LPG leakage and explosion accident analysis based on a new SAA method

The petrochemical industry has inherently high safety risks. On 5^th June 2017, a liquefied petroleum gas tanker in the storage and transportation department of Linyi Jinyu Petrochemical Co., Ltd. leaked during unloading, causing a major explosion and fire. Ten people were killed and nine were injured. To prevent the recurrence of similar accidents, a retrospective accident analysis was conducted using the system accident analysis method known as ‘24Model’. This analysis proved the coupling relationship between accident causes involving multiple organisations and multiple factors. The analysis results show that the five modules of maintenance and design, that is, loading and unloading valves, emergency training, management of subsidiaries and contractors, multi-level supervision, and task arrangement need to be checked from top to bottom by relevant organisations.In order to verify the reliability of 24Model analysis results, three SAA methods, namely STAMP, FRAM, AcciMap, were used to analyse the accident, and results obtained by the four methods were evaluated qualitatively and quantitatively. The results show that the output of 24Model is reliable and has a more understandable framework, which can be used as reference for the development of other linear accident cause models and application of system accident analysis methods to real applications.     

HFACS中不安全监管因素与事故致因24 Model中不安全动作因素的对比分析

为了使HFACS这种事故分析方法能够在我国各种类型事故中得到应用,研究了HFACS的不安全监管因素中各指标的定义和分类,并将其与事故致因24 Model中的不安全动作因素进行对比,得出两者的对应关系和各自特点。结果表明:HFACS中多数不安全监管因素属于24 Model中的不安全动作,这些不安全动作的发出者都是监管者;24 Model中不安全动作的发出者既可以是事故的直接引发者,也可以是监管者。从监管的范畴来看,HFACS中不安全监管因素的范围小于24 Model中的监管范围,只包括组织内部的监管。     

HFACS与24 Model:不安全动作原因的对比研究

不安全动作的定义、分类与识别尚未有统一标准,这给事故分析与预防带来许多困难。基于此,对人因分析与分类系统(HFACS)和24 Model中的不安全动作层面进行对比研究。在不安全动作对应方面:HFACS中的不安全动作均能对应到24 Model中的不安全动作,但HFACS没有涉及24 Model中不违章、未引起事故但高风险的不安全动作,因而无法实现事前预防。在间接原因对应方面,HFACS中不安全动作的产生原因均可与24 Model中的1个或多个间接原因相对应;HFACS中不安全动作的产生涉及较多生理、心理层面的原因,而考虑到实用性原则,24 Model暂未给出该两方面原因的具体分类方法。在不安全动作发出者方面:24 Model涉及组织内各层级人员,而HFACS仅指一线员工。在实际应用方面:两种模型均可用于不安全动作原因的统计分析;24 Model给出的不安全动作分类范围较HFACS广,在事故分析时所受局限性小,但易造成不安全动作遗漏;在用24 Model进行不安全动作分析时,应尽量细化动作分类及分析的深入程度,以及动作发出者的员工层级。     

Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP

Three accident causation models, each with their own associated approach to accident analysis, currently dominate the human factors literature. Although the models are in general agreement that accidents represent a complex, systems phenomenon, the subsequent analysis methods prescribed are very different. This paper presents a case study-based comparison of the three methods: Accimap, HFACS and STAMP. Each was used independently by separate analysts to analyse the recent Mangatepopo gorge tragedy in which six students and their teacher drowned while participating in a led gorge walking activity. The outputs were then compared and contrasted, revealing significant differences across the three methods. These differences are discussed in detail, and the implications for accident analysis are articulated. In conclusion, a modified version of the Accimap method, incorporating domain specific taxonomies of failure modes, is recommended for future accident analysis efforts.     

基于贝叶斯网络的煤矿事故人因推理

煤矿事故的不可重现性决定了事故原因的调查具有很强的不确定性,如何通过事故发生后的相关信息提高事故深层次原因调查的准确性是非常重要的。将HFACS与贝叶斯网络相结合,以煤矿事故HFACS分析结果为样本,通过卡方检验和让步比分析建立人因的贝叶斯网络因果图,进一步利用最大似然估计算法确定了煤矿事故人因的贝叶斯网络参数。最后,以双柳煤业顶板事故的调查信息为证据推理导致煤矿事故发生的深层次原因,提高事故原因调查的准确性,从而验证模型的有效性。     

An urban pipeline accident model based on system engineering and game theory

Urban pipeline accidents are caused by complex social-technical factors, in which urban communities and pipeline systems are involved. Such accidents can thus be investigated from the viewpoint of system engineering. System-Theoretic Accident Model and Processes (STAMP) is a systemic method for safety assessment, which has been adopted in many domains. This approach can provide deep insights of accident causes by considering direct and indirect factors. Meanwhile, competition and cooperation between stakeholders in accidents are observed. Therefore, these parties can also be analyzed with the game theory. That is, stakeholders in STAMP can be regarded as players in game. The aim of this paper is to provide a new insight to analyze urban pipeline accidents by considering both STAMP and game theory. In this paper, we proposed an accident model for urban pipelines, with a case study of China-Qingdao pipeline accident occurred in 2013. We concluded that accident reasons can be investigated in-depth and lessons can be learned from analyzing causal factors by using STAMP. Based on results generated from STAMP, we applied the game theory to analyze roles that government and companies act in the China-Qingdao urban pipeline accident. The results show that current punishment and incentive systems are incomplete, lacking of the driving force and constraining force for the stakeholders involved in the accident.     

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.     

基于STAMP模型的建筑事故致因因素定量分析方法研究

为揭示建筑安全事故致因因素间的相互关系从而对其进行有效预防和控制,探讨1种STAMP模型的定量分析方法,用于深入剖析事故致因因素间的逻辑关系和属性特征。基于STAMP系统事故理论模型,从建筑工程安全控制结构入手逐层定性分析事故的致因因素;引入灰色DEMATEL与ISM相结合的方法对系统事故间的复杂逻辑关系进行层级划分;运用MICMAC分析计算各致因因素的驱动力和依赖度数值并判断其属性类别。结果表明:提出的定量分析方法运用到江西丰城冷却塔坍塌事故中的分析结果与事故调查报告相契合,能较全面地说明各层次结构间的相互作用。     

基于STAMP模型的丰城坍塌事故原因分析

为了系统地分析建筑施工事故原因、有效预防同类事故,运用STAMP模型从控制角度详细分析了一起特别重大坍塌事故,分别从物理过程及环境因素、基层操作原因以及管理层原因3方面分析了导致事故的控制缺陷,并且根据分析结果,提出事故控制措施及建议。结果表明:STAMP模型不仅可以分析各个层级的原因,还可以找出层级之间以及层级内不同组织之间的交互影响原因;建设方、施工方、监理方以及承包方对项目管理内容交叉与重叠,且沟通与协调缺失是导致错误决策和不恰当控制动作产生的主要因素;基层不安全控制动作直接导致事故发生,但取决于管理因素,管理层的原因是预防同类事故的重点。     

STAMP模型在危化品道路运输事故分析中的应用研究

为保障危化品道路运输行车安全,基于STAMP模型构建危化品道路运输的分层安全控制结构,将安全问题看作是控制问题,并将系统工程思想融入事故预防中。在此基础上,引入沪昆高速湖南邵阳段“7.19”特别重大道路交通危化品爆燃事故并对其进行实证分析,从物理层、基础层、运营层及监管层动态分析导致事故发生的控制缺失。结果表明:基于STAMP模型的安全分析方法不仅可考虑由组件失效引起的事故,还可发现组件之间的组织问题及决策背景,并对事故致因做出更为详细的解释,为类似事故的分析和预防提供思路与参考。     

STAMP-based analysis on the railway accident and accident spreading: Taking the China–Jiaoji railway accident for example

Each hazard analysis technique is based on a model of accident causation. Most accident models regard accidents as resulting from a chain or sequence of events, such models are fit for accidents caused by failures of physical components and for relatively simple systems, but suffer from serious deficiencies when they are applied to software-intensive, complex engineering systems. Recently, a new accident model called System-Theoretic Accident Models and Process (STAMP) for system safety has been proposed, it is based on control theory and enforces constraints on hazards and thereby prevent accidents. In this paper, taking the China–Jiaoji railway accident happened on April 28, 2008 as an example, the STAMP approach has been used to analyze the railway accident and some improvement measures have been proposed. As the occurrence of one accident can cause many other accidents happen, based on the STAMP-based analysis, the accident spreading processes have also been discussed and modeled, which will be helpful to analyze accidents spreading in a broad sense and establish effective emergent measures for accident response management.     

Analysis on causes of chemical industry accident from 2015 to 2020 in Chinese mainland: A complex network theory approach

Chemical manufacturing is a long-process industry, where an end product may pass through numerous dangerous and complex steps. In such long chains of coordinated activity, accidents remain common. This study made loss-prevention recommendations for the chemical industry after conducting a review of accident reports and creating a complex network model. A human factor analysis and classification system (HFACS) was used to classify data from 109 investigation reports from the Chinese mainland (2015–2020). Levels Ⅱ and Ⅲ of the HFACS output were fed into a complex network model to generate a map of causes and chains of risk. It was shown that most accidents were directly or indirectly caused by human action, and human factors played a decisive role in occurrence, evolution, and resolution. The model used was visualized in Gephi, and the key cause nodes were identified by their topological characteristics. A modularity algorithm was used to derive the community structures and segment the network map. Crucial nodes in each community were compared with factors for each class in the HFACS model. It was also found that there was a biasing factor in the causal processes of explosive accidents and poisoning and asphyxiation accidents according to the associations classified by modularity. Risk abatement strategies were proposed for the crucial factors.     

基于HFACS的化工企业火灾爆炸事故人因分析*

为研究化工企业火灾爆炸事故的主要人为因素,以63起火灾爆炸事故案例为样本,构建人为因素分析与分类系统（HFACS）模型,进行火灾爆炸事故人为因素分类统计与分析,并利用卡方检验和比值比分析HFACS模型上下层级间的因果关系。结果表明:HFACS模型中上下层级人为因素间存在显著的因果关系,层级1中的“不良的组织氛围”及“组织过程漏洞”和层级2中“监督不充分”在HFACS模型中可以显著增大事故发生的可能性,且“资源管理漏洞”、“不良的组织氛围”、“组织过程漏洞”→“监督不充分”→“人员因素”→“违规”是引发事故的关键路径,并根据HFACS模型中引发事故的关键路径及其人为因素的主要表现形式,提出针对性的化工企业火灾爆炸事故预防措施。     

建筑安全事故人为因素分类研究

为系统研究导致建筑安全事故的人为因素及对策,首先,在文献分析和专家访谈的基础上结合建筑行业特征提出人为因素分类分析系统（HFACS）框架中应增加社会环境层,在修正框架层次和人为因素的基础上构建建筑安全事故人为因素分类分析系统（C-HFACS）框架;其次,对150起建筑安全事故进行案例分析,探讨C-HFACS框架中对事故影响显著的人为因素及其内在关联性,验证了构建C-HFACS框架的合理性;最后,得出政府监管等九个人为因素对事故和下层人为因素影响显著,并从政府、企业、现场和个体四个维度提出独立第三方“飞行式”巡检等有针对性的对策,以期为建筑安全事故分析和管理提供新的方法和工具。     

A case study analysis to examine motorcycle crashes in Bogota,Colombia

IntroductionContributory factors to motorcycle crashes vary among populations depending on several aspects such as the users' profiles, the composition and density of traffic, and the infrastructure features. A better understanding of local motorcycle crashes can be reached in those places where a comprehensive analysis is performed. This paper presents the results obtained from a case study analysis of 400 police records of accidents involving motorcycles in Bogota.MethodTo achieve a deeper level of understanding of how these accidents occur, we propose a systemic approach that uses available crash data. The methodology is inspired by accident prototypical scenarios, a tool for analysis developed in France.ResultsWhen grouping cases we identified three categories: solo motorcycle accidents, motorcyclist and pedestrian accidents, and accidents involving a motorcycle and another vehicle. Within these categories we undertook in-depth analyses of 32 groups of accidents obtaining valuable information to better comprehend motorcyclists' road crashes in a local context. Recurrent contributory factors in the groups of accidents include: inexperienced motorcyclists, wide urban roads that incite speeding and risky overtaking maneuvers, flowing urban roads that encourage high speed and increased interaction between vehicles, and lack of infrastructure maintenance.Practical ApplicationsThe results obtained are a valuable asset to define measures that will be conveniently adapted to the group of accident on which we want to act. The methodology exposed in this paper is applicable to the study of road crashes that involve all types of actors, not only the motorcyclists, and in contexts different than those presented in Bogota.     

Behavior and lifestyle characteristics of male Kuwaiti drivers

Introduction: The high traffic accident risk among young drivers is a well-known and well-documented fact in most countries. Lifestyle has proven to affect driving behavior as well as accident risk. This study covers the lifestyle component of the problems related to young male Kuwaiti drivers’ accident risk. Methods: The purpose of the study is to measure the relationship between lifestyle and accident risk. Lifestyle is measured through a questionnaire, where 302 male Kuwaiti drivers (mean age = 28 years; range 25-35 years) answer 39 questions related to behavioral and social factors, road conditions, police enforcement, and life satisfaction. They also report their involvement in accidents and traffic violations. Results: The questionnaire's validity and reliability (Cronbach's alpha = 0.7) were achieved. Principal component analysis reduced the 39 items on the questionnaire to 5 factors. Inadequate police enforcement is strongly correlated (r = 0.862) to accident risk and traffic violations and is thus considered the best predictor of traffic accidents in Kuwait. Impact on Industry: As driving-related incidents (on-the-job and off-the-job) are a significant source of fatalities and lost-work-days, the study points to the importance of considering cultural factors in the design of comprehensive safety programs for industry.     

基于STAMP-ISM的铁路危险品运输系统风险-事故分析方法*

为预防铁路危险品运输系统事故的发生,采用STAMP-ISM模型分析铁路危险品运输系统风险-事故。首先,利用STAMP模型详细分析事故,得到控制结构的相关安全约束、不充分控制行为及产生原因,以及系统的安全动态变化;其次,采用ISM分析事故致因因素之间的关联关系并划分层级;最后,基于STAMP和ISM分析结果提出系统改进方案。以我国一起匿名夹带事故为背景进行案例研究,结果表明,ISM模型的加入可深入挖掘事故因素间的相互关系,为事故致因因素重要度划分层级,分析结果及建议更具针对性。     

Arabian,Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives

Introduction. Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. Method. A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. Results. Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p?<?0.05). Conclusion. Although not given much consideration, national culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.     

Understanding factors associated with misclassification of fatigue-related accidents in police record

IntroductionFatigue is one of the riskiest causes of traffic accidents threatening road safety. Due to lack of proper criteria, the identification of fatigue-related accidents by police officers largely depends on inferential evidence and their own experience. As a result, many fatigue-related accidents are misclassified and the harmfulness of fatigue on road safety is misestimated.MethodIn this paper, a joint model framework is introduced to analyze factors contributing to misclassification of a fatigue-related accident in police reports. Association rule data mining technique is employed to identify the potential interactions of factors, and logistic regression models are applied to analyze factors that hinder police officers' identification of fatigue-related accidents. Using the fatigue-related crash records from Guangdong Province during 2005–2014, factors contributing to the false positive and false negative detection of the fatigue-related accident have been identified and compared.ResultsSome variables and interactions were identified to have significant impacts on fatigue-related accident detection.ConclusionsBased on the results, it can be inferred that the stereotype of certain groups of drivers, crash types, and roadway conditions affects police officers' judgment on fatigue-related accidents.Practical applicationsThis finding can provide useful information for training police officers and build better criteria for fatigue identification.