Safety assessment of the film boiling chemical vapor infiltration (FB-CVI) process through a system-theoretic accident model and process (STAMP)

Film boiling chemical vapor infiltration (FB-CVI) is considered as one of the fastest process methodologies for manufacturing carbon-carbon (C–C) composite products and possesses various advantages compared to conventional methodologies. However, there are safety concerns associated with this process for large-scale manufacturing, mainly owing to the intrinsic nature of the precursor and the process conditions. Considering the multifunctional interactions of the various systems during the process, a system-theoretic process analysis (STPA)/system theoretic accident model and process (STAMP) model is used to perform a safety analysis of the hazardous states of the FB-CVI process at the system level. As a case study, the FB-CVI process equipment employed for the manufacturing of C–C composites is considered. The safety constraints present in the system are assessed for adequacy through a hazard analysis by STPA/STAMP. The analysis through STPA/STAMP demonstrated the capability to create proactive strategies for the design and realization of process equipment that can be employed to manufacture C–C composite products through the FB-CVI process.     

Using a system theory based method (STAMP) for hazard analysis in process industry

Different hazard analysis techniques are used in the chemical process industry. Most of these techniques were developed long time ago. There is an argument that significant changes have occurred in the process industry but these techniques have not been modified accordingly. Therefore, there may be limitations in identifying hazards related to the modern process industry in complex sociotechnical environment using these techniques. Recently new hazard analysis techniques based on systems theory have been introduced. STPA (System-Theoretic Process Analysis) is one of these systemic techniques. It has been used in some fields with promising results but with limited application in the process industry. This paper applies STPA to a process plant as an industrial case study. Recommendations generated by STPA are compared with the HAZOP study of the process plant which is a traditional technique. Conclusions are presented on the application of systemic techniques to the process industry as a complementary study to analyze the safety of the system as a whole and also to capture interactions between component of the system. Further studies are required to study STPA in more details and evaluate if it can be used as an alternative to HAZOP.     

Competency requirements for process hazard analysis (PHA) teams

Process hazard analysis (PHA) is a cornerstone of process safety management programs. The quality of the PHA performed directly affects the level of risk tolerated for a process. The lower the quality of a PHA, the more likely higher risk will be tolerated. There are few requirements for PHA team members in the U.S. Occupational Safety and Health Administration's process safety management regulations. More detailed requirements for participation in a PHA are desirable.A competency management program should be used to ensure PHA practitioners and teams are appropriately qualified. Criteria for selecting PHA team leaders, or facilitators, and other team members are key to such a program and are described in this paper. The criteria cover both technical and personal attributes. Application of the criteria is described and team performance metrics, which can be used to correlate performance with the assessment of competency to validate the criteria and methods used, are discussed.Owing to the importance of the role played by team leaders, certification of their competency is desirable. Criteria for certification are described and their application is discussed.     

Process safety management lessons learned from a fire and explosion accident caused by a liquefied petroleum gas leak in an aromatics reforming unit in Taiwan

A severe fire and explosion accident was caused by a liquefied petroleum gas leak in Taiwan in 2019. This accident resulted in the loss of approximately US$3.5 billion in output value due to a one-and-a-half-year shutdown after the accident; however, no casualties were recorded at the accident scene. An analysis of the accident pipelines demonstrated that the pipeline leak had been caused by hydrochloric acid corrosion. Cause analysis based on the accident timeline, fault tree analysis, and causal factor charting indicated inadequacies in five elements of process safety management (PSM) namely mechanical integrity (MI), management of change, emergency planning and response, process hazard analysis (PHA), and process safety information (PSI) as the root causes of the accident. Furthermore, insufficient PSI (i.e., a lack of comprehensive understanding regarding corrosion mechanisms) was deemed to have been the core problem leading to the accident. This accident revealed common shortcomings that are often overlooked in PSM implementation in Taiwan; thus, the present research can serve as a vital reference for improving PSM programs in Taiwan.     

Uncertainty aspects in process safety analysis

Uncertainties of input data as well as of simulation models used in process safety analysis (PSA) are key issues in the application of risk analysis results. Mostly, it is connected with an incomplete and uncertain identification of representative accident scenario (RAS) and other vague and ambiguous information required for the assessment of particular elements of risk, especially for determination of frequency as well as severity of the consequences of RAS. The authors discuss and present the sources and types of uncertainties encountered in PSA and also methods to deal with them. There are different approaches to improve such analysis including sensitivity analysis, expert method, statistics and fuzzy logic. Statistical approach uses probability distribution of the input data and fuzzy logic approach uses fuzzy sets. This paper undertakes the fuzzy approach and presents a proposal for fuzzy risk assessment. It consists of a combination of traditional part, where methods within the process hazard analysis (PHA) are used, and “fuzzy part”, applied quantitatively, where fuzzy logic system (FLS) is involved. It concerns frequency, severity of the consequences of RAS and risk evaluation. In addition, a new element called risk correction index (RCI) is introduced to take into account uncertainty concerned with the identification of RAS. The preliminary tests confirmed that the final results on risk index are more precisely and realistically determined.     

A critique of the Hazard and Operability (HAZOP) study

Conventional wisdom holds that the Hazard and Operability (HAZOP) study is the most thorough and complete process hazard analysis (PHA) method. Arguably, it is the most commonly-used PHA method in the world today. However, the HAZOP study is not without its weaknesses, many of which are not generally recognized. This article provides a critique of the method to assist study teams in compensating for them to the extent possible and to help guide the development of improved methods.     

Reasonableness of a proposed System Theoretic Process Analysis (STPA) validation framework: An interview study

Since its inception, the STPA technique has gained increasing popularity among researchers and industry practitioners. Nevertheless, the validity of its application has not yet received much scientific attention. Although some informal validation approaches have been used by STPA users, no formalized validation framework has been elaborated for practical use. This paper investigates the reasonableness of the recently proposed STPA validation framework, which includes 15 validation tests, each focusing on a specific step of an STPA analysis. To do so, STPA experts in both academia and industry were interviewed. First, it is investigated what approaches they have been using for validating an STPA analysis, the findings of which were categorized and mapped with the proposed validation framework. This aims to investigate the similarities and dissimilarities between the theory-based validation framework and the informal methods applied by experts in current practice. Then, the proposed framework was presented to the interviewees to seek their judgments about its reasonableness. Feedback from practitioners indicated that the proposed STPA validation framework has certain strengths, while several opportunities exist for further improvement. In particular, the findings indicate that most of the proposed theory-based tests have been already used by STPA experts in an unstructured manner. The experts appreciated the framework in that it provides clear guidance on how to validate each step of an STPA analysis systematically, and found some additional theory-based tests interesting for consideration in practice. The results also suggest that further research is needed to develop systematic techniques for performing each test to facilitate its application by STPA experts.     

ExSys-LOPA for the chemical process industry

The chemical process industries are characterized by the use, processing, and storage of large amounts of dangerous chemical substances and/or energy. Among different missions of chemical plants there are two very important ones, which: 1. provide a safe work environment, 2. fully protect the environment. These important missions can be achieved only by design of adequate safeguards for identified process hazards. Layer of Protection Analysis (LOPA) can successfully answer this question. This technique is a simplified process of quantitative risk assessment, using the order of magnitude categories for initiating cause frequency, consequence severity, and the likelihood of failure of independent protection layers to analyze and assess the risk of particular accident scenarios. LOPA requires application of qualitative hazard evaluation methods to identify accident scenarios, including initiating causes and appropriate safeguards. This can be well fulfilled, e.g., by HAZOP Studies or What-If Analysis. However, those techniques require extensive experience, efforts by teams of experts as well as significant time commitments, especially for complex chemical process units. In order to simplify that process, this paper presents another strategy that is a combination of an expert system for accident scenario identification with subsequent application of LOPA. The concept is called ExSys-LOPA, which employs, prepared in advance, values from engineering databases for identification of loss events specific to the selected target process and subsequently a accident scenario barrier model developed as an input for LOPA. Such consistent rules for the identification of accident scenarios to be analyzed can facilitate and expedite the analysis and thereby incorporate many more scenarios and analyze those for adequacy of the safeguards. An associated computer program is under development. The proposed technique supports and extends the Layer of Protection Analysis application, especially for safety assurance assessment of risk-based determination for the process industries. A case study concerning HF alkylation plant illustrates the proposed method.     

Event investigations at nuclear power plants in Sweden: Reflections about a method and some associated practices

The MTO-E method for event investigation is described in the light of almost 20 years of usage in the Swedish nuclear industry. Various problems are addressed in the context of the method, e.g. accident models, causality, the use of the barrier concept, the meaning of safety culture, and the process of going from problem identification to problem solving. It is argued that future applications of in-depth investigations should focus more on (innovative) methods when suggesting remedial actions as a consequence of information derived from event investigations.     

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.     

Metrics and analytics for process hazard analysis

Process hazard analysis (PHA) studies (e.g. HAZOP) identify hazard scenarios and each scenario is examined individually to decide whether risk reduction measures are needed. However, much more can be done to benefit from the contents of studies.PHA studies contain so much data that a manual review is precluded from yielding insights into their results. Fortunately, valuable information can be extracted using metrics and analytics that consider all the contents of a PHA study. The management of safety, operability, reliability, utilization, and loss prevention can all be improved.Metrics evaluate the contents of PHA studies to provide insights into the safety of processes and the quality of studies. Measures of process safety and study quality can be compared with norms to identify possible departures that may need to be addressed.Rather than focusing decision making on the risks of individual hazard scenarios, as is common practice, analytics enable a deeper analysis of the entire set of scenarios for a process. This enables better decisions to be made on where and how risk reduction resources should be allocated. Analytics can also be used to prioritize maintenance, training, and other activities.Various analytics and metrics for PHA studies are described together with examples that illustrate their use.     

Improved management practice and process hazard analysis techniques for minimizing likelihood of process safety incidents in Taiwan

In Taiwan, process safety accidents often occur despite the prior implementation of process hazard analysis (PHA). One of the main reasons for this is the poor quality of the PHA process; with the main hazards not being properly identified, or properly controlled. Accordingly, based on the findings of 86 process safety management (PSM) audits, dozens of post-accident site resumption review meetings, and hundreds of PSM review sessions, this study examines the main deficiencies of management practice and PHA implementation in Taiwan, and presents several recommendations for improved PHA assessment techniques and procedures. The study additionally examines the feasibility for using PSM-related information, such as process safety information and process incident information, as a tool for further enhancing the PHA quality. Overall, the study suggests that, in addition to following the basic rules of PHA and requirements of OSHA (1992),management in Taiwan should also provide training in the enhanced assessment techniques proposed herein and take active steps to incorporate PSM information into the PHA framework in order to improve the general quality of PHA and reduce the likelihood of process safety accidents accordingly.     

600 m3湿式氢气贮柜燃烧爆炸伤害效应预测

建立了某动力公司600m^3易燃易爆湿式氢气贮柜燃烧爆炸事故的6种模型,给出边界条件和计算过程,提出爆炸事故伤害效应预测指标。进行燃烧爆炸事故伤害效应预测,为氢气贮柜发生燃烧爆炸事故危害性评估提供了理论依据。     

Requirements for improved process hazard analysis (PHA) methods

In order to develop better process hazard analysis (PHA) approaches, weaknesses in current approaches first must be identified and understood. Criteria can then be developed that new and improved approaches must meet. Current PHA methods share common weaknesses such as their inability specifically to address multiple failures, their identification of worst-consequence rather than worst-risk scenarios, and their focus on individual parts of a process. There has been no comprehensive analysis of these systemic weaknesses in the literature. Weaknesses are identified and described in this paper to assist in the development of improved approaches. Knowledge of the weaknesses also allows PHA teams to compensate for them to the extent possible when performing studies.Key criteria to guide the development of improved methods are proposed and discussed. These criteria include a structure that facilitates meaningful brainstorming of scenarios, ease of understanding and application of the method by participants, ability to identify scenarios efficiently, completeness of scenario identification, exclusion of extraneous scenarios, ease of updating and revalidating studies, and ease of meeting regulatory requirements. Some proposals are made for moving forward with the development of improved methods including the semi-automation of studies and improvements in the training of team members.     

Development of a FRAM-based framework to identify hazards in a complex system

System-based approaches such as Functional Resonance Analysis Model (FRAM) are developed to model the complex interactions of system variables and their performance variabilities that may lead to a hazardous scenario in a complex system. However, they have limitations to be applied in process industries for hazard identification since they are heavily based on qualitative analysis and expert elicitations. To overcome the limitations of the system-based hazard identification, the study developed a FRAM-based framework to integrate a human performance model, an equipment performance model, and a first-principle based chemical process model into a hybrid simulator, which will be able to aid hazard analysis in the process industries. The simulator is capable of simulating the performance variabilities of the functions through the aggregation of mathematical models within a complex system, which can be used to simulate potential hazard situations and identify the corresponding interactions. Interaction analysis is conducted by applying association rule mining to the simulated data. The impact of the interactions among upstream functions on the performance of downstream functions can be identified by interpreting the rules, whose antecedents contain upstream functions and consequents contain downstream functions.     

System safety principles: A multidisciplinary engineering perspective

System safety is of particular importance for many industries. Broadly speaking, it refers to the state or objective of striving to sustainably ensure accident prevention through actions on multiple safety levers (technical, organizational, and regulatory). While complementary to risk analysis, it is distinct in one important way: risk analysis is anticipatory rationality examining the possibility of adverse events (or accident scenarios), and the tools of risk analysis support and in some cases quantify various aspects of this analysis effort. The end-objective of risk analysis is to help identify and prioritize risks, inform risk management, and support risk communication. These tools however do not provide design or operational guidelines and principles for eliminating or mitigating risks. Such considerations fall within the purview of system safety.In this work, we propose a set of five safety principles, which are domain-independent, technologically agnostic, and broadly applicable across industries. While there is a proliferation of detailed safety measures (tactics) in specific areas and industries, a synthesis of high-level safety principles or strategies that are independent of any particular instantiation, and from which specific safety measures can be derived or related to, has pedagogical value and fulfills an important role in safety training and education. Such synthesis effort also supports creativity and technical ingenuity in the workforce for deriving specific safety measures, and for implementing these principles and handling specific local or new risks. Our set of safety principles includes: (1) the fail-safe principle; (2) the safety margins principle; (3) the un-graduated response principle (under which we subsume the traditional “inherently safe design” principle); (4) the defense-in-depth principle; and (5) the observability-in-depth principle. We carefully examine each principle and provide examples that illustrate their use and implementation. We relate these principles to the notions of hazard level, accident sequence, and conditional probabilities of further hazard escalation or advancement of an accident sequence. These principles are a useful addition to the intellectual toolkit of engineers, decision-makers, and anyone interested in safety issues, and they provide helpful guidelines during system design and risk management efforts.     

STAMP-based analysis on the railway accident and accident spreading: Taking the China–Jiaoji railway accident for example

Each hazard analysis technique is based on a model of accident causation. Most accident models regard accidents as resulting from a chain or sequence of events, such models are fit for accidents caused by failures of physical components and for relatively simple systems, but suffer from serious deficiencies when they are applied to software-intensive, complex engineering systems. Recently, a new accident model called System-Theoretic Accident Models and Process (STAMP) for system safety has been proposed, it is based on control theory and enforces constraints on hazards and thereby prevent accidents. In this paper, taking the China–Jiaoji railway accident happened on April 28, 2008 as an example, the STAMP approach has been used to analyze the railway accident and some improvement measures have been proposed. As the occurrence of one accident can cause many other accidents happen, based on the STAMP-based analysis, the accident spreading processes have also been discussed and modeled, which will be helpful to analyze accidents spreading in a broad sense and establish effective emergent measures for accident response management.     

危险源相关事故致因理论及概念分析

与危险源相关的事故致因理论,包括能量单元、二类危险源理论和三类危险源理论,均可用于指导事故预防工作,在安全工作实践中发挥良好的作用。二类危险源理论和三类危险源理论的思路是一致的,用于事故预防工作时的应用方式清晰、明确,但这两个事故理论中使隐患的概念变得模糊,危险源的概念也需要加以界定。基于此,本文分析了危险源、隐患和风险的定义、特性及关系,讨论了与危险源相关各事故致因理论的应用方式和存在问题的解决方案,建议将各类危险源视作风险的不同分类,或者在应用过程中对各类危险源做出界定性说明,以理清相关概念在应用时产生的困惑,使这两种事故致因理论在事故预防工作中发挥更好的作用。     

Accidents at work during temporary agency work in Finland – Comparisons between certain major industries and other industries

Accidents at work during temporary agency work (TAW) are analysed and compared with those occurring in other industries in Finland on the basis of national statistics databases. The general trend is analysed between 1998 and 2007. The years 2006–2007 are analysed in more detail. Frequency distributions and accident frequencies are calculated for data analysis. Statistically significant differences between TAW and other industries are also tested. The results suggest that the accident risk is increasing in TAW and is higher than in other industries. This might be due to increased use of TAW in traditionally accident prone industries. However, workplace accidents were not so often severe in TAW compared to other industries. The results also indicate that certain work assignments, namely manual work in production and construction, etc. are more common in TAW compared to other industries, which affects the typical kind of accidents. Differences in workplace accidents between TAW and other industries should be taken into account in accident prevention. However, further research is needed to identify the underlying accident mechanisms and their significance in order to guide accident prevention effectively. Information retrieval concerning accidents at work in TAW should continue to be made available in the future.     

Analysis of equipment failures as contributors to chemical process accidents

A database study of chemical process accident cases was carried out. The objective of the study is was to identify the reasons for equipment based accidents. The most frequent accident causing equipment were piping (25%), reactors and storage tanks (both 14%) and process vessels (10% of equipment accidents). The six most accident-prone equipment is process related involve nearly 80% of accidents.78% of equipment accident contributors are technically oriented including design and human/technical interface faults. Purely human and organizational reasons are the most common accident contributors for storage tanks (33%), piping (18%) and heat transfer equipment (16% of causes). For other equipment the technical accident causes are most common.The accident contributors were divided to main and sub-contributors. On average process equipment failures have 2.2 contributors. The contributors, which frequent and act often as main contributors, should be focused. These risky contributors were identified for several equipment types. Also a deeper analysis of the accident causes and their interconnections was made. Based on the analysis a checklist of main risk factors was created for hazard identification on different types of equipment.