly proposed methodology “SCAP”

An increase in the number of accidents in the process industries and the concomitant damage potential is a cause of concern in many countries. In order to control the alarming risk posed by these industries, the United States government has asked each manufacturing facility to carry out a worst-case disaster study and to develop alternatives to control this high risk. Other developed and developing countries such as Canada and India have taken similar measures.Recently Khan and Abbasi (J. Loss Prevent. Process Ind. (2001a) in press) have proposed a maximum credible accident analysis with a maximum credible accident scenario approach, which scores over a worst-case scenario approach for being realistic and reliable. In another effort, Khan and Abbasi (J. Hazard. Mater. (2001b) in press) have developed an efficient and effective algorithm for probabilistic fault tree analysis. These two approaches have been combined to yield a new methodology for a more realistic, reliable, and efficient safety evaluation and the design of risk control measures. The methodology is named SCAP: Safety, Credible Accident, Probabilistic fault tree analysis. The methodology is comprised of four steps of which the last step is a feedback loop. This paper recapitulates this methodology and demonstrates its application to ethylene oxide (EO) plants. The application of SCAP to EO plants identifies five units as risky and needing more safety measures. Further, this study recommends safety measures and demonstrates through SCAP that their implementation lower the risk to an acceptable level.     

Development of a field well head safety system for use with radiation generating devices

This paper discusses the design, testing and application of a new interlock system for field use with neutron generating bore hole probes at the Idaho National Engineering and Environmental Laboratory. Such probes produce 14 MeV neutrons at a yield up to 3×10⁸ neutrons/s, and present an ionizing radiation hazard to personnel particularly when operated in an unshielded configuration. This interlock system prevents personnel from being exposed to the relatively high radiation fields caused by an unsafe condition when an operating neutron generator probe is withdrawn from a well in the ground. An electromechanical interlock prototype system has been designed, built and tested, and has been found to be effective at preventing this event. The design is simple, is effective in mitigating the hazard, and can be installed in minutes. The system could be modified to interlock radiation-generating devices other than neutron generators that are used in similar environments.     

Predicting major accidents in the process industry based on the barrier status at scenario level: A practical approach

OCI Nitrogen wants to gain knowledge of (leading) indicators regarding the process safety performance of their ammonia production process. This paper answers the question whether indicators can be derived from the barrier system status to provide information about the development and likelihood of the major accident processes in the ammonia production process.The accident processes are visualized as scenarios in bowties. This research focuses on the status of the preventive barriers on the left-hand side of the bowtie. Both the quality – expressed in reliability/availability and effectiveness – and the activation of the barrier system give an indication of the development of the accident scenarios and the likelihood of the central event. This likelihood is calculated as a loss of risk reduction compared to the original design. The calculation results in an indicator called “preventive barrier indicator”, which should initiate further action. Based on an example, it is demonstrated which actions should be taken and what their urgency is.     

Analyzing system safety and risks under uncertainty using a bow-tie diagram: An innovative approach

A bow-tie diagram combines a fault tree and an event tree to represent the risk control parameters on a common platform for mitigating an accident. Quantitative analysis of a bow-tie is still a major challenge since it follows the traditional assumptions of fault and event tree analyses. The assumptions consider the crisp probabilities and “independent” relationships for the input events. The crisp probabilities for the input events are often missing or hard to come by, which introduces data uncertainty. The assumption of “independence” introduces model uncertainty. Elicitation of expert's knowledge for the missing data may provide an alternative; however, such knowledge incorporates uncertainties and may undermine the credibility of risk analysis.This paper attempts to accommodate the expert's knowledge to overcome missing data and incorporate fuzzy set and evidence theory to assess the uncertainties. Further, dependency coefficient-based fuzzy and evidence theory approaches have been developed to address the model uncertainty for bow-tie analysis. In addition, a method of sensitivity analysis is proposed to predict the most contributing input events in the bow-tie analysis. To demonstrate the utility of the approaches in industrial application, a bow-tie diagram of the BP Texas City accident is developed and analyzed.     

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.     

Inherent risk assessment methodology in preliminary design stage: A case study for toxic release

At preliminary design stage, process designers normally lack of information on the risk level from process plant. An inherently safer process plant could be designed if the information of risk levels could be known earlier at the preliminary design stage. If the risk level could be determined, there is a possibility to eliminate or reduce the risk by applying the well-known concept: inherent safety principle. This paper presents a technique to determine the risk levels at preliminary process design stage using a 2-region risk matrix concept. A model to calculate the severity and likelihood of a toxic release accident was developed in Microsoft Excel spreadsheet. This model is integrated with process design simulator, iCON to allow for data transfer during preliminary design stage. 2-region risk matrix is proposed and used to evaluate the acceptability of the inherent risk based on the severity and likelihood rating. If the inherent risk level is unacceptable, modification for improvement can be done using the inherent safety principles. A case study has been carried out to illustrate the benefit of applying this newly developed technique. It was successfully shown that an inherently safer plant could easily be designed by applying this technique.     

Data mining of tree-based models to analyze freeway accident frequency

INTRODUCTION: Statistical models, such as Poisson or negative binomial regression models, have been employed to analyze vehicle accident frequency for many years. However, these models have their own model assumptions and pre-defined underlying relationship between dependent and independent variables. If these assumptions are violated, the model could lead to erroneous estimation of accident likelihood. Classification and Regression Tree (CART), one of the most widely applied data mining techniques, has been commonly employed in business administration, industry, and engineering. CART does not require any pre-defined underlying relationship between target (dependent) variable and predictors (independent variables) and has been shown to be a powerful tool, particularly for dealing with prediction and classification problems. METHOD: This study collected the 2001-2002 accident data of National Freeway 1 in Taiwan. A CART model and a negative binomial regression model were developed to establish the empirical relationship between traffic accidents and highway geometric variables, traffic characteristics, and environmental factors. RESULTS: The CART findings indicated that the average daily traffic volume and precipitation variables were the key determinants for freeway accident frequencies. By comparing the prediction performance between the CART and the negative binomial regression models, this study demonstrates that CART is a good alternative method for analyzing freeway accident frequencies. IMPACT ON INDUSTRY: By comparing the prediction performance between the CART and the negative binomial regression models, this study demonstrates that CART is a good alternative method for analyzing freeway accident frequencies.     

GIS应用于城市重大危险源监控的综述

系统地总结出GIS在重大危险源监控方面的应用现状,简要介绍了地理信息系统的概念及其在重大危险源监控方面的作用。重点论述利用GIS的基本功能强化重大危险源安全管理;利用WebGIS技术对整个地区的重大危险源进行监控,实现信息共享;利用基于GIS的监控预警技术,降低事故率;利用GIS和GPS结合的方法,减少事故引发的损失;利用GIS决策支持技术,指导监控及应急救援。经过分析论证得出的结论是:研究GIS空间分析、模型分析和基础数据的获取技术是今后努力的方向。提出GIS在重大危险源监控方面的应用的发展趋势,为GIS技术在我国重大危险源监控方面的应用发展提供借鉴。     

Root cause analysis of an old accident in an explosives production plant

Twenty-six years ago, a massive accident occurred in the Semtin explosives plant in Czechoslovakia. The results of investigations which were carried out (but kept confidential at the time) were made available after 1989, but have not been published in a summarized form to date. Reopening of the results of old investigations and application of root cause analysis deepens our understanding of accident causes and leads to the conclusion that, according to today’s standards, the analysis was not completed at the time of the accident and therefore neither some of the practical aspects of the event nor the social, professional, and political climate it should have exposed have ever been fully understood. New analysis shows that plant safety management had decayed. The results demonstrate as well how substantial a shift has occurred in the understanding of causes and in performing and organizing their analyses during the elapsed quarter-century. The new examination employs a few innovations of root cause analysis. A tight connection between the analysis and the assumptions about the structure of safety management of investigated processes will be underlined. Suitable illustration will be proposed. Detail requirements on the form and content of a root cause map will be specified. Finally it is shown that even the root cause analysis has its limitations and that it may not be sufficient to finish the investigation of causes satisfactorily. This motivates for the identification of levels of causes which underlie the root causes.     

Export inherent safety NOT risk

The author presents a personal view that production of bulk chemicals and the attendant risks are being transferred from developed to developing nations. Some evidence is presented on the transfer of production. The transferred risk is increased because of the larger scale plants that are now built in locales that are less able to cope with the increased hazards. Bhopal was an example of an inherently unsafe plant, with major hazards that could have been avoided or drastically reduced by design. It behoves the industry to adopt the inherently safer philosophy and practice in the new plants that it builds, in order to minimise the opportunity for another accident like Bhopal and the threat to our industry that such an accident would pose.     

煤矿瓦斯爆炸事故隐患及风险的表征方法

为治理煤矿瓦斯爆炸事故隐患,管控其风险大小,基于证据对瓦斯爆炸事故隐患进行了系统辨识,利用逻辑图分析了隐患之间的耦合关系和风险演化路径;从事件发生的可能性、事件自身的严重性以及受体的暴露程度3个方面对瓦斯爆炸风险进行表征,并提出三维风险矩阵对事故风险进行分级评价。该方法可以为瓦斯爆炸事故隐患辨识、风险分析、风险评价以及设计事故预防措施提供借鉴。