Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

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.     

Learning lessons from incidents: A paradigm shift is overdue

Drawing on historical data we show that the international community of process engineers has not been good at learning lessons from their past accidents. We call for a paradigm change in the way we approach this and the creation of a single new, multi-national, multilingual accident database that is free at the point of use and that includes immediate and underlying causes as well as “lessons learned”. It must be user-friendly and provide links to key source documents. The purpose of this paper is to challenge those in authority, and with the power to do so, to make this happen. We give some preliminary views on what may be required. In countries that so choose this could include an element of compulsion to consult the database in specific circumstances and a sign-off procedure to verify that this has been done.     

Process industry accidents in Sri Lanka: Analysis and basic lessons learnt

Accidents in the process industry could be prevented or reduced by having good safety management measures. Such preventive measures could be further improved through the experiences and lessons learnt from past accidents. Therefore, analysis results of past accidents are valuable sources of information for determining root causes and as case material to prevent and reduce the adverse consequences of accidents in the process industry.This paper looks at accidents in the process industry that have occurred in the past 10 years from 1997 to 2006 in Sri Lanka to gain an understanding of the nature and consequences of accidents. Lessons and main areas of concern to improve safety in the Sri Lanka process industry are discussed. The analysis is done for different event types based on specific operating process stage during which the accident occurred such as processing, loading and unloading, repair and maintenance and storage, the immediate effect types such as fire, explosion, chemical releases and emissions and the consequences of each accident. Fire incidents were observed in 38 accidents analyzed. The results show that the highest number of accidents has occurred during processing operations followed by accidents during maintenance and repair work. The cause analysis shows that many accidents have occurred due to technical and human failures.The accidents are then classified according to the severity of the consequences in order to compare the nature of accidents experienced in Sri Lanka with respect to accidents in other countries in the world.     

A little knowledge is a dangerous thing – Unexpected reaction case studies make the case for technical discipline

The old saying, “what you don't know can't hurt you,” implies that ignorance is bliss. “A little knowledge is a dangerous thing,” may be closer to the truth; however, it is not the little that we know that is dangerous, but that which is not known. By design, the processes used in the chemical industry are reactive, and the intended reaction receives much scrutiny. However, other reactions occur, often unexpectedly, and possibly with severe consequences. The lessons we learn from these reactions must drive the improvement of our process development and technology management processes and the culture that shapes those processes, a culture of Technical Discipline.Technical Discipline, analogous to Operating Discipline in the manufacturing organization, is a culture committed to fully identifying and characterizing chemical and reaction hazards, and properly documenting and communicating those hazards to create a permanent knowledge and understanding within the organization operating that process.A culture of Technical Discipline will reveal reaction hazards that might otherwise remain unknown until being unveiled in a dramatic and unexpected fashion. Until you fully identify and characterize the hazards of the materials you handle in your processes…what you don't know can hurt you.     

Prevention and mitigation of injuries and damages arising from the activity of subliminal enterprises: A case study in Slovakia

The paper focuses on risk sources under no legislative pressure in the field of prevention of major accidents. Despite this, they can represent significant sources of risk of accidents.The aim of the paper is to present the results of the risk assessment associated with the operation of enterprises not regulated by the SEVESO III Directive (the so-called subliminal enterprises), to provide information on possible operational problems and to verify the applicability of recognized risk analysis methods for these specific sources of risk. Last but not least, its purpose is to point out that subliminal enterprises, due to their location close to residential areas or areas with a high concentration of population, pose a serious risk to the population.The paper summarizes the results of the quantitative risk assessment of a specific enterprise not included in the Seveso Directive – a filling station. Filling stations are frequently located in built-up areas with a dense coefficient of habitability. Due to their number, location (e.g. close to residential areas), frequency of occurrence of persons in the area and handling of dangerous substances during normal operation, they can have negative or even tragic consequences to the life and health of the population.Due to the non-existent risk assessment methodology for enterprises with subliminal quantities of dangerous substances and the lack of a systematic search for risk sources, a risk assessment procedure for these companies is designed.     

基于GIS的危险化学气体泄漏事故应急响应研究

为了研究危险化学气体泄漏事故扩散过程以及受灾人员疏散规划问题。提出以GIS为“连接器”,将危险化学气体的泄漏和扩散过程模拟、气体扩散风险分析和最优疏散方案生成3个过程进行集成,实现泄漏事故的综合应急响应。研究结果显示:方法能针对各类泄漏事故模拟气体的动态扩散过程,并生成受灾人员疏散规划方案,有助于应急处置机构及时决策,进而减少生命财产的损失。     

Causative factors for vapour cloud explosions determined from past-accident analysis

Past-accident analysis shows that most dangerous incidents are related to process operations. Often these operations are carried out under high pressures and/or high temperatures. The consequences, therefore, are significant. A scientific analysis of past accidents which led to vapour cloud explosion has been performed. The analysis has provided vital information for most probable accident scenarios for a new situation. Factors such as chemical characteristics, its release mode, time etc. show trends and relationships for the occurrence of vapour cloud explosions.     

基于改进LEC法的危化企业静电点燃危险评价

危化企业爆炸性危险环境下由静电放电引发的火灾爆炸时有发生,针对这一问题分析了危化企业气体、液体、固体、粉体及人体在不同生产工艺过程中静电电荷来源以及可能的静电放电形式。综合考虑静电点燃源形成可能性、爆炸性环境形成可能性、监控与控制措施有效性以及静电事故后果严重度,构建了基于改进LEC法的静电点燃危险评价方法,该评价方法能实现对危化企业静电点燃源危害的量化评估与分级。应用该方法对某加油站进行静电点燃危险评价,并根据评价结果提出了预防改进措施。     

Three accidents in European dynamite production plants: An attempt to improve the external lessons learning

Three serious accidents occurred in three dynamite manufacturing plants within three European countries during a relatively short time period triggering the question of effective external learning. The article discusses the lessons for the prevention of accidents learned from retrospective comparative analysis. It advocates for a better process for learning lessons. It attempts to show how a two level approach to accident analysis may help to reveal a common deeper learning hidden under diverse routine lessons.     

Analysis of accidents and incidents occurring during transport of packaged dangerous goods by sea

The release of packaged or containerized dangerous goods during transport can have serious consequences on board a ship. This study was focused on identifying factors contributing to these types of releases and on investigating the contribution of dangerous goods accidents to overall container ship accident rates. Records of dangerous goods releases from a US and a UK database for an 11-year period covering 1998–2008 were analyzed to identify and categorize main contributing factors. The majority of releases, estimated as 97% of the US events and 94% of the UK events, did not follow another primary accident type such as a collision. Faults that occurred during activities such as preparation of the goods for transport, packaging, stuffing containers, and loading the ship were main factors contributing to the release of the dangerous goods on board the ship. For container ship casualties occurring worldwide during the same period, 1998–2008, accidents involving packaged dangerous goods were estimated to account for 15% of all fatalities. Self-ignition or ignition of incorrectly declared dangerous goods was identified as a contributing factor for the fatal accidents. Ensuring that dangerous goods are correctly prepared and documented for marine transport is thus very important for preventing releases and improving on board safety.     

危险化学品仓储事故演化规律及消防力量需求研究

危险化学品仓储火灾事故复杂,处置难度大,易引发事故多米诺效应,对人民的生命和财产造成严重威胁。本文分析了危化品仓储火灾爆炸事故的演化规律和事故风险,结合事故案例剖析危化品仓储火灾爆炸事故后果及对周边区域的影响。针对危险化学品仓储火灾爆炸事故,建立危化品仓储火灾扑救泡沫需求评价二级指标体系,采用模糊层次分析法建立了泡沫灭火剂用量评价数学模型,并根据救援力量类别需求、各种应急救援装备与作战人员需求建立危化品火灾消防力量需求预测模型,准确预测危化品仓储事故消防力量需求。     

Maintenance-related major accidents: Classification of causes and case study

The potential for major accidents is inherent in most industries that handle or store hazardous substances, for e.g. the hydrocarbon and chemical process industries. Several major accidents have been experienced over the past three decades. Flixborough Disaster (1974), Seveso Disaster (1976), Alexander Kielland Disaster (1980), Bhopal Gas Tragedy (1984), Sandoz Chemical Spill (1986), Piper Alpha Disaster (1988), Philips 66 Disaster (1989), Esso Longford Gas Explosion (1998), Texas City Refinery Explosion (2005), and most recently the Macondo Blowout (2010) are a few examples of accidents with devastating consequences.Causes are being exposed over time, but in recent years maintenance influence tends to be given less attention. However, given that some major accidents are maintenance-related, we intend to concentrate on classifying them to give a better insight into the underlying and contributing causes.High degree of technological and organizational complexity are attributes of these industries, and in order to control the risk, it is common to deploy multiple and independent safety barriers whose integrity cannot be maintained without adequate level of maintenance. However, maintenance may have a negative effect on barrier performance if the execution is incorrect, insufficient, delayed, or excessive. Maintenance can also be the triggering event.The objectives of this article are: (1) To investigate how maintenance impacts the occurrence of major accidents, and (2) To develop classification schemes for causes of maintenance-related major accidents.The paper builds primarily on model-based and empirical approaches, the latter being applied to reports on accident investigation and analysis. Based on this, the Work and Accident Process (WAP) classification scheme was proposed in the paper.     

The functioning and status of the EC's major accident reporting system on industrial accidents

This paper describes the functioning and current status of the European Commission's Major Accident Reporting System (MARS), dedicated to collect in a consistent way data on major industrial accidents involving dangerous substances from the Member States of the European Union under the requirements of the `Seveso Directives', to analyse and statistically process them, and to distribute all non-confidential accidents data and analysis results to the Member States. This modern information exchange and analysis tool is made up of two connected parts: one for each local unit (i.e. for the Competent Authority of each Member State), and one central part for the European Commission. The local as well as the central parts of this network can serve both as data logging systems and, on different levels of complexity, as data analysis tools. The central database allows complex pattern analysis, identifying and analysing the succession of disruptive factors leading to an accident. On this basis, “lessons learned” can be formulated for the industry or regulatory bodies for further accident prevention. Results of various overall analyses of the contents of MARS are given. The availability of MARS data and analysis results is described.     

Modeling the major accident prevention legislation change process within Europe

The factors giving impulse to changing major accident prevention legislation within Europe, the so-called Seveso Directive, have not been thoroughly studied and molded into an understandable model thus far. For example the exact relationship between major industrial accidents and an ever changing legislation is still unexplored. This paper thoroughly investigates the parameters having influenced the change of the 1996 Seveso II Directive into the 2003 Seveso Directive Amendment 2003/105/EC and develops the accompanying legislation change process. The official major accident reports of Baia Mare, Enschede and Toulouse are studied in-depth, as well as many other official EU documents. Furthermore, experts from academia, government and industry who witnessed and/or participated into the legislation change process were interviewed in-depth. More profound insights into the societal debate following a major accident may help private companies to adapt their safety management system and their prevention policies, and may aid the legislator to develop more efficient and effective regulations. This way, the societal demand to change legislation in an ad hoc manner may be unpressurized.     

Rail ruminations for process safety improvement

Process safety practices have undergone multiple refinements over the past few decades, but major accidents continue to occur. Most organizations strive to improve performance by strengthening existing methods or by adopting new and/or different approaches. Central to these continual improvement efforts is the practice of applying lessons learned as a means to drive out potential risk exposures. Often, lessons learned may be transferred from other industries; indeed, high-performing organizations regularly benchmark practices outside of their immediate industry.In pursuit of continual process safety improvement, this paper examines risk management practices in the Rail Industry, and explores how methods intended for managing passenger and public rail safety may be transferred to drive continual improvement of process safety. Rail safety has its roots in engineered safety solutions; modern practices have additionally embraced the human aspects of safety performance. A selection of approaches for rail safety assessment and risk management are described in three areas considered fundamental to safety management: management of systems, management of technology, and management of human elements. In light of these examples, the authors provide views regarding how the field of process safety management may leverage the rail experience.     

渤海湾客滚船危险货物安全运输现状分析与对策

针对近五年来渤海湾客货滚装船车载化工产品货物常见种类及危险性分布情况进行了全面的统计,阐述了渤海湾航线客货滚装船车载化学品运输现状,分析了渤海湾航线客货滚装船车载化学品运输存在的问题以及载有危险货物运输车辆客货滚装船在发生事故时可能带来的危害.提出了加强管理部门间协作、疏导与查堵相结合、制定适应渤海湾短途航运的货物危险性测试标准以及引导和促进货物生产商、经营者、运输单位提前进行货物危险性测试分类,并采用合适的包装方式及警示标志等加强载有危险货物运输车辆客滚船安全管理的重要措施.     

Development of a new chemical process-industry accident database to assist in past accident analysis

Past accident analysis (PAA) is one of the most potent and oft-used exercises for gaining insights into the reasons why accidents occur in chemical process industry (CPI) and the damage they cause. PAA provides invaluable ‘wisdom of hindsight’ with which strategies to prevent accidents or cushion the impact of inevitable accidents can be developed.A number of databases maintain record of past accidents in CPI. The most comprehensive of the existing databases include Major Hazard Incident Data Service (MHIDAS), Major Accident Reporting System (MARS), and Failure and Accidents Technical Information Systems (FACTS). But each of these databases have some limitations. For example MHIDAS can be accessed only after paying a substantial fee. Moreover, as detailed in the paper, it is not infallible and has some inaccuracies. Other databases, besides having similar problems, are seldom confined to accidents in chemical process industries but also cover accidents from other domains such as nuclear power plants, construction industry, and natural disasters. This makes them difficult to use for PAA relating to CPI. Operational injuries not related to loss of containment, are also often included. Moreover, the detailing of events doesn’t follow a consistent pattern or classification; a good deal of relevant information is either missing or is misclassified.The present work is an attempt to develop a comprehensive open-source database to assist PAA. To this end, information on about 8000 accidents, available in different open-source clearing houses has been brought into a new database named by us PUPAD (Pondicherry University Process-industry Accident Database). Multiple and overlapping accident records have been carefully eliminated and a search engine has been developed for retrieval of the records on the basis of appropriate classification. PUPAD doesn’t aim to replace or substitute the well established databases such as MHIDAS and MARS but, rather, aims to compliment them.