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.     

Origin of equipment design and operation errors

The paper discusses the origin of chemical process equipment accidents by analyzing past accident cases available in the Failure Knowledge Database (FKD). The design and operation errors of the process equipment that caused the accidents were analyzed together with their time of occurrence. It was found that design errors contributed to 79% of accidents while the rest were only due to human and organizational errors in the operation stage and external factors. The most common types of errors were related to layout, organizational errors in the operation stage, considerations of reactivity and incompatibility, and wrongly selected process conditions (each approx. 13% of total accident contributors). On average there were about 2 design errors per accident. The timing of the errors was quite evenly distributed between various lifecycle stages. Nearly half (47%) of the errors were made in process design-oriented stages, one fourth (26%) in detailed engineering, and one fifth (20%) in operation. In addition, the most frequent design and operation errors for each equipment type were identified. A points-to-look-for list was created for each equipment type, showing also the typical time of occurrence of the error. The knowledge of type and timing of design errors can be utilized in design to focus the hazard analysis in each stage on the most error-prone features of design.     

Accident prevention approach throughout process design life cycle

The accident rate in the chemical process industry (CPI) has not been decreasing although majority of accident causes have been identified and could have been prevented by using existing knowledge. These recurring accidents show that the existing knowledge has not been used effectively. In this paper, accident knowledge learned from earlier accident analyses are utilized to predict the common design errors during chemical plant design. An accident prevention approach throughout process design life cycle is proposed for a safer design consideration where designers are guided to identify common design errors, accident contributors and critical points to look for. The accident prevention approach has been applied to analyze the BP Texas City Refinery Explosion and Fire tragedy.     

Design as a contributor to chemical process accidents

The paper discusses the design errors in chemical process industry (CPI) by analyzing major equipment related accident cases from Failure Knowledge Database (FKD). The aim is to recognize the contribution of design to chemical process accidents and to evaluate the time of occurrence of the errors in a plant design project. The analysis of accident cases found out that the contribution of design to accidents is very significant: 79% of accident cases analyzed were contributed by design errors. The most critical design errors were poor layout (17%), insufficient consideration of chemical reactivity and incompatibility (16%) and incorrectly chosen process conditions (16%). The design errors were initiated at basic (32%), detailed (32%) and preliminary (22%) design phases of the project. Errors in fundamental aspects of chemical processes e.g. route selections are more severe (as compared to others errors class) and might creates many similar errors in later phases of design project. Based on the accident information gathered, a straightforward point-to-look list for error detection and elimination was suggested for process lifecycle stages.     

Method for identifying errors in chemical process development and design base on accidents knowledge

It has been claimed that the high accident rate in the chemical process industry is due to poor dissemination of accident knowledge that affects directly the level of learning from accidents. In response to this situation, this paper utilized past accident knowledge as a basis to develop a safety oriented design tool whereby the accident information were directly disseminated into plant design. The method was developed based on our previous accident analysis of design error in which the common design errors were ranked in accordance to their frequency and its origins during normal plant design project. Based on the design error ranking and its origin at a specific design phases, a method for design error detection is proposed. The method is expected to be able to identify the possible design error and its causes throughout chemical process development and design. The main objective is to trigger safe design thinking at the specific design phases so that appropriate action for risk reduction could be timely implemented. The Bhopal and BP Texas tragedies are used as case studies to test and verify the method. The proposed method can detect up to 74% of design errors.     

基于“2-4模型”的化工生产事故原因分析

为进一步研究化工生产事故发生的原因,运用“2-4模型”对从安全管理网等网站收集的125起化工生产安全事故进行分析,结果表明对于事故的直接原因方面,作业人员的不安全动作主要表现在违规操作和无证上岗,管理人员的不安全动作主要表现在其工作不认真等方面,不安全物态最主要的是设备年久失修。对于事故的间接原因,主要表现在安全意识不够、安全知识不足、安全习惯不佳3方面。事故的根本原因则主要表现在缺乏安全培训等方面。为制定化工生产事故预防措施提供了依据。     

防提安全装置现场应用事故分析与规避措施

防提安全装置是起下钻杆中防止误操作的安全设备,但长时间未对其进行结构改进,且其在应用过程中存在操作不规范情况,从而在油田钻井过程中引起诸多问题,甚至导致一系列严重事故的发生。以某油田防提安全装置现场应用事故为例,从装置系统设计,现场操作和人为因素等方面分析出了此次事故发生的直接原因与间接原因。同时结合其他类似事故的调研分析结果,对防提安全装置提出了可行的优化与改进方案,规范了该装置操作与监督岗位的作业要求,且细化了该装置维护与故障处理的具体措施,从而做到了从多方面预防类似事故的发生。通过应用发现,防提安全装置的事故原因分析方法和规避措施可有效地防止类似故障的发生,提高油气钻采过程井口设备的安全性,其也可作为油田其他类似装置优化改进以及规范现场操作的参考。     

基于数据挖掘的化工生产事故致因主题抽取

为充分挖掘化工生产事故数据中的有效信息和潜在规律,提高对化工事故认知水平,针对某化工集团2010—2016年共1 578起事故数据,利用社会网络分析等方法揭示事故要素间的关联关系;运用潜在狄利克雷分配（LDA）模型进行事故聚类,并抽取到5个事故致因主题。研究结果表明:LDA主题模型等数据挖掘技术能有效挖掘大量事故数据中的潜在信息;5个事故致因主题中,4个涉及到人因或组织层面的缺陷;员工注意力不集中和现场风险管理不足这2个致因主题间具有较强相关性;员工注意力不集中、现场风险管理不足以及设备问题是导致事故发生的主要原因。     

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。     

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。     

基于蒙特卡洛模拟的多米诺事故风险量化管理*

为降低危化品相关的化工事故造成的人员伤亡和财产损失,以化工多米诺事故为研究对象,探讨由初始事故引发1个或多个次生事故的连锁反应机理与风险评估方法。提出应用蒙特卡洛模拟对多米诺事故风险进行动态量化的方法,梳理化工多米诺事故风险的识别、分析、评定、处理全周期管理流程,并以1个天然气压气站为案例,验证基于蒙卡模拟的化工多米诺事故风险量化方法的有效性。结果表明:该方法可以更准确地对化工多米诺事故风险进行定量评估。多米诺事故风险全周期管理流程的梳理能够有效指导化工企业开展安全管理、事故预防等工作。     

基于MAIB事故报告的人为失误灰色关联分析

人为失误作为海上交通事故的主要原因,受到多种因素的影响。为了识别这些影响因素,避免或减少因人为失误导致的海上交通事故,基于96件英国海事调查委员会(MAIB)事故报告,应用熵加权灰色关联分析,分别按船旗国、船舶类型、事故类型计算人为失误与影响因素之间的关联度。结果表明,能力/技能/知识、团队协作、程序和现行规程、设备、交流(内部和外部)和管理/检验/检查是影响人为失误的主要因素。     

基于事故统计分析的地铁运营安全管理研究

为了预防和减少地铁运营事故的发生,本文通过统计分析某城市地铁5年的运营事故资料,探讨了地铁运营事故的发生规律,从人、机、环、管几个方面分析了导致地铁运营事故发生的主要原因。结果显示:统计年度内地铁运营事故年度总量较为平稳,事故的发生对月份变化敏感度较低,受气象条件影响较小;信号故障、车辆故障是发生最频繁的事故类型,合计占事故总数的56%。事故原因分析显示,设备设施因素导致的事故占事故总数的87%;人为因素导致的事故占事故总数的7%。根据地铁运营事故特点,从人、机、环、管4方面提出了相应的安全管理对策,可为制定科学合理的地铁运营安全管理措施提供依据。     

Why bad things happen to good people

Accidents in the process industries are extensively investigated to determine root causes, for lessons learned, and many times in search of the “guilty”. Accidents are seldom simple and most accidents have human elements that led to or facilitated the accident. Many times the people involved in these accidents, when considered individually on their merit, would be considered “good” people yet “bad things” (accidents) still occur.Human errors can be classified as individual, group, and organizational. Individual human errors have been addressed in a number of studies and papers. Many of these classify human errors and treat them probabilistically or cognitively. Less has been said regarding the individual psychological/sociological response/interaction mechanisms that might contribute to an industrial accident. These elements also contribute to a lack of situational awareness which often plays a large part in human error. Group and organizational interactions/dynamics can also contribute negatively to situational awareness and to the chain of events of an accident. Organization errors, which are typically latent, can also facilitate an accident and are many times people enabled for personal and business vested interests.This paper will discuss the effect of human error at the practical plant level in contributing to accidents in the process industries from individual, group, and organizational perspective. The discussion will include psychological/sociological response/interaction mechanisms that can contribute to situational awareness and human error. It will also discuss how complexity, veracity, and quantity of available information can affect the human decision-making process leading to mistakes.Accidents are seldom simple and most accidents have a number of elements that led to or facilitated the accident. When looking at individual elements probabilistically, multiplying probabilities together, it is hard to see how an accident could have occurred. A common refrain “That’s double jeopardy and we don’t have to consider that” is essentially a qualitative probabilistic analysis. Yet we have cases of triple, quadruple, n-jeopardy occurring to cause accidents. The paper will discuss the superimposition of causes and a similar concept of functional resonance in causing accidents.     

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.     

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].     

Misoperation monitoring and early warning during startup and shutdown of petrochemical units

Most petrochemical units run under extreme conditions, such as high temperatures, pressures, and speeds. Consequently, the equipment operators may commit errors because the startup and shutdown processes usually involve complicated operation steps; moreover, the operators may lack experience in handling abnormal situations. Misoperation can lead to accidents, including fires and explosions. Thus, risk analysis for process operations and the development of preventive measures have become an effective means of avoiding misoperation-related accidents. However, it is challenging to ensure the comprehensiveness of risk-analysis results. In this paper, we present a method for misoperation monitoring and early warning in the startup and shutdown processes of petrochemical units. The mechanisms of misoperation occurrence are summarized based on investigations of serious accidents in the recent past. Knowledge regarding the mechanisms of misoperation is crucial for the risk analysis of petrochemical units. The potential risk information, such as causes, adverse consequences, key monitoring parameters, and prevention control solutions, should be acquired and be employed to construct an early-warning knowledge database. Furthermore, misoperation judgment rules need to be formulated to identify misoperations. The data obtained from the monitoring module, misoperation judgment rules, and analysis results can aid in developing schemes to avoid possible abnormal situations. This paper reports a misoperation monitoring and early-warning system for a hydrogenation unit. As demonstrated, conducting risk analysis to determine the potential operational risks and formulating misoperation judgment rules to analyze the process data are essential for enabling early warning. The application of this method will contribute to operational guidance, economic loss reduction, and accident avoidance.     

A novel knowledge database construction method for operation guidance expert system based on HAZOP analysis and accident analysis

An expert system for operation guidance will contribute to identifying the operatoration problems and indicating the resolutions thereof, because the information stored in the expert system can be utilized to resolve the corresponding technical problems. However, there are several problems that should be solved in the practical application of the expert system, such as lack of corresponding knowledge or resolutions utilized to cope with the problems, inapplicable resolutions, too many resolutions for the operators to choose from to obtain the best one in the first time, etc. Obtaining and storing as much as information in the database of the expert system are important issues in the construction process of the expert system. The accident analysis results contain a limited number of accident cases and the HAZOP analysis only refers to a single deviation analysis. This paper has presented a novel knowledge database construction method for an operation guidance expert system based on the HAZOP analysis and the accident analysis, which can be used to resolve the above problems. The HAZOP analysis results are combined with the accident analysis results and the combination information can be stored in the database of the expert system, and can be employed to forecast accidents or identify accident causes. The structures of the operation guidance table and the accident investigation table have been illustrated. The residuum hydrotreating process expert system is taken as an example to illustrate the knowledge database construction method. With the aid of this expert system, the operators will well understand the operations and adopt the best resolutions to deal with the abnormal situations. Also the operators can identify potential risks existing in the plant which will result in accidents according to the accident analysis results associated with the HAZOP analysis results.     

因果图和层次分析法在事故预防中的应用研究

通过引入因果图法和层次分析法,首先将导致事故发生的原因用因果图法进行分析和表示,然后根据一定的内在机理将因果图转换成AHP的层次结构模型,利用AHP严格的数学逻辑定量计算方法,求得各原因事件的权值,得出各原因事件导致事故发生的重要程度,从而确定影响事故发生的关键原因,进而作为事故预防的重点。以高速公路交通事故诊断为例,得出驾驶员的技术水平和安全意识是影响高速公路交通事故的主导因素的结论。结果表明,运用该法得出的结果符合实际,对事故预防有借鉴意义。     

A study of maintenance-related major accident cases in the 21st century

This paper is based on a review of 183 detailed, major accident investigation and analysis reports related to the handling, processing and storage of hydrocarbons and hazardous chemicals over a decade from 2000 to 2011. The reports cover technical, human and organizational factors. In this paper, the Work and Accident Process (WAP) classification scheme is applied to the accident reports with the intention of investigating to what extent maintenance has been a cause of major accidents and what maintenance-related causes have been the most frequent.The main objectives are: (1) to present more current overall statistics of maintenance-related major accidents, (2) to investigate the trend of maintenance-related major accidents over time, and (3) to investigate which maintenance-related major accident causes are the most frequent, requiring the most attention in the drive for improvement.The paper presents statistical analysis and interpretation of maintenance-related major accidents’ moving averages as well as data related to the types of facility, hazardous substances, major accidents and causes. This is based on a thorough review of accident investigation reports.It is found that out of 183 major accidents in the US and Europe, maintenance was linked to 80 (44%) and that the accident trend is decreasing. The results also show that “lack of barrier maintenance” (50%), “deficient design, organization and resource management” (85%) and “deficient planning/scheduling/fault diagnosis” (69%) are the most frequent causes in terms of the active accident process, the latent accident process and the work process respectively.