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.     

Learning lessons from tunnel accidents – Recommendations in support of the implementation of Article 15 on Reporting of the EU Directive 2004/54/EC

Tunnels in the trans-European road network (TEN) facilitate the transport of persons and goods on European roads. Following a series of major tunnel accidents European Union Directive 2004/54/EC was adopted to support the achievement of uniform and high tunnel safety levels. With future accident prevention and mitigation in mind and in support of the effective implementation of Article 15 on Reporting of the Directive we outline a procedure for learning lessons and discuss every step in the process with specific regard for its implications on Article 15. This includes accident investigation, reporting, data collection and analysis, learning lessons and their implementation. The realization that validated information on tunnel accidents is not easily available or accessible, or suffers from a lack of detail or accuracy fed into the development of a data-collection template. By its very nature the template development also guided the formulation of key recommendations for accident investigation and reporting as the main information source. In addition, key recommendations on data analysis, learning lessons and implementation were also made to assist the actors responsible for reporting or sharing information under the EU Directive.     

Rate of occupational accidents in the mining industry since 1950--a successful approach to prevention policy

This paper deals with the decrease in the rate of accident insurance claims in the German mining industry over the last five decades. It intends to show that this process is above all the result of a prevention policy where companies and the body responsible for the legal accident insurance in the mining industry, the Bergbau-Berufsgenossenschaft (BBG), work hand in hand. A system like the German accident insurance scheme, combining prevention, rehabilitation, and compensation, enables successful and modern safety and health measures.     

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.     

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].     

Organizational Factors Affecting Safety Implementation in Food Companies in Thailand

Thai food industry employs a massive number of skilled and unskilled workers. This may result in an industry with high incidences and accident rates. To improve safety and reduce the accident figures, this paper investigates factors influencing safety implementation in small, medium, and large food companies in Thailand. Five factors, i.e., management commitment, stakeholders’ role, safety information and communication, supportive environment, and risk, are found important in helping to improve safety implementation. The statistical analyses also reveal that small, medium, and large food companies hold similar opinions on the risk factor, but bear different perceptions on the other 4 factors. It is also found that to improve safety implementation, the perceptions of safety goals, communication, feedback, safety resources, and supervision should be aligned in small, medium, and large companies.     

建筑业人身意外伤害保险探讨

建筑业是伤害事故多发的行业 ,实行建筑业人身意外伤害保险 ,在《中华人民共和国建筑法》和《中华人民共和国安全生产法》里有明确规定 ,也是一项国际惯例。建筑业实施人身意外伤害保险 ,对促进建筑市场和保险市场的发育、减轻企业风险和维护社会稳定意义重大 ,同时有利于建筑业的安全管理以及与国际惯例接轨。目前 ,我国由于企业风险意识薄弱、法规不完善、保险公司不能提供优良的服务以及缺乏保险中介等原因 ,使得意外伤害保险的推行情况不甚理想。为大力推动我国建筑业人身意外伤害保险的发展 ,需要加强风险和保险的宣传、完善配套法规、采取强制与服务并重的措施并扶植我国工程保险中介组织的发展     

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.     

Project safety as a sustainable competitive advantage

Introduction: To be consistently profitable, a construction company must complete projects in scope, on schedule, and on budget. At the same time, the nature of the often high-risk work performed by construction companies can result in high accident rates. Clients and other stakeholders are placing increasing pressure on companies to decrease those accident rates. Clients routinely demand copies of safety plans and evidence of past results at the “pre-qualification” or “request for proposal” stages of the procurement process. Are high accident rates and the associated costs just a part of business? Findings: Companies that deliver on scope, schedule, and budget have a competitive advantage. Is it possible for projects with low accident rates to use it as a competitive advantage? Is the value added by safety just a temporary or parity issue, or does a successful safety program offer significant advantage to the company and the client? Impact on Industry: This article concludes that in the case of a high-risk industry, such as the construction industry, an organization with a successful safety program can promote safety performance as a sustainable competitive advantage. It is a choice the company can make.     

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.     

Risk assessment tools incorporating human error probabilities in the Japanese small-sized establishment

Although it has been estimated that as many as 80% of all occupational accidents have human errors as a cause, no risk assessment tools incorporating human-related elements have been developed for small companies. Human error probability (HEP) and human error analysis (HEA) have been used for large-scale, safety-critical industries for last three decades, but these tools are not suitable for smaller, more general industries that comprise the majority of accident settings.Here, we describe and verify a risk assessment tool that includes human-related elements for small companies. The tool expands on traditional risk assessment methods, such as matrix, risk graph and numerical scoring method, by adding human-related elements. The tool is easy-to-use in occupational environments, and includes assessments of human behavior and potentially outdated machinery at work place.     

航空人为差错事故/事件分析(ECAR)模型研究

为深入研究航空人为差错事故/事件的影响因素,以人为差错相关理论为基础,对比分析几种典型的人为差错分析模型;通过借鉴ECCAIRS分析框架,并在基元事件分析(EEAM)逻辑和CCAR396部的分类方法基础上,构建航空人为差错事故/事件分析(ECAR)模型,它从事件层、描述层、原因层和组织因素与改进建议层,分析航空事故和不安全事件的人为差错。此外,还将组织因素概念引入该模型。     

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.     

基于HFACS的空中相撞事故分析及建议

空中相撞事故往往是由诸多人为差错相互叠加、耦合和作用而导致的,要找出事故的真正诱因,防止类似事故再次发生,难度非常大。为了有效地分析和定位人为差错,以更好地服务于防相撞的管理与决策,提出一种基于人为因素分析分类系统（HFACS）的空中相撞事故分析方法,它按照从显性差错到隐性差错的思路来分析事故的诱因,最终找出组织因素对事故的影响。并利用HFACS对巴西卡欣布上空发生的一起空中相撞事故进行了系统分析。案例分析结果表明,该方法不仅能够找出导致空中相撞事故的人为差错,解释事故发生的原因和过程,而且能够据此提供防止相撞事故发生的安全建议。     

Comparison of techniques for accident scenario analysis in hazardous systems

In this paper, three accident scenario analysis techniques are presented and compared regarding their efficiency vs. the demanded resources. The complexity of modern industrial systems has prompted the development of accident analysis techniques that should thoroughly investigate accidents. The idea of criteria classification to fulfill this requirement has been proposed by other researchers and is examined here too. The comparison is done through the application of Event Tree analysis, Fault Tree analysis and Petri Nets technique—two relatively simple and a more demanding methodology—on the same hazardous chemical facility in view of analyzing an accident scenario of a hazardous transfer procedure. Accident scenario analysis techniques are essential not only in learning lessons from unfortunate events in the chemical industry but also in preventing the occurrence of such events in the future and in communicating risk more efficiently.     

Incident tree model and incident tree analysis method for quantified risk assessment: An in-depth accident study in traffic operation

Fault tree analysis (FTA) is a logically structured process that can help identify potential causes of system failure before the failures actually occur. However, FTA often suffers from a lack of enough probabilistic basic events to check the consistency of the logic relationship among all events through linkage with gates. Sometimes, even logic relationship among all events is difficult to determine, and failures in system operation may have been experienced rarely or not at all. In order to address the limitations, this paper proposes a novel incident tree methodology that characterizes the information flow in a system instead of logical relationship, and the amount of information of a fuzzy incident instead of probability of an event. From probability statistics to fuzzy information quantities of basic incidents and accident, we propose an incident tree model and incident tree analysis (ITA) method for identification of uncertain, random, complex, possible and variable characteristic of accident occurrence in quantified risk assessment. In our research, a much detailed example for demonstrating how to create an incident tree model has been conducted by an in-depth analysis of traffic accident causation. The case study of vehicle-leaving-roadway accident with ITA illustrates that the proposed methodology may not only capture the essential information transformations of accident that occur in system operation, but also determine the various combinations of hardware faults, software failures and human errors that could result in the occurrence of specified undesired incident at the system level even accident.     

人-机系统事故预防理论研究

分析人-机系统事故发生原因,剖析经典以人失误为主因的事故致因模型存在的不足,在该模型基础上增加"刺激"形成的原因,构建了改进事故致因模型。对两模型进行比较研究,指出人机工程学与防止事故的关系,提出了人机工程学防止事故的方法,并给出人机界面合理性主观评价检查表。研究及论证表明:预防人-机系统事故的本质在于有效防止人失误的发生,除安全管理措施以外,最重要的是人机工程学问题,笔者提出的基于人机工程学的人-机系统事故预防理论,对人-机系统事故的预防起到积极的指导作用。     

Learning organisations for major hazards and the role of the regulator

A learning organisation is one that not only values and encourages learning from its own experiences, but also looks beyond itself for lessons, and avoids complacency. To be a learning organisation is a key part of the safety culture of any organisation involved with major hazard processes. It facilitates learning which can reduce the risk from major accident hazards. The paper provides a learning organisation toolkit which synthesises, from various literature sources, an understanding of what a learning organisation is and how to begin to develop one within an organisation. The paper illustrates how the regulator can be a learning organisation for major hazards, using the example of HSE's offshore fire, explosion and risk assessment team.     

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors

IntroductionCurrently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs.MethodsA Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry.ResultsOne GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ² test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident.ConclusionsSCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices.Practical applicationsGeneral aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.