Lessons learned from recent incidents: Facility siting, atmospheric venting, and operator information systems

Recent incidents have focused attention on a number of technical and management systems that need to be addressed by industry. A multiple layer of protection approach is essential for the prevention of incidents and/or reduction of consequences. Safety culture and operational discipline are the overall embracing factors that influence the safety performance of a facility. However, as recent events have indicated, there are a number of technical and engineering issues that must also be developed and implemented appropriately. Some of these issues that could lead to incidents with catastrophic consequences include facility siting and atmospheric relief venting. Impact of operator information systems on the prevention of releases of hazardous materials from their containment is also another significant factor that should be given appropriate attention.

This paper describes these three topics based on the findings from recent incidents and historical data. Engineering standards, regulatory requirements, and industry practices are discussed for facility siting, atmospheric relief venting, and operator information systems. Finally, a summary of gaps and needs in technology, standards, and practices is presented.     

Measuring safety climate: identifying the common features

In UK industry, particularly in the energy sector, there has been a movement away from ‘lagging’ measures of safety based on retrospective data, such as lost time accidents and incidents, towards ‘leading’ or predictive assessments of the safety climate of the organisation or worksite. A number of different instruments have been developed by industrial psychologists for this purpose, resulting in a proliferation of scales with distinct developmental histories. Reviewing the methods and results from a sample of industrial surveys, the thematic basis of 18 scales used to assess safety climate is examined. This suggests that the most typically assessed dimensions relate to management (72% of studies), the safety system (67%), and risk (67%), in addition themes relating to work pressure and competence appear in a third of the studies.     

学校突发事件应急管理存在的问题及解决对策研究

阐述学校突发事件的定义,针对目前学校安全的严峻形势和现状,分析了学校突发事件应急管理的重要性。基于应急管理理论,剖析我国学校突发事件特点。通过对学校安全应急管理体制系统的分析,指出存在的主要问题,进而提出可行性对策:必须构建统一的学校安全应急管理体制、建立健全应急管理机构、充分发挥各级政府效能,完善应急预警。最后,提出加强学校突发事件的应急管理,有必要建立学校安全应急指挥决策系统;完善我国学校安全法律法规与标准体系;必须建立一个科学、系统、全面的学校安全应急管理体制。     

Risk management of cost consequences in natural gas transmission and distribution infrastructures

A critical aspect of risk management in energy systems is minimizing pipeline incidents that can potentially affect life, property and economic well-being. Risk measures and scenarios are developed in this paper in order to better understand how consequences of pipeline failures are linked to causes and other incident characteristics. An important risk measure for decision-makers in this field is the association between incident cause and cost consequences. Data from the Office of Pipeline Safety (OPS) on natural gas transmission and distribution pipeline incidents are used to analyze the association between various characteristics of the incidents and product loss cost and property damage cost. The data for natural gas transmission incidents are for the period 2002 through May 2009 and include 959 incidents. In the case of natural gas distribution incidents the data include 823 incidents that took place during the period 2004 through May 2009. A two-step approach is used in the statistical analyses to model the consequences and the costs associated with pipeline incidents. In the first step the probability that there is a nonzero consequence associated with an incident is estimated as a function of the characteristics of the incident. In the second step the magnitudes of the consequence measures, given that there is a nonzero outcome, are evaluated as a function of the characteristics of the incidents. It is found that the important characteristics of an incident for risk management can be quite different depending on whether the incident involves a transmission or distribution pipeline, and the type of cost consequence being modeled. The application of this methodology could allow decision-makers in the energy industry to construct scenarios to gain a better understanding of how cost consequence measures vary depending on factors such as incident cause and incident type.     

Injuries in special transportation services for elderly and disabled--a multi-methodology approach to estimate incidence and societal costs

OBJECTIVE: Previous research has shown that elderly and disabled travelers using Special Transportation Services (STS) are injured without being involved in a vehicle crash. In order to estimate the true costs for these vehicle-related injuries, the focus needs to be adjusted towards an incident/traveler-oriented perspective. The aim of the project was thus to utilize such a perspective, in order to make a best estimation of the true costs for injury incidents, related to STS in Sweden. METHODS: In order to address the chosen perspective, a mixed-method approach was used, involving quantitative as well as qualitative research methods applied on four different sets of data, the hospital-based material (n=32), two sets of STS material (n=127), and interview-based material (n=1,000). RESULTS: The results showed that the injury incidence rate in STS is considerable, i.e., 3.2 per 100,000 trips (ranging from 1.5-1.9 in STS taxis and 3.6-5.6 in STS special vehicles). However, this high incidence rate is not due to road traffic crashes, but to non-collision injury incidents involving elderly and frail passengers, easily sustaining injuries from minor to moderate external violence. Typically, this violence is affecting an older female STS user, while entering and exiting the vehicle. The true costs were estimated to be $35 million per annum or $2.6 per trip. CONCLUSION: Future injury prevention measures should thus focus on safety in entering and exiting procedures.     

航天器AIT未遂事件管理系统设计及数据分析

为了加强对航天器AIT未遂事件的管理及数据采集、分析,确保航天器AIT作业安全,结合北京卫星环境工程研究所安全管理工作实际,从加强航天器AIT未遂事件管理入手,利用EXCEL服务器,设计了未遂事件管理模式及管理流程,建立了未遂事件管理系统及数据库,实现了未遂事件的“上报-信息录入-数据分析-整改验证”流程的有效闭环;同时,基于研究所2014—2016年未遂事件统计数据,进行了多维度解析和定性分析,利用层次分析法对未遂事件的形成原因进行了定量分析,为加强安全管理、持续改进安全管理体系提供了方向。     

Violence in the workplaces in Finland

The aim of this study was to describe violence in Finnish workplaces by comparing it with leisure-time violence. The data were derived from 13,762 interviews made from a representative sample of the Finnish population in 1988. The subjects were asked to report all the violent incidents they had encountered during the previous 12 months. There were 394 victims of violence in workplaces, that is, 40.6 victims per 1,000 workers. The rate of occupational violence was almost identical for males (40.6) and females (40.5). The most hazardous occupations were prison guard, police officer, and mental health nurse. The main reasons for violence at work were related to refusal of an authority's order to go away or to the relationship between doctor or nurse and patient. A typical assailant was an unaccompanied man who was under the influence of alcohol.     

What can the trove of CSB incident investigations teach us? A detailed analysis of information characteristics among chemical process incidents investigated by the CSB

Understanding the commonalities among previous chemical process incidents can help mitigate recurring incidents in the chemical process industry and will be useful background knowledge for designers intending to foster inherent safety. The U.S. Chemical Safety and Hazard Investigation Board (CSB) reports provide detailed and vital incident information that can be used to identify possible commonalities. This study aims to develop a systematic approach for extracting data from the CSB reports with the objective of establishing these commonalities. Data were extracted based on three categories: attributed incident causes, scenarios, and consequences. Seventeen causal factors were classified as chemical indicators or process indicators. Twelve chemical indicators are associated with the hazards of the chemicals involved in the incidents, whereas five process indicators account for the hazards presented by process conditions at the time of the incident. Seven scenario factors represent incident sequences, equipment types, operating modes, process units, domino effects, detonation likelihood for explosion incidents, and population densities. Finally, three consequence factors were selected based on types of chemical incidents, casualties, population densities, and economic losses. Data from 87 CSB reports covering 94 incidents were extracted and analyzed according to the proposed approach. Based on these findings, the study proposes guidelines for future collection of information to provide valuable resources for prediction and risk reduction of future incidents.     

Assessing safety management systems

Traditionally, both academe and practitioners have tended to address fire safety by focusing on technical aspects and looking for the immediate causes of fire incidents or accidents after they have taken place. More recently, organisations have focused on assessing the consequences of the fire risk inherent in their operations pro-actively. However, fire safety still tends to be addressed in isolation, though fire loss is an emergent property. An organisation's emergent property results from the interrelated activities of people who design it, manage it and operate it. There is still a need for a systemic approach to understand the systemic nature of fire safety. This paper describes a fire safety management system (FSMS) model that aims to maintain fire risk within an acceptable range in an organisation's operations in a coherent way. This systemic approach can be used as a diagnostic tool to assess the effectiveness of existing safety management systems (SMS). It is hoped that this approach will lead not only to more effective management of fire safety, but also to more effective management of safety, health and the environment for any organisation.     

Worker-fatigue contributing to workplace incidents in New Zealand Forestry

ProblemReports of incidents in dangerous work environments can be analysed to identify common hazards, in turn aiding in the prevention of future accidents. Whilst studies exist that do this, most focus on causes that involve physical risks. In this paper we propose an alternative approach, and illustrate causes of forestry incidents from the perspective of worker-failure and fatigue. Method This paper outlines the analysis of eight years’ worth of New Zealand forestry incident data, with a focus on the cause of, and time that, incidents occur. Results This has resulted in two main findings. First, 70% of incidents can be attributed, at least in part, to worker-failures. Second, 78% of worker-failure based causes show indications of fatigue. This indicates that a significant number of forestry incidents are caused by worker-fatigue. Finally, this dataset showed inconsistencies in data quality, similar to those that exist in other datasets. This did not affect our analysis. However, these types of errors have the potential to affect the data quality in the national reporting system. Impact on industry The results from this study will be used in a larger project on detecting fatigue in forestry workers for injury and incident prevention. It is also our hope that other researchers may find these results of interest for further fatigue prevention research in hazardous industries.     

Identification of managerial shaping factors in a petrochemical plant by resilience engineering and data envelopment analysis

Resilience engineering (RE) is a novel approach that is capable of controlling and limiting incidents and accidents. This study identifies managerial shaping factors in a petrochemical plant by RE and data envelopment analysis (DEA). To do this, a standard questionnaire containing resilient factors is completed by managers of a petrochemical plant. Then, the best DEA model is selected based on average efficiency and statistical test. In addition, sensitivity analysis are performed to identify the most important shaping factors. Reporting culture, management commitment, and preparedness are identified as the most important factors in this paper, respectively. Finally, the proposed model is validated and verified through statistical experiment. The proposed approach would help managers to have a comprehensive understanding of the plant with respect to the RE. To the best of our knowledge this is the first paper that examines resilient shaping factors in a petrochemical plant with respect to management and organization by DEA.     

Workplace violence intervention effectiveness: A systematic literature review

This is a systematic review of literature published since 1992, to determine the effectiveness of interventions in preventing workplace violence and to suggest interventions that need further evaluation research. The health care industry is the topic of 54% of the papers, the retail industry is the topic of 11% of the papers, and the remaining papers address the workplace in general or other situations. This finding drives the organization of this review: the first group of papers discussed in this review evaluates interventions to prevent workplace violence in the retail industry – mostly to prevent robbery and violence to retail workers. Singly or in combination, environmental designs in the retail industry, such as increased lighting to improve visibility and a limited cash-handling policy, can make workers safer, but more research is needed to overcome the barriers to implementation of environmental designs, especially in small businesses. The second group of papers in this review is about interventions to prevent violence to health care workers – mostly training and techniques of dealing with combative patients. Training health care workers to better cope with violent patients and to avoid injury is becoming standard practice, but research is needed to identify specific aspects of training and patient management programs that are most effective.     

基于Petri网的进近操作管理模型研究

据世界民航所发生的飞行事故情况看,进近着陆阶段时间短、任务重、环境复杂,是飞行事故多发阶段,占很大的比重,因此进近着陆是保证飞行安全的重要阶段。大多数事故是发生在仪表着陆系统出现故障的非精密进近方式。以机组非精密进近的主要飞行操作为基础建立基于Petri网的事故致因模型,统计分析相关的致因因素,计算相关风险值,通过对数据的分析反馈,形成对相应飞行员的针对性学习及训练的系统性管理模式。     

Method for evaluating learning from incidents using the idea of “level of learning”

Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be questioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.     

Subsea pipelines incidents prevention: A case study in Brazil

There are more than 4000 subsea pipelines in Brazil. These pipes include umbilicals, drilling risers, flexible risers, rigid risers, hybrid risers, flowlines, and export pipelines. Despite all standards, regulations, guides, and risk management tools designed to avoid events, subsea pipeline incidents still occur, revealing possible failures in companies' risk control. Identifying similarities between different subsea pipeline failure events is crucial to improving the design, risk management practices, and regulation requirements, besides promoting accident prevention. This paper proposes applying the life cycle and management practices combined to analyze subsea pipeline incidents from the RDI (Detailed Incident Report) and investigations reported to ANP (Brazilian National Agency of Petroleum, Gas, and Biofuels), the Brazilian safety regulatory agency. Furthermore, subsea pipeline incidents data were analyzed: correlated circumstances, consequences, and causes. The results show that most riser and flowlines causal factors are related to equipment failures, and recurrent root causes are design errors and integrity control. Based on the proposed approach, it was possible to identify gaps in most riser and flowlines accident investigations since there are few causal factors, root causes, and the absence of riser and flowlines failure mode and mechanisms. Therefore, the development of accident recommendations can be compromised. Thus, this paper proposes improvements to current Brazilian regulations to clarify the minimal subsea pipeline accident investigation requirements.     

What can be learned from incidents in chemistry labs

Students of chemistry should achieve certain safety competencies. Among other things they should be able to learn from undesirable events that happen during their work. In order to facilitate this we decided to analyze, together with our students, the specific causes of a few undesirable events which have happened in our school laboratories. We applied an approach based on root cause analysis and on the classification of four levels of safety assurance. Our examples showed the effectiveness of this approach, leading us at once not only to the identification of errors committed by students, but to those of teachers as well. This enabled us to compile a set of recommendations for the possible prevention of such incidents. Above all, our analysis strongly reinforced the conviction that this approach – learning from actual incidents – is more than just a cause analysis technique. It is a pattern of behavior, a cultural pattern. A technique may be analyzed and taught, but the most effective way to pass on a behavioral pattern is to set an example. The best way to show students how to learn from their own errors is for teachers to demonstrate how they have learned from their own experiences. Work in chemistry labs provides ample opportunities for this.     

矿山企业安全生产管理缺陷预警系统

矿山企业安全管理预警是针对可能发生的事故进行事先预测和防范.介绍了企业安全管理预 警系统的模型、预警系统各模块的功能及基于J2EE模式体系的设计与实现.     

基于知识图谱的应急管理研究态势分析

为直观展现国际范围内应急管理的研究态势,以2001—2011年间SSCI数据库中相关文献和数据为基础,运用Cite SpaceⅡ软件绘制应急管理研究领域的知识图谱。通过知识图谱可视化分析,展示国际应急管理领域主要研究力量的分布,应急管理研究的起源与知识基础,其学科领域和前沿的基本态势。研究结果表明,应急管理已成为研究热点,主要力量集中在欧美发达国家。相关研究起源于医疗卫生领域,目前研究内容延伸到自然灾害、事故灾难、公共卫生事件与社会安全事件等诸多领域。研究前沿问题集中在"恐怖主义"、"实时生产监控"、"突发事件"、"应急响应"、"应急护理"等方面。     

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。     

近十年中国民航事故及事故征候的统计分析

对1996—2005年我国民航发生的32起事故及1147起事故征候进行统计分析,其结果表明:我国民航事故和事故征候的万架次率及万时率均呈下降态势,机组、机械和机务原因是我国民航事故和事故征候的主要原因,事故征候的主要类型是鸟击、空中停车、偏出/冲出跑道/场外接地,事故征候发生阶段依次为巡航、起飞、着陆、爬升和进近。该研究成果有助于寻找事故和事故征候成因和规律。明确安全管理重点和难点;采取有效的预警和预控对策。