Multilevel learning from accidents – Case studies in transport

Substantial efforts have been devoted to accident investigations, but do we gain a reasonable benefit from these efforts? The current study explores multilevel (individual, company, sector/trade, authorities) learning from major accidents and serious incidents. Specifically, this involves identifying a set of learning criteria, i.e. factors or indicators that potentially support and contribute to multilevel learning processes. Identifying such criteria is based on: (i) the accident investigation process, (ii) the follow-up efforts, and (iii) contextual aspects. Three Norwegian accident investigations in transportation (aviation, marine, rail) represent the empirical foundation for the study. Learning criteria were derived by both document analyses from the accidents (e.g. investigation reports) and literature reviews on organizational learning. These were the basis for a workshop regarding learning from accidents, with participants from the aviation, marine, and rail sector. Key results from this workshop are presented and discussed. The study concludes by presenting a set of criteria for learning from accidents.     

Rare event risk analysis – application to iceberg collision

To design an engineering system, testing in extreme conditions is at least recommended if not required. There are ambiguities about how to define an extreme state and how to consider it in the design of a system or its operation. The probability estimation of such an event is challenging due to data scarcity, especially in many engineering domains, e.g. offshore development. In this study, available techniques for analyzing the probability of extreme events are examined for their suitability in engineering applications, and a framework is proposed for rare event risk analysis. The framework is comprised of three phases. In the first phase, the outlier based extreme value theory is implemented to estimate the rare event probability. The maximum likelihood criterion is used to estimate the extreme distribution parameters. In the second phase, the rare event is considered as a heavy tail event, and the tail index is estimated through the Hill and the SmooHill estimator. In the third phase, The uncertainty analysis is conducted, and the risk is computed. The proposed methodology is tested for extreme iceberg risk assessment on large offshore structures in the Flemish Pass basin. For this specific case, the estimated design extreme iceberg speed was 4.31 km/h, with an occurrence probability of 3.61E-06.     

Building Safety indicators: Part 1 – Theoretical foundation

Development of early warning indicators to prevent major accidents – to ‘build safety’ – should rest on a sound theoretical foundation, including basic concepts, main perspectives and past developments, as well as an overview of the present status and ongoing research. In this paper we have established the theoretical basis for development of indicators used as early warnings of major accidents. Extensive work on indicators have been carried out in the past, and this could and should have been better utilized by industry, e.g., by focusing more on major hazard indicators, and less on personal safety indicators. Recent discussions about safety indicators have focused on the distinction between leading and lagging indicators; however, a discussion on terms should not impede the development of useful indicators that can provide (early) warnings about potential major accidents.     

Rotating biological contactors for wastewater treatment – A review

Rotating biological contactors (RBCs) for wastewater treatment began in the 1970s. Removal of organic matter has been targeted within organic loading rates of up to 120 g m⁻² d⁻¹ with an optimum at around 15 g m⁻² d⁻¹ for combined BOD and ammonia removal. Full nitrification is achievable under appropriate process conditions with oxidation rates of up to 6 g m⁻² d⁻¹ reported for municipal wastewater. The RBC process has been adapted for denitrification with reported removal rates of up to 14 g m⁻² d⁻¹ with nitrogen rich wastewaters. Different media types can be used to improve organic/nitrogen loading rates through selecting for different bacterial groups. The RBC has been applied with only limited success for enhanced biological phosphorus removal and attained up to 70% total phosphorus removal. Compared to other biofilm processes, RBCs had 35% lower energy costs than trickling filters but higher demand than wetland systems. However, the land footprint for the same treatment is lower than these alternatives. The RBC process has been used for removal of priority pollutants such as pharmaceuticals and personal care products. The RBC system has been shown to eliminate 99% of faecal coliforms and the majority of other wastewater pathogens. Novel RBC reactors include systems for energy generation such as algae, methane production and microbial fuel cells for direct current generation. Issues such as scale up remain challenging for the future application of RBC technology and topics such as phosphorus removal and denitrification still require further research. High volumetric removal rate, solids retention, low footprint, hydraulic residence times are characteristics of RBCs. The RBC is therefore an ideal candidate for hybrid processes for upgrading works maximising efficiency of existing infrastructure and minimising energy consumption for nutrient removal. This review will provide a link between disciplines and discuss recent developments in RBC research and comparison of recent process designs are provided (Section 2). The microbial features of the RBC biofilm are highlighted (Section 3) and topics such as biological nitrogen removal and priority pollutant remediation are discussed (Sections 4 Biological nutrient removal in RBCs, 5 Priority pollutant remediation in RBCs). Developments in kinetics and modelling are highlighted (Section 6) and future research themes are mentioned.     

Falls prevention through community intervention – A Swedish example

In order to control and reduce fall-related injuries, particularly among women over the age of 55, a safety management and falls prevention campaign was structured and implemented during 2006–2007 in the small industrial town of Södertälje, Sweden. A local campaign was launched to recruit falls prevention agents, to inform key target groups in the local community, and to educate older people about fall risks. A survey showed that the campaign had a greater impact among professionals with a special relation to fall risk than among the general population. Medical records were used in the evaluation of the outcomes. The results show that between 2005 and 2007 there was a drop of fractures related to falls in the council: an overall drop of 16.7% in the population; among men 55 or older a drop of 12%, among women 55 or older a drop of 15%, among home-dwelling women 55 or older a drop of 5.7% and among women in special accommodation a drop of 44.4%. Expressed in terms of years lost to disability (YLD), the overall drop in hip fractures treated at the local hospital between 2005 and 2007 was 48%. A comparison with National medical records for the same period shows the drop for the intervention area to be much larger than that for Sweden as a whole, although the effect was not statistically significant. The study demonstrates the advantages of a broad, community-based approach to injury prevention.     

Minimum ignition energy of medicinal powder – Florfenicol and Tilmicosin

This work aims to help improve the electrostatic safety design and explosion prevention of medical facilities. In this study, the minimum ignition energies (MIEs) of Florfenicol, Tilmicosin and mixtures of Florfenicol and Tilmicosin at ratios of 1:1, 1:2, 2:1 and 1:4 were measured in a Hartmann apparatus. The results demonstrated that the MIEs for Florfenicol, Tilmicosin and mixtures of Florfenicol and Tilmicosin at ratios of 1:1, 1:2, 2:1 and 1:4 are 200, 70, 180, 150, 200 and 110 mJ, respectively. Tilmicosin is more sensitive to static electricity, which is more dangerous than the other two powders examined in this paper. Furthermore, the MIEs of the mixtures are proportional to the Florfenicol content. For all powders, the MIE first decreased with the powder mass and later reached its minimum value. In addition, scanning electron microscopy (SEM), differential scanning calorimetry (DSC) were used to investigate the morphological specificity and thermal decomposition of the powders to elucidate the parameters governing the powder explosions further.     

Process chemicals – An ever present concern during plant shutdowns

Chemical accidents during process plant shutdowns may have severe consequences. In spite of this, the safety management systems in place in many companies still mainly cover the normal operations and little explicitly addresses the maintenance shutdown and plant start-up phases. A Finnish research project found that the level of safety during shutdowns is more closely related to the skills of key individuals at the plants and less due to the systematic safety management system of the companies. A guidebook on the topic in conjunction with tools to improve the situation were developed during the project in order to help the companies improve their documentation associated with chemical safety during shutdowns.     

Tanks A Lot – Trevor: For enduring process safety contributions

Trevor Kletz has left an indelible mark on worldwide chemical process safety. He generously shared his insight for decades and I have been fortunate to have spent my process safety career in the shadow of Trevor Kletz’s influence. In the early 1980s I purchased one of the first commercially available process safety awareness training modules. The module was entitled the “Hazards of Over and Under Pressurizing Tanks,” developed by Trevor, and distributed by the Institution of Chemical Engineers (IChemE). The module contained a collection of short case histories and each incident provided a message on fundamentals. It was an easy to use module with a couple of dozen vivid 35 mm slides and focused on the frail nature of tanks.This paper, “Tanks A Lot – Trevor” mimics the IChemE approach of three decades ago and could serve as an introductory awareness lesson for the newbie or trainee who desires to learn about the frail nature of tanks. But most likely, it will serve as a reminder to the seasoned reader of things he or she has previously seen or worse yet, experienced.Storage tanks in chemical plants, oil refineries, related distribution terminals and pressure vessels associated in these industries are vital components and a major investment within their facilities. These essential vessels come in all sizes and many shapes and are built to various codes. They may hold large inventories of hazardous materials.Tanks can and do very safely contain a wide variety of raw materials, intermediates and finished products for years. If the tank or its accessories are poorly designed, abused by operations or are neglected with respect to effective inspection and basic maintenance, bad things can happen.This paper includes a few tank system fundamentals as well as case histories of failures in design, operation, inspection and maintenance. Previous vessel incidents must be understood.     

Dustiness in workplace safety and explosion protection – Review and outlook

Behavior of dust/air mixtures is very complex and difficult to predict since it depends on material properties as well as boundary conditions. Without other influences airborne particles deposit due to gravity but the time it takes for total deposition as well as easiness of resurrection depends very much on the specific dust sample and the boundary conditions. It still lacks a complete understanding of all interacting reasons and one approach is using experimentally determined characteristics, one is named dustiness.Dustiness is the tendency of dust to form clouds and to stay airborne. Dustiness is determined with two basic principles, which are light attenuation and ratio of filled-in and measured mass. Assessment of dustiness of industrial powders has been done for a long time regarding work place safety. Dustiness is used there to determine inhalable fraction and to evaluate health risks. Lately it became interesting in dust explosion protection as well. Dustiness could be used to optimize determination of zones, adaption of venting area and/or for positioning of suppression systems.Dustiness can be useful in many ways but is not a physical property of dusts, therefore it depends on material properties such as density, particle size distribution, shape and water content as well as boundary conditions or determination method. This makes it very difficult to compare dustiness for different techniques and apparatuses and determination method as well as results should be considered carefully. This work gives an overview of existing standards, recent research and suggests improvements to the new dustiness as proposed for dust explosion protection.     

Skin reactions to latex in dental professionals – first Croatian data

Purpose. To determine the prevalence of undesirable skin reactions to latex in dental professionals and students of the School of Dental Medicine in Zagreb, Croatia. Methods. Our research included 444 participants, of which 200 agreed to undergo a skin prick test (SPT). All participants answered a questionnaire in which we asked about incidence of skin lesions, duration of occupational exposure to latex, localization of skin lesions and symptoms. Statistical analysis of the questionnaire and test results was then carried out. Results. Of the total 444 participants surveyed, 249 (56.1%) reported lesions on their skin (professionals 64.8%, students 6.1–58.5%). From the questionnaire, 239 (96.0%) respondents reported lesions on the hands and fingers, mostly in the form of erythema (37.0%) and occasional dryness of skin (29.0%). Positive SPT results were found in 14 (7.0%) out of the 200 respondents who underwent the test. Conclusions. While a large number of subjects (56.1%) reported skin lesions when using latex products at their workplace, the SPT test was positive only in 7.0%. The results show that the prevalence of self-reported skin lesions was significantly related to the length of occupational exposure, with a substantial effect size (p?<?0.001; V?=?0.334).     

Dispersion modeling of LNG-Vapor on land – A CFD-Model evaluation study

Based on methane from renewable resources, LNG is an alternative fuel for heavy and long-distance traffic in land transport. Contrary to its positive properties, the fuel contains risks from an explosion and extremely low temperatures for personal and infrastructure safety. CFD-models are suitable for doing risk analyses for arbitrary scenarios. For examining how to model for risk research the dispersion of LNG-vapor, this paper contains a model variant study, with an evaluation by experiments.This paper describes the use of the CFD-code ANSYS Fluent for simulating experiments of the ‘LNG Safety Program Phase II‘. The content of the well-documented experiments was the research of the vaporization rate of LNG on land and the dispersion of LNG-vapor in the air. Based on the comparison to two experiments, overall 12 CFD-model variants with varying thermal and turbulence parameters were examined how they affect the transient LNG-vapor dispersion in air.The definition of turbulence-boundary-condition at the domain borders had the biggest impact on modeling, followed by the turbulence model. The most accurate model variant had been applied for observing the spreading behavior of LNG-vapor in the air after evaporation on land and analyzing the influence of the LNG-composition to the dispersion. The results show that the mixture of LNG-vapor and the air in the free field is cooler than the ambient air and spreads like a heavy gas on the ground.     

Safety management in different high-risk domains – All the same?

In view of safety management being introduced in more and more industries, the aim of this paper is to discuss what different high-risk industries can learn from each other and what limits for generalizing safety management methods within and across industries exist. After presenting core components of safety management, three attributes crucial to any organization’s functioning are described, which also affect the way safety management systems should be designed, run, and assessed. These attributes are (1) the kinds of safety to be managed, (2) the general approach to managing uncertainty as a hallmark of organizations that manage safety, and (3) the regulatory regime within which safety is managed. By discussing safety management in the context of these three attributes, contingencies are outlined that can help decision-makers in companies to tailor safety management to their own situation and support regulators in drawing up and evaluating safety management requirements for different industries while also promoting learning between different high-risk domains. Standards and procedures, safety training, incident reporting and investigation, and safety culture are taken as examples to illustrate why and how different aspects of organizational functioning should be taken into account when designing and evaluating safety management systems or elements thereof.     

Product safety – Principles and practices in a life cycle perspective

This article describes a new product life cycle model that can be used by producers to improve safety and to prevent defective products from being placed on the market. The model has eight phases and the article describes and discusses the required safety-related issues in each phase. Analytical methods that should be used in the various phases are identified. Both consumer and industrial products are covered. The article outlines main product safety requirements with focus on European product safety legislation. The concept adequate safety is introduced as an acceptance criterion for the producer during the product development process, and factors that should be taken into account when deciding whether or not a product has adequate safety are discussed.     

Determination of explosion limits – Criterion for ignition under non-atmospheric conditions

Many industrial processes are run at non-atmospheric conditions (elevated temperatures and pressures, other oxidizers than air). To judge whether and if yes to what extent explosive gas(vapor)/air mixtures will occur or may be generated during malfunction it is necessary to know the safety characteristic data at the respective conditions. Safety characteristic data like explosion limits, are depending on pressure, temperature and the oxidizer. Most of the determination methods are standardized for ambient conditions. In order to obtain determination methods for non-atmospheric conditions, particularly for higher initial pressures, reliable ignition criteria were investigated. Ignition tests at the explosion limits were carried out for mixtures of methane, propane, n-butane, n-hexane, hydrogen, ammonia and acetone in air at initial pressures up to 20 bar. The tests have been evaluated according to different ignition criteria: visual flame propagation, temperature and pressure rising. It could be shown that flame propagation and occasionally self-sustained combustion for several seconds occurred together with remarkable temperature rise, although the pressure rise was below 3%. The results showed that the combination of a pressure rise criterion of 2% and a temperature rise criterion of 100 K seems to be a suitable ignition criterion for the determination of explosion limits and limiting oxidizer concentration at higher initial pressures and elevated temperatures. The tests were carried out within the framework of a R&D project founded by the German Ministry of Economics and Technology.     

Safety of stationary grinding machines – impact resistance of work zone enclosures

Guards on machine tools are intended to protect persons from being injured by parts ejected with high kinetic energy from the work zone of the machine. Stationary grinding machines are a typical example. Generally such machines are provided with abrasive product guards closely enveloping the grinding wheel. However, many machining tasks do not allow the use of abrasive product guards. In such cases, the work zone enclosure has to be dimensioned so that, in case of failure, grinding wheel fragments remain inside the machine’s working zone. To obtain data for the dimensioning of work zone enclosures on stationary grinding machines, which must be operated without an abrasive product guard, burst tests were conducted with vitrified grinding wheels. The studies show that, contrary to widely held opinion, narrower grinding wheels can be more critical concerning the impact resistance than wider wheels although their fragment energy is smaller.