Study of Major Accidents Involving Chemical Reactive Substances: Analysis and Lessons Learned

The objective of this paper is to present the results of the analysis performed on a selection of accidents included in the MARS database. This is a database of past accidents that occurred in Europe maintained by the European Commission, in order to help the Member States to meet the requirements of the Seveso and Seveso II directives. The study is focused on those accidents that involve reactions between chemical substances, whether wanted or unwanted, that generated a hazardous situation by loss of control of such reactions. Runaway reactions are known to be especially dangerous, given that many times they are unexpected, or their possible consequences underestimated, so sometimes chemical industries are not ready to cope with the effects of loss of control of reactive processes. The aim of the analysis is to obtain lessons learned from past accidents in order to prevent similar situations in the future, or to reduce their consequences. Understanding the causes of past accidents, including equipment failures, deviations in the expected course of a reaction, or deficiencies in process operations performed, can help to a better understanding of similar processes. Industries working with potentially dangerous chemicals should consider introducing lessons learned into their safety management systems.     

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].     

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.     

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.     

基于PDCA模式的化工企业安全文化探讨

近年来,化工事故屡次发生,给国家和人民带来了巨大的经济损失.为了减少化工企业的安全生产事故,有的通过HSE管理体系降低安全事故率,有的通过危险性评价来控制危险源.从文化管理的角度探讨化工企业的安全文化建设问题,以期减少化工企业的安全生产事故. 根据安全文化管理的优势以及化工生产的特点,引入PDCA管理模型,把化工企业安全文化建设分4个阶段,系统地讨论了化工企业的安全文化建设问题,并且形成了一套化工企业的文化建设体系,可供企业参考.     

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.     

Building Safety indicators: Part 2 – Application,practices and results

Petroleum exploration and production in the Barents Sea is a controversial topic. The Goliat field outside the northern coast of Norway will be the first offshore oil development in this region, with planned production start in 2013–2014. Avoiding major accidents at Goliat is critical; not only to reduce the risks to human lives and the environment, but also to gain political acceptance. Providing early warnings of major accidents for Goliat is one of the main objectives of the research project ‘Building Safety’. The objective of this paper is to describe the development of early warnings in the form of indicators. In addition, the paper includes an overview of current status of early warnings of accidents in other major hazard industries; the nuclear power industry, the chemical process industry, and aviation. Experiences from these industries, including lessons learned from recent major accidents, have been used as important input to the development of early warning indicators.     

Process safety challenges for SMEs in China

While process safety regulations and standards have been in place in western countries for more than two decades, China has only recently started to officially embrace these issues with the adoption of its Process Safety Management (PSM) regulation AQ/T 3034-2010 (SAWS, 2010). However, compliance with this regulatory framework requires substantial resources and may therefore appear too complex to be efficiently implemented by small and medium sized enterprises (SMEs) in the chemical sector. This is of particular relevance as about 99% of chemical companies in China are SMEs, accounting for more than 80% of all chemical accidents. To address this issue, additional local regulations and planning activities related to process safety have been implemented in China, including the establishment of hundreds of chemical industry parks. Some of the process safety problems faced by chemical industry parks are identified and discussed in this paper. To help solve these problems, UNEP's “Responsible Production approach for Chemical Hazards Management along the Value-Chain” is introduced in this paper and suggested as a simplified PSM approach targeted specifically at SMEs which, regardless of handling hazardous chemicals in their daily operations, may not have the knowledge or capacity to efficiently implement PSM and may not fall in the scope of the PSM regulation AQ/T 3034-2010. By introducing PSM to SMEs in a more manageable way, relevant steps can be progressively implemented by companies towards full compliance with the current regulatory framework, contributing to increased safety in chemical industry parks in China.     

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.     

The impact of the BP Baker report

Introduction

This study examined the impact of the British Petroleum (BP) Baker Panel Report, reviewing the March 2005 BP-Texas City explosion, on the field of process safety.

Method

Three hundred eighty-four subscribers of a process safety listserv responded to a survey two years after the BP Baker Report was published.

Results

Results revealed respondents in the field of process safety are familiar with the BP Baker Report, feel it is important to the future safety of chemical processing, and believe that the findings are generalizable to other plants beyond BP-Texas City. Respondents indicated that few organizations have administered the publicly available BP Process Safety Culture Survey. Our results also showed that perceptions of contractors varied depending on whether respondents were part of processing organizations (internal perspective) or government or consulting agencies (external perspective).

Conclusions

This research provides some insight into the beliefs of chemical processing personnel regarding the transportability and generalizability of lessons learned from one organization to another.

Impact on Industry

This study has implications for both organizational scientists and engineers in that it reveals perceptions about the primary mechanism used to share lessons learned within one industry about one major catastrophe (i.e., investigation reports). This study provides preliminary information about the perceived impact of a report such as this one.     

跨区域应急协作视角下化工园区空间布局的失衡与应对策略分析

随着工业化进程加快,我国化工园区呈现出数量逐年递增且集中分布的态势,增加了跨区域重大突发事件的风险,如何实现跨区域的应急协作成为化工园区安全规划所面临的重点与难点问题之一。基于此,搜集近15 a全国化工园区的安全事故,采用自组织特征映射神经网络分类方法与多元回归模型研究全国范围内化工园区安全事故的空间分布规律及影响因素,进而从风险分布与应急协作需求的匹配性角度讨论我国现有应急协作机制存在的潜在问题。研究结果表明:我国化工园区整体空间布局呈现出以区域优势为导向的趋势,其选址大多忽略了化工园区集中区域的高风险与应急能力不足的问题,这种布局的失衡使得政府无法形成高效的跨区域应急协作体制;化工园区数量上的增加并非是导致危机事故的主要原因,强调了化工园区自身特征与危机事故严重程度的相关性,区域间应急联动协作在化工园区危机应对过程中的重要作用;最后,从空间布局、跨区域协作角度提出化工园区区域应急协作的相应政策建议。     

Exploratory study on safety climate in Chinese manufacturing enterprises

This study was conducted in eastern cities of China; 1060 employees were sampled from 144 enterprises located in East China, and 796 (75.1%) responded validly. The level of safety climate of Chinese manufacturing enterprises as well as the differences in safety climate between large enterprises and small and medium-sized enterprises (SMEs) were examined. This study revealed that the safety climate level that the employees’ perceived was rather low in Chinese manufacturing enterprises, and differences in terms of mean scores of total safety climate, factors composing the safety climate, and items to measure this climate between large enterprises and SMEs were statistically significant (at p < 0.05). Among all the factors, the largest difference between large enterprises and SMEs was the employees’ perception of safety training, followed by management support. It suggests that SMEs should pay more attention to safety training and management support to improve the safety climate.     

Revising HFACS for SMEs in the chemical industry: HFACS-CSMEs

Chemical accidents have occurred frequently in recent years, and most have occurred in small and medium-sized enterprises (SMEs). SMEs in the chemical industry face greater challenges than large enterprises with regard to accident prevention. However, SMEs have been unable to effectively learn from accidents due to the limited resources. The accident causation model is an effective tool to help the analyst learn from accidents. As a systematic accident causation model, the causes classification in the human factors analysis and classification system (HFACS) can match the characteristics of SMEs, but the cause of chemical accidents can be ineffectively identified by HFACS. In this study, HFACS was revised for the SMEs in the chemical industry, mainly consisting of three parts. First, based on the definition of factors in the original HFACS, the extended HFACS framework was obtained, which include 78 manifestations with the characteristics of the chemical accidents. Second, 101 accidents occurring in a SME in the chemical industry from 2012 to 2016 were analyzed though the extended HFACS framework. Finally, a new model, known as the HFACS-CSMEs, was obtained by further revising the manifestations and causes classification according to the statistical results of the accident analysis. HFACS-CSMEs consists of 15 cause factors and 56 manifestations, which can effectually identify and distinguish the causes in chemical accidents. Moreover, the easy-to-understand and statistically acceptable features of HFACS-CSMEs can cater to the SMEs regarding accident analysis. HFACS-CSMEs solves the problem that HFACS cannot be directly applied to chemical accidents and provides new ideas about preventing accidents in SMEs in the chemical industry.     

How can process safety and a risk management approach guide pandemic risk management?

The coronavirus disease (COVID-19) brought the world to a halt in March 2020. Various prediction and risk management approaches are being explored worldwide for decision making. This work adopts an advanced mechanistic model and utilizes tools for process safety to propose a framework for risk management for the current pandemic. A parameter tweaking and an artificial neural network-based parameter learning model have been developed for effective forecasting of the dynamic risk. Monte Carlo simulation was used to capture the randomness of the model parameters. A comparative analysis of the proposed methodologies has been carried out by using the susceptible, exposed, infected, quarantined, recovered, deceased (SEIQRD) model. A SEIQRD model was developed for four distinct locations: Italy, Germany, Ontario, and British Columbia. The learning-based approach resulted in better outcomes among the models tested in the present study. The layer of protection analysis is a useful framework to analyze the effect of different safety measures. This framework is used in this work to study the effect of non-pharmaceutical interventions on pandemic risk. The risk profiles suggest that a stage-wise releasing scenario is the most suitable approach with negligible resurgence. The case study provides valuable insights to practitioners in both the health sector and the process industries to implement advanced strategies for risk assessment and management. Both sectors can benefit from each other by using the mathematical models and the management tools used in each, and, more importantly, the lessons learned from crises.     

构建新型危险化学品安全管理体制

随着我国经济的快速发展,危险化学品事故频频发生。现行危险化学品安全管理体制存在漏洞是其主要原因。笔者认为现行危险化学品安全管理体制主要存在5个方面不足:管理体制与市场经济体制不符;行业管理未能实现;中介作用没有发挥;工会维权力量薄弱;公众参与严重不足等。为此,建议建立政府、市场和民众相互协调的危险化学品安全管理体制,即“政府监管、市场调节和社会监督”。其中,政府监管包括政府管理和国家监督,市场调节包括企业责任和中介服务,社会监督包括员工维权和公众参与。     

The legacy of Bhopal: The impact over the last 20 years and future direction

Chemical process safety was not a major public concern prior to 1984. As far as chemical hazards were concerned, public fears focused on disease (cancer) and environmental degradation. Even a series of major process incident tragedies did not translate into widespread public concerns about major incidents in chemical plants that might disastrously affect the public. This situation changed completely after the December 1984 disaster at the Union Carbide plant in Bhopal. Not only was the public's confidence in the chemical industry shaken, the chemical industry itself questioned whether its provisions for protection against major incidents were adequate.

The recognition of the need for technical advances and implementation of management systems led to a number of initiatives by various stakeholders throughout the world. Governments and local authorities throughout the world initiated regulatory regimes. Has all that has resulted from the legacy of Bhopal reduced the frequency and severity of incidents? How can we answer this question? As we move into more and more globalization and other complexities what are the challenges we must address? According to the authors, some of these challenges are widespread dissemination and sharing of lessons learned, risk migration because of globalization, changing workforce, and breakthroughs in emerging areas in process safety.     

Improved management practice and process hazard analysis techniques for minimizing likelihood of process safety incidents in Taiwan

In Taiwan, process safety accidents often occur despite the prior implementation of process hazard analysis (PHA). One of the main reasons for this is the poor quality of the PHA process; with the main hazards not being properly identified, or properly controlled. Accordingly, based on the findings of 86 process safety management (PSM) audits, dozens of post-accident site resumption review meetings, and hundreds of PSM review sessions, this study examines the main deficiencies of management practice and PHA implementation in Taiwan, and presents several recommendations for improved PHA assessment techniques and procedures. The study additionally examines the feasibility for using PSM-related information, such as process safety information and process incident information, as a tool for further enhancing the PHA quality. Overall, the study suggests that, in addition to following the basic rules of PHA and requirements of OSHA (1992),management in Taiwan should also provide training in the enhanced assessment techniques proposed herein and take active steps to incorporate PSM information into the PHA framework in order to improve the general quality of PHA and reduce the likelihood of process safety accidents accordingly.     

我国危险化学品事故统计分析及对策研究

基于2005—2008年我国发生的1565起危险化学品事故,从事故发生时间、发生地点、发生环节等方面分析事故的致因、特点以及规律,可以发现:近3年来我国危险化学品事故呈逐渐下降趋势;石化产业大省是危险化学品事故高发省份;每年3—8月是危险化学品事故高发时期;每天上午10点和下午3点是危险化学品事故高发时间;生产、运输、储存是危险化学品产业链六大环节中的事故高发环节。根据统计结果分析,指出我国危险化学品安全管理存在的问题,并提出预防和减少危险化学品事故的对策。     

Smart chemical industry parks in China: Current status,challenges, and pathways for future sustainable development

The chemical industry has been pivotal to the rapid economic expansion and high standards of living in China. As an important carrier of the chemical industry, China has designated as many as 723 chemical industrial parks (CIPs). Unfortunately, safety concerns have become an obstacle to the sustainability of China's CIPs. Ever since the two devastating hazardous chemical accidents, namely “Tianjin Port 8·12 Explosion” and “Jiangsu 3·21 Explosion,” which occurred in 2015 and 2019 respectively, China has prioritized the safety of CIPs. The smart chemical industrial parks (SCIPs) are considered the optimal strategies toward the goal of sustainable development in China's CIPs. However, there has been a lack of research and subsequent discussion on the role of SCIPs in the forthcoming years. The period between 2020 and 2025 is considered a crucial period for the future development of CIPs and SCIPs in China mainly because the country has released a series of important government documents and national standards (such as “Fourteenth Five-Year (2020–2025) Plan for Hazardous Chemical Safety” and “Guidelines of SCIPs construction”) to promote hazardous chemical safety. With the aim of analyzing the future sustainable development for the construction of SCIPs in China, this paper proposes a systematic methodology in order to conduct an integrated and in-depth review on the standardization construction status (framework with Chinese characteristics, key events, spatial features, and national pilots), future tasks, problems, and sustainable development pathways of China's SCIPs. The method is implemented in accordance with the current scenarios of hazardous chemical safety in China and the latest government documents, regulations, and standards. Furthermore, this study provides basic data and a basis for future studies associated with the safety and sustainability of the SCIPs construction and chemical industry, both within China and in other countries.     

基于HFACS-BN模型的危险化学品事故人因路径分析*

为提高危险化学品安全管理水平,收集我国134起以人为主因的危险化学品事故,构建危险化学品事故的HFACS-BN模型,并基于贝叶斯网络对危险化学品事故中的人因路径及各因素灵敏度进行分析。研究结果表明:行为违规是导致事故的最主要不安全行为;在复杂路径中,环境因素和操作者状态具有较高的灵敏度,与其相关的风险认知与处理不当是阻碍事故预防的关键因素;在非复杂路径中,操作者状态与运行计划不当具有较高的灵敏度,其所涉及的监督违规、组织过程和组织氛围,是导致危险化学品事故的根本起点,并可依此分析事故直接原因和间接原因;操作者状态在2种路径中均表现出高灵敏度,因此化工企业在人员管理上要加强关注职工状态,减少不安全行为的出现。