The development and evaluation of accident prevention routines: A case study

Information resulting from the occurrence of accidents and near-accidents is the basis for most accident prevention efforts. However, such information may not normally be incorporated into local safety activities. A group to assist supervisors in their investigations of accidents and a procedure to prompt the reporting of near-accidents by employees were tested at one company as means of improving local safety activities. The accident investigation group was in operation in all departments and was associated with improved accident reporting and prevention activities as well as a reduction in accident severity. The near-accident reporting procedure was tested in one department and led to improved knowledge about risks, although no reductions in accident frequency and severity were shown. On the basis of these results, the company safety committee decided at the end of the first year to extend the mandate of the investigation group but not to continue with near-accident reporting. Follow-ups after 2 and 3 years indicated that improvements in prevention activities had been maintained and that accident severity had been further reduced.     

Causes and lessons of five explosion accidents

This paper describes five disastrous explosion accidents that occurred in recent years that had serious consequences for lives and property. The five explosions were: 1) The explosion at a TNT workshop of a chemical factory, Liaoning province, on February 9, 1991 in which 17 employees died and 107 were injured; 2) The nitro-amine explosive production workshop of a chemical factory in Hubei province on June 27, 1992, which led to the deaths of 22 employees and 13 injuries; 3) An explosion in storage warehouses containing dangerous goods in Shenzhen City on August 5, 1993, where 141 were injured; 4) A explosion of a truck loaded with 1.05 million detonators on October 23, 1994 causing 5 deaths and 95 injuries; and 5) An RDX explosive accident in Hunan province on January 31, 1996 in which 134 people died and 17 were injured. In this paper, the causes of these accidents are described and the lessons to be learned from these accidents are summarized.Great changes and significant achievements have taken place and the national economy has been developing at high speed since China reform and open policy. But as far as safety in production is concerned, catastrophic explosion accidents have occurred in recent times and some of them have been exceptionally serious. The author has participated in the investigation of many explosion accidents, which brought about heavy casualties and great economic losses. The bitter experiences have given us many beneficial lessons written in blood from which we must try to avoid such similar unnecessary accidents. In this paper, the causes of five disastrous explosion accidents are analyzed and lessons learned from these accidents are summarized. Proposals for safety production are also put forward.     

基于多米诺效应的定量风险评价研究

多米诺效应是引发化工重大事故的主要原因之一.本文综合国内外的研究成果,对火灾热辐射、冲击波超压等造成的多米诺效应进行了深入分析,建立基于多米诺效应的定量风险评价模型,其中包括了评价流程、传播概率、阈值距离计算、多米诺效应对事故频率的影响及后果分析的内容.最后利用Matlab7.1计算平台,以汽油储罐进行实例分析,结果表明该方法是一种适用于多米诺效应定量评价的良好方法,能够比较科学、有效的对危险单元进行风险评价,使重大事故风险评价更切合实际,为政府监管部门和化工企业进行事故的控制和预防提供决策技术.     

Scenario derivation and consequence evaluation of dust explosion accident based on dynamic Bayesian network

In order to clarify the correlation between the evolution path of dust explosion accidents and emergency decision-making, and to accurately predict the disaster damage levels of various disaster bearing bodies. This paper extracts 56 key scenario elements from four aspects, namely state, answer, goal and environment, based on the analysis of typical dust explosion accident cases. At the same time, a general scenario evolution path of dust explosion accident is constructed. Using fuzzy number set theory and dynamic Bayes joint probability model, the accurate solution of scenario state probability was realized. With the help of accident cases and dynamic Bayes approach, the dust explosion consequence prediction index system and evaluation criteria were constructed, covering factors such as dust explosion intensity, casualties, direct economic losses, equipment damage, building damage, environmental damage and other factors. A polyethylene wax dust explosion accident in a city of China was used to verify the dust explosion accident scenario evolution model and consequences prediction model. The predicted results were in good agreement with the actual damage of various carriers of the accident, which indicated that the model could be used for dust explosion accident prediction and disaster loss prediction. The research results provided reference and technical support for the prediction of dust explosion accident evolution direction, emergency aid measures decision and deployment, disaster damage prediction and evaluation.     

商业综合体灾害链风险评估研究

为了对商业综合体灾害链进行风险研究,基于链式风险评估模型的建模方法,构建商业综合体灾害链风险评估模型,并应用复杂网络结构对商业综合体灾害链的演化过程进行表征,综合灾害事件的致灾率、灾害损失程度、灾害链的脆弱度3个指标得到每条灾害链的风险度量值,最后以泸州摩尔玛商场爆炸事件为实例进行评估,辨识出每条灾害链的风险值。研究结果表明:该模型与实际情况具有较高的吻合性,为商业综合体次生或衍生灾害的防控提供了可靠的理论依据。     

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.     

小煤矿透水事故分析及预防

通过对乡镇小煤矿透水事故典型案例分析,得出其事故发生原因主要在于从业人员素质较差、内部管理混乱、技术装备力量薄弱和行业主管部门监督不力。因此,煤矿防治水害要坚持以防为主。同时,提出不仅要从辨识透水征兆、留设防水煤柱、规范探放水安全距离、组建探放水机构等技术方面上,还要加强从业人员培训、编制防灾救援预案、行业主管部门监督等方面采取措施。另外,还提出"防、堵、疏、排、截"5项综合治理措施。     

A conceptual offshore oil and gas process accident model

The purpose of this paper is to present and discuss an accident prevention model for offshore oil and gas processing environments. The accidents that are considered in this work relate specifically to hydrocarbon release scenarios and any escalating events that follow. Using reported industry data, the elements to prevent an accident scenario are identified and placed within a conceptual model to depict the accident progression. The proposed accident model elements are represented as safety barriers designed to prevent the accident scenario from developing. The accident model is intended to be a tool for highlighting vulnerabilities of oil and gas processing operations and to provide guidance on how to minimize their hazards. These vulnerabilities are discussed by applying the 1988 Piper Alpha and the 2005 BP Texas City disaster scenarios to the model.     

油库火灾爆炸事故多米诺效应定量评价

引入多米诺效应定义,介绍多米诺效应定量评价的方法。结合具体实例对油库进行火灾爆炸事故的风险分析,给出事故多米诺效应定量评价的具体程序。通过油库火灾爆炸事故多米诺效应评价,得出油库事故的升级因素和导致事故扩大的途径,并指出相应的多米诺效应控制措施。与传统的评价方法相比,多米诺效应评价方法可预测次生事故发生情况和发生概率及后果,从而可以有针对性地采取相应的预防措施,预防事故多米诺效应,降低次生灾害的发生率,提高油库的本质安全程度。     

Scenario deduction of Natech accident based on dynamic Bayesian network: A case study of landslide accident in a liquor storage tank area in Guizhou Province,China

Industrial technical accidents caused by natural disasters are defined as Natech accidents, such as earthquakes and landslides, which can cause tremendous damage to industrial storage tanks, and lead to accidental leakage and even serious fire and explosion accidents. In this study, a landslide-induced storage tank accident model under earthquake disasters was proposed, and the relationship between landslide mass impact and target impact resistance was taken into account. Also, tank failure and the formation of the pool fire were considered to be the consequences of the Natech accident. Through scenario deduction, the dynamic process of landslide Natech was transformed qualitatively into a disaster chain network diagram composed of a scenario state, a disaster-causing factor and emergency management. The Bayesian network was used to learn and deduce the parameters of the network diagram, and in this process, the prior probability and conditional probability of nodes were obtained primarily by Monte Carlo simulation, and by an improved expert scoring method based on the fuzzy set theory. Through visualization software, the sensitivity analysis of landslide Natech was achieved. Finally, a case study of a liquor storage tank area in Guizhou Province, China was carried out, and the results show that a large amount of hazardous material leakage caused by buckling is key to the formation of pool fire accidents, and several prevention measures for earthquake-induced landslide Natech was proposed according to the sensitivity analysis.     

陆上原油长输管道泄漏爆炸事故情景构建研究

以某陆上原油长输管道为例,设定了陆上原油长输管道泄漏爆炸事故情景背景信息及演化过程,从预防、准备、预警、响应、恢复等阶段,梳理分析了事故情景应对全过程的任务及职责主体;针对各项任务从计划预案、人员队伍、装备物资、培训演练、运行机制等方面开展了情景应对能力评估;并针对存在的差距和不足,从企业和政府2个层面提出了针对此类情景的应急能力提升对策建议。该研究可为相关政府及企业加强油气长输管道事故应急准备能力建设提供参考。     

基于动态风险平衡的海洋平台事故连锁风险研究

针对海洋平台事故风险特点,提出动态风险平衡概念,以此建立事故动力模型,并将该模型运用到墨西哥湾"深水地平线"井喷事故。动态风险平衡表征事故动力与事故阻力之间的动态平衡状态,具有动态性和暂时稳定性。事故动力模型以海洋平台可能发生的重大事故为研究对象,从工艺、技术和管理等角度分析事故可能致因和事故发展可能影响因素。该模型首先分析对象的初始事故动力,建立事故连锁风险图,然后计算初始动力发生情况下,传递动力和传递阻力的概率分布,最后提出相应风险控制措施。实例分析表明,基于动态风险平衡建立的事故动力模型能有效分析海洋平台事故连锁风险。     

催化裂化装置火灾及爆炸事故后果分析

对石油化工企业典型生产装置--催化裂化装置发生火灾及爆炸事故后果进行分析,研究分析了催化裂化装置油浆泵泄漏引发池火灾和石油气泄漏引发无约束蒸气云爆炸两种事故的后果情况,给出这两种事故的各种伤亡半径,从而直观的为企业提供了事故后果情况,为企业的事故预防工作提供依据.     

木制品企业粉尘爆炸灾害与防治

分析了木制品企业发生粉尘爆炸的潜在危险性，以某木制品企业的一起木材粉尘爆炸事故为例，对事故发生的过程和原因进行了仔细分析，在此基础上从预防和防护两个方面提出了防止类似系统发生火灾及粉尘爆炸事故的措施。     

Korean experience of process safety management (PSM) regulation for chemical industry

From the 1960s, Korean industries have been encouraged by the government to nurture heavy and chemical industry and to modernize the economics and industrial structures. The development of chemical industry particularly became the turning point in industrial development, and played a major role in the construction of a new industrialized country. However, the process systems in the chemical industry have become more complex and larger, and the inventories of dangerous chemicals that are produced or consumed have continuously increased. Therefore, the hazards from potential accidents such as fire and explosion or release of toxic chemicals have also increased. In fact, from the end of 1980s to the beginning of 1990s in Korea, a number of major industrial accidents such as ABS extruder explosion, TDI release and dryer explosion, etc. Occurred and caused many fatalities. As the chemical companies recognized the importance of preventing major hazards, PSM system, the prevention of major industrial accidents, was introduced in January 1995 by amending Industrial Safety and Health Act, and it has been enforced from January 1, 1996. According to the law, the business owner of a workplace with hazardous or dangerous equipment shall submit a process safety report to the Government to prevent any accidents, which could inflict an immediate damage on workers or on areas in the vicinity of the workplaces. As a result of PSM implementation for 19 years, chemical accident prevention system has been stabilized and various kinds of effectiveness and desirable customer satisfaction have been made.     

质子交换膜燃料电池电站多米诺事故概率和风险研究

为探究氢能电站火灾爆炸事故发展规律,采用多米诺效应对电站进行事故概率和风险研究,建立氢能电站多米诺效应定量风险分析模型。基于设备受损概率模型与多米诺理论基础,提出氢能电站多米诺效应概率计算方法,并将方法运用到实际案例,结合SAFETI软件对具体多米诺事故场景进行定量计算。研究结果表明：氢能电站易发生多米诺事故,考虑一级多米诺效应后人员潜在死亡概率增加56%。研究结果可为制定氢能电站安全防控措施以及降低火灾爆炸事故对人员和设备的危害提供依据。     

事故灾难类重大突发事件情景构建概念模型

近期重特大事故灾难频发,表现出我国安全管理水平和应急处置能力依然不足。为引导地区或企业有序地开展应急准备工作,设计了事故灾难类重大突发事件情景构建概念模型,分析了概念模型中的“机会窗”和“准备效益”等重要理念,总结了概念模型在我国当前阶段的重要指导意义。最后,以某化工园区为真实背景,开展了生产安全事故情景构建的原型研究,证明了在事故灾难领域开展情景构建的实际价值。     

我国化工企业火灾爆炸事故统计分析及事故表征物探讨

从事故统计分析的角度,对2001—2006年我国化工企业发生事故的设备、事故介质进行分析;对设备发生事故的规律以及事故介质的分布特征进行总结;对在火灾爆炸事故调查中具有普遍代表性的事故表征物:爆炸抛射物、火灾爆炸容器、喷溅物和烟尘及烟熏痕迹的特征进行分析;从定量、半定量化的角度,对事故原因进行探讨,事故分析结果,对于从理论的角度分析事故原因、有效预防事故都具有重要的作用。     

Industrial accidents in spray dryer plants for dairy products in Europe

Despite the fact that the information about past accidents is an integral part of accident prevention, the information about industrial accidents is not commonly available in food and agricultural sectors. Spray dryer plants for dairy products are not an exception. The aim of this paper is the creation of the representative database for industrial spray drying accidents in order to identify their major causes. The paper is divided into 8 chapters. The first two chapters deal with the general information about technology of spray drying of dairy products. The third chapter provides the outputs from the authors' database containing records of 25 accidents in milk drying facilities in Europe. These accidents took place between 1999 and 2019 in six European countries. Based on the accident database, the most common causes of accidents were identified. Processes that can cause a fire, an explosion, or damage to environment are described in the fourth, fifth and sixth chapter. The seventh chapter deals with process, technical and organizational measures; these were discussed using literature research and the results of the accident database. The eighth chapter is the conclusion with a focus on further improvement of process safety through newly developed protective tools.     

事故致因“2-4”模型及其事故原因因素编码研究

事故致因模型是用于事故原因分析和预防的重要理论依据,模型的可操作性是决定事故预防效果的重要影响因素。对目前国内研究较为持续和系统的事故致因"2-4"模型进行了深入研究,以增强其在事故分析时的可操作性。首先,研究了事故致因"2-4"模型中组织内、外部原因的各个阶段原因因素的划分情况;其次,根据得到的各阶段原因因素划分结果,对应用事故致因"2-4"模型分析事故原因的因素进行了编码;最后,以一起重大瓦斯爆炸事故为例,对事故致因"2-4"模型原因因素编码系统的有效性进行了实证研究。划分了事故致因"2-4"模型中的各原因模块中的原因因素,并得到了不安全动作和物态、习惯性不安全行为、安全管理体系、安全文化、外部因素等5个层级原因,确定了基于事故致因"2-4"模型的30个原因因素。对事故原因因素进行系统编码,提高了应用事故致因"2-4"模型进行事故原因分析和事故预防的可操作性,增强了其应用实践性。