Modeling patterns of breakdown (or archetypes) of human and organizational processes in accidents using system dynamics

Systems approaches to safety have received growing attention in modern accident investigation techniques (e.g., STAMP, Accimap) with the emphasis shifted to the organizational dynamics (or archetypes) that may lead to an erosion of defenses and a drift out of the safety margins. Although the literature contains many applications of archetypes and system dynamics to safety, this richness comes at a cost of learning. It has become very difficult for safety practitioners to integrate the diverse studies of system dynamics with their diverging models. To provide a practical tool of system dynamics in accident investigation, this article reviews earlier studies and integrates them as a classification of patterns of breakdown (or archetypes) of both human and organizational processes on the basis of two control models, that is, the Extended Control Model (ECOM) and the Viable System Model (VSM). In this article, archetypes are represented as variants of two generic templates of performance which exploit many elements of complexity theory and system control. Apart from providing a practical tool to safety practitioners to access the literature on archetypes, the generic templates of ECOM and VSM can be used in building simulators of individual and organizational processes for risk analysis.     

高危工艺热爆炸事故鉴定中的模拟验证方法研究

根据高危工艺热爆炸事故反应速度快、爆炸威力强、物证破坏严重的特点,提出3类适合该类事故分析鉴定的模拟验证法:数学模型验证法、实测模拟验证法及热分析仪器实验验证法。通过对3种模拟验证法的由来、定义及操作程序的研讨,同时对3种方法的用药量、结果可信度、优点及缺点进行比较,从而总结出3类方法在不同事故背景、物证收集情况及前期推断基础下的适用范围。最后,通过对一起高危工艺热爆炸事故的调查鉴定,探讨热分析仪器实验验证法在调查鉴定中的应用,并给出模拟验证方法的选用技巧及运行步骤,为事故鉴定工作提供切实可用的科学参考。     

10种事故致因模型的对比研究

为了给事故致因模型的研究提供理论支持,为日常管理中事故致因模型的选用提供参考依据,从事故的影响对象、模型的组成和事故发生的路径3个维度对10种事故致因模型进行了对比分析。研究结果表明:事故致因模型对事故影响对象的涵盖越来越全面;事故致因模型的组成日趋全面,且趋于对模型中各模块给出清晰定义以能保证分析结果的准确性;故发生的路径描述由链式向系统网状发展;根据充分性和效率的需求对模块化模型和非模块化的模型进行选择。     

Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models

The purpose of this paper is to reflect on accident causation models and accident investigation methods. Theories on accident causation and the modelling of accident mechanisms, as well as a number of methods for accident investigation have been developed and described in the literature. The evolution of accident causation models over time shows a shift from the sequence of events to the representation of the whole system. Respectively, the evolution of accident investigation methods over time reveals a gradual shift from searching for a single immediate cause, to the recognition of multiple causes. In order to evaluate the accident investigation methods, specific plausible requirements were established in order to verify that a specific accident investigation method fulfils the principles of a specific accident causation model or give evidence to the degree of alignment between them. Since different models approach accident causation in different ways, methods linked to these models provide fragmentary information regarding the accident. It is therefore expected that using a combination of model-method pairs could provide a more reliable platform for accident analysis.     

Rating accident models and investigation methodologies

This is a report of research to identify, rate, and rank accident models and accident investigation methodologies. Models and methodologies used in 17 selected government agencies were examined. The examination disclosed 14 accident models and 17 different accident investigation methodologies in those agencies. To determine their relative merit, evaluation criteria and a rating scheme were developed from user data, statutes, applications, and work products, and each model and methodology was rated. The ratings indicated significant differences in their relative merit. The highest rated model and methodology were tested to determine if the estimated ratings were supported by observable differences in actual performance and to compare investigative results against previously reported cases. Differences found prompted further examination of the benefits and problems that would result from implementation of the preferred model and methodology. Additional exploration of comparative performance measurement techniques disclosed further differences affecting the selection decisions. The models, methodologies, criteria, ratings, rankings, test results, and initial measurement findings are summarized in this report. Issues ranging from oversimplification to ethical questions were discovered during this work. The findings strongly suggest that significant accident investigation program changes should be considered in agencies and organizations using lower-ranked accident models or investigation methodologies and that a compelling need exists for more exhaustive research into accident model and accident investigation methodology selection decisions.     

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。     

Evolution of road risk disparities at small-scale level: example of Belgium

PROBLEM: Road accident outcomes are traditionally analyzed at state or road network level due to a lack of aggregated data and suitable analytical methods. The aim of this paper is to demonstrate usefulness of a simple spatiotemporal modeling of road accident outcomes at small-scale geographical level. METHOD: Small-area spatiotemporal Bayesian models commonly used in epidemiological studies reveal the existence of spatial correlation in accident data and provide a mechanism to quantify its effect. The models were run for Belgium data for the period 2000-2005. Two different scale levels and two different exposure variables were considered under Bayesian hierarchical models of annual accident and fatal injury counts. The use of the conditional autoregressive (CAR) formulation of area specific relative risk and trend terms leads to more distinctive patterns of risk and its evolution. The Pearson correlation tests for relative risk rates and temporal trends allows researchers to determine the development of risk disparities in time. RESULTS: Analysis of spatial effects allowed the identification of clusters with similar risk outcomes pointing toward spatial structure in road accident outcomes and their background mechanisms. From the analysis of temporal trends, different developments in road accident and fatality rates in the three federated regions of Belgium came into light. Increasing spatial disparities in terms of fatal injury risk and decreasing spatial disparities in terms of accident risk with time were further identified. IMPACT ON INDUSTRY: The application of a space-time model to accident and fatal injury counts at a small-scale level in Belgium allowed identification of several areas with outstandingly high accident (injury) records. This could allow more efficient redistribution of resources and more efficient road safety management in Belgium.     

LPG leakage and explosion accident analysis based on a new SAA method

The petrochemical industry has inherently high safety risks. On 5^th June 2017, a liquefied petroleum gas tanker in the storage and transportation department of Linyi Jinyu Petrochemical Co., Ltd. leaked during unloading, causing a major explosion and fire. Ten people were killed and nine were injured. To prevent the recurrence of similar accidents, a retrospective accident analysis was conducted using the system accident analysis method known as ‘24Model’. This analysis proved the coupling relationship between accident causes involving multiple organisations and multiple factors. The analysis results show that the five modules of maintenance and design, that is, loading and unloading valves, emergency training, management of subsidiaries and contractors, multi-level supervision, and task arrangement need to be checked from top to bottom by relevant organisations.In order to verify the reliability of 24Model analysis results, three SAA methods, namely STAMP, FRAM, AcciMap, were used to analyse the accident, and results obtained by the four methods were evaluated qualitatively and quantitatively. The results show that the output of 24Model is reliable and has a more understandable framework, which can be used as reference for the development of other linear accident cause models and application of system accident analysis methods to real applications.     

事故的组织管理原因文献综述

组织管理原因是一类重要的事故致因,对其全面了解才能有效预防事故。就组织管理原因对事故的作用机理、定义与内容、事故分析对其研究的现状进行文献综述。通过文献梳理发现,在一维链式事故模型和系统论为基础的事故模型中,组织管理原因对事故作用机理不同,但对事故发生都具有重要作用。现阶段研究中,组织管理原因没有统一的定义和内容,但具有的区别于其他事故致因的特性能得到共识。现阶段常见的事故分析模型对组织管理原因进行定量和定性分析,但仍需继续完善。最后,对组织管理原因的研究方向提出展望。     

The Bhopal gas leak: Analyses of causes and consequences by three different models

The Bhopal Gas Leak, India 1984 is the largest chemical industrial accident ever. Haddon's and Berger's models for injury analysis have been tested, together with the project planning tool Logical Framework Approach (LFA).

The three models provide the same main message: That irrespectively of the direct cause to the leakage, it is only two parties that are responsible for the magnitude of the disaster: Union Carbide Corporation and the Governments of India and Madhya Pradesh. The models give somewhat different images of the process of the accident.

Models developed for analysis of injuries can be used for analysing a complicated mega accident like the Bhopal gas leak, although different models might stress different aspects.     

Role of gender in road accidents

Influence of driver sex on road accidents is assessed in this article. Accident records for 3 years and for three different income regions were analyzed. Annual distance traveled, social and economic participation, and effect of public vehicle accidents were considered. Effects of environmental factors and driver age were also included. Driver faults analysis identified possible reasons for accident differences. Analysis of accident severity was used to assess degree of harm. Statistical analysis at the 5% significance level was used to evaluate all differences. The results show that male accident rates are significantly higher. This trend is consistent through all the analyses. Accident differences are significant only in normal driving conditions. Drivers over age 50 had the lowest accident rates. Accident rate differences were caused by lack of attention and impatience among male drivers. Appropriate means of communication should alert concerned populations to these findings.     

Time series analysis of coal mine accident experience

This study investigates several forecasting techniques that can be useful to mine safety managers for studying mine accident rate behavior. Three time series models were studied for extrapolation of accident rates. These models are applied to historical accident incidence data from a coal mine. Further, a method is presented for evaluating the three models for the selection of an appropriate model. For this particular mine application, it is concluded that the more complex Box-Jenkins ARMA model as well as first order autoregressive model do not give better results than the simple exponential smoothing model. However, when the random variations or autocorrelations in the accident experience rates between periods are different, the models may predict differently. As such, specific models must be developed for each mine on the basis of statistical analysis of the mine accident experience data over time. Moreover, the importance of incorporating human judgement to interpret the results of statistical forecasting cannot be overemphasized. Integration of policy or operating changes, which may impact mine safety performance, with statistical forecasting techniques is essential to arrive at a realistic prediction of future performance.     

基于风险的化工园区布局优化决策支持系统

为加强化工园区风险辨识和布局优化,主要研究化工园区布局优化决策支持系统。在分析该系统主要功能的基础上,介绍基于风险的化工园区布局优化决策支持系统的理论模型:对化工园区重大危险源事故预测建模,包括重大危险源事故发生概率预测和事故后果预测;从个人风险、社会风险和财产风险3个模型评价化工园区区域动态风险,依据这3种风险值,计算区域综合风险;分别就功能区布局、消防布局和交通布局,对化工园区提出动态布局优化方法和建议措施。通过理论模型建立决策系统软件,结合实证分析,证明该决策支持系统的合理性。     

基于Logistic的不同车型碰撞行人事故严重程度致因分析

为定量分析不同车型碰撞行人事故严重程度影响因素,以美国北卡罗来纳州2007-2016年人车碰撞事故数据为样本,将其分为小轿车、SUV、货车碰撞行人事故3类,以事故严重程度为因变量,交通参与者属性、道路、环境条件和事故特征为候选自变量,分别建立累计logistic模型进行对比分析,探究人、车、路和环境因素对人车碰撞事故严...     

On the need for system-theoretic hazard analysis in the process industries

Most process hazard analysis (PHA) studies today are conducted using traditional methods such as the hazard and operability study (HAZOP). Traditional methods are based on a chain-of-events model of accident causality. Current models of accident causality are based on systems theory and provide a more complete representation of the causal factors involved in accidents. Consequently, it is logical to expect that PHA methods should reflect these models, that is, system-theoretic hazard analysis (STHA) should be used. Indeed, system-theoretic process analysis (STPA) has been developed as such a method. STPA has been used in a variety of industries but, at this time, it has not gained acceptance by the process industries. This article explores the reasons for this situation. Expectations for PHA in the process industries are examined and issues for the application of STPA in the process industries are discussed. It is concluded that a variety of matters must be addressed before STPA can be considered as a viable PHA method for the process industries and the case for the use of STHA in the process industries is not yet proven.     

Applicability of accident analysis methods to Chinese construction accidents

IntroductionIt is necessary to clearly understand construction accidents for preventing a rise in Chinese construction accidents and deaths. Better analysis methods are required for Chinese construction sector accidents.MethodsChoosing and analyzing a typical construction accident based on four popular contemporary accident causation models: STAMP, AcciMap, HFACS, and the 2-4 Model. Then we evaluated the models' applicability to construction accidents, including their usability, reliability, and validity.ResultsSTAMP addressed how complexity within the accident system influenced the accident development, and its output makes the responsibilities clearer for the accident. AcciMap described the entire system's failure, the entire accident's trajectory, and the relationship between them. AcciMap showed that the accident was a dynamic developing process, and this method has a high usability. The taxonomic nature of HFACS is an important feature that provides it with a high reliability. In the accident reviewed here, we found that poor management was a critical factor rather than the individual factor in the accident. The 2-4 Model provided detailed causes of the accident and established the relationship among the accident causes, the safety management system, and the safety culture. It also avoided capturing all of the complexity in the large sociotechnical system and revealed a dynamic analysis and developing process. We confirmed that it has a high usability and validity. Therefore, the 2-4Model is recommended for future Chinese construction accident analysis efforts.Practical ApplicationsThe study provides a useful, reliable, and effective analysis method for Chinese construction accidents.     

PDE accident model from a safety information perspective and its application to Zhangjiakou fire and explosion accident

Accident models can provide theoretical frameworks for determining the causes and mechanisms of accidents, and thus are theoretical bases for accident analysis and prevention. The role of safety information in accident causation is profound. Thus, safety information is an important and essential perspective for developing accident models. This study presents a new accident model developed from a safety information perspective, called the Prediction—Decision—Execution (PDE) accident model. Because the PDE accident model is an emerging accident model that was proposed in 2018, its analysis logic and viability remain to be discussed. Thus, the main contributions of this study include two aspects: (i) detailed explanation of the analysis logic of the PDE accident model, and (ii) case-study examination of the Zhangjiakou fire and explosion accident, a serious accident that occurred in China in 2018, to demonstrate the viability of the PDE accident model. Results show that this is a safety-information-driven accident model that can provide a new and effective methodology for accident analysis and prevention, and safety management.     

矿井通风系统安全评价方法及发展趋势

对国内矿井通风系统安全评价技术常用的模糊综合评价法、层次分析法、灰色关联度分析法、未确知测度评价法、人工神经网络评价法等进行分析和比较,给出了各种方法的数学原理和评价程序与步骤.然后,介绍多种评价方法相结合的复合评价模型及其应用.最后,分析和探讨了评价方法及其应用中存在评价指标与权重标准不统一、多种评价方法对同一资料的评价结果存在差异、缺乏评价支持软件系统等方面的问题;指出安全评价应引入非线性科学等交叉学科理论和开展基于方法集的综合集成评价研究;建立科学合理的评价指标体系和综合集成评价的决策支持系统,形成"人-机-环境-评价对象"一体化评价模式.     

燃气管网定量风险分析方法综述

以城市燃气管网的风险为研究对象,分析并提出一种可用于城市燃气管网定量风险分析的新思路,包含了不同事故后果及其物理模型的分析即事故可能性分析、后果分析和风险评价,分为失效事故假定、泄漏率计算、物理效应计算、致死率计算、风险值计算、风险评价等环节;整理、研究城市燃气管网定量风险分析所涉及的多种物理模型,并通过比较不同模型的特点,分析各个模型的不足之处;最后针对国内外研究现状及燃气管网风险的特点,指出研究发展方向:研究风险在燃气管网内的传播,提出燃气管网相继失效的风险分析方法。所提出的分析思路、计算方法可与工程应用相结合。     

工程项目群安全评价分析模型研究

在项目群大系统工程的安全综合评价分析中,存在较为复杂的评价要求。利用统计学的理论方法,采用单项指标与综合建模及量纲归一技术,全面论述安全评价的目的、意义和功能。首先构建一组综合无量纲指数作为安全指数,提出项目群安全指数综合分析模型、安全业绩综合考核模型和项目群安全率的分析模型,测评项目群系统的安全综合业绩,并对项目群安全建设的投入产出作出分析,建立工程项目群重大事故损失影响强度分析模型,最后通过实例计算工程项目群最优安全贡献率,以验证相关的数学方法和模型的可行性。