Totalitarian loss of responsibility in an explosives production plant

One of the largest accidents of communist era in former Czechoslovakia occurred in an explosion production plant in Semtín 26 years ago. Original analysis of the accident concentrated on technical causes and did not look for root causes. Additional root cause analysis showed that the plant’s safety management had been decaying and that other layers of causes had lain under the root causes. According to deeper analysis in this article, the event represents an accident that shows the decay of safety management after decades of dispersed ownership in a totalitarian society. We attempt to understand the mechanisms which led the plant into such a state. Their substantial aspects are identified and a model of the development of managers’ attitude to safety is constructed. The analysis points at the replacement of ideal managers’ behavior in safety management by distorted behavior which is here termed the totalitarian loss of responsibility. Presumably, more accidents with similar backgrounds can be identified in totalitarian surroundings. The analysis shows that the Chernobyl disaster can be considered one of them. Tools that helped deepen the analysis are based on the STAMP model and on the archetypes of safety. The analysis integrates various ideas and models into a single procedure based on the original representation of assumptions about the structure of safety management.     

行为安全视角下的氨泄漏事故分析

为了提高涉氨制冷企业的安全业绩,基于事故致因"2-4"模型分析典型氨泄漏事故的直接、间接、根本和根源原因。结果表明:氨泄漏事故的直接原因是操作人员在涉及氨制冷管道、有毒有害环境及带电作业中的违章操作和氨设备设施的不安全物态;间接原因是员工对于氨危险性认识的不足、较差的安全习惯以及安全意识不高;根本原因是组织缺失特定的安全管理组织程序,制度执行不力;根源原因可追溯到员工对安全的重要度、安全制度执行方式等安全文化元素理解不到位。进而提出实用性对策措施,为提高涉氨制冷企业安全管理水平提供理论依据与技术参考。     

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.     

Process safety management lessons learned from a fire and explosion accident caused by a liquefied petroleum gas leak in an aromatics reforming unit in Taiwan

A severe fire and explosion accident was caused by a liquefied petroleum gas leak in Taiwan in 2019. This accident resulted in the loss of approximately US$3.5 billion in output value due to a one-and-a-half-year shutdown after the accident; however, no casualties were recorded at the accident scene. An analysis of the accident pipelines demonstrated that the pipeline leak had been caused by hydrochloric acid corrosion. Cause analysis based on the accident timeline, fault tree analysis, and causal factor charting indicated inadequacies in five elements of process safety management (PSM) namely mechanical integrity (MI), management of change, emergency planning and response, process hazard analysis (PHA), and process safety information (PSI) as the root causes of the accident. Furthermore, insufficient PSI (i.e., a lack of comprehensive understanding regarding corrosion mechanisms) was deemed to have been the core problem leading to the accident. This accident revealed common shortcomings that are often overlooked in PSM implementation in Taiwan; thus, the present research can serve as a vital reference for improving PSM programs in Taiwan.     

冬瓜山铜矿安全生产事故统计分析及改进措施

为查找冬瓜山铜矿安全生产事故规律,提出有效的改进措施,预防和减少事故发生,运用三维预防安全管理体系研究成果,对冬瓜山铜矿2003~2013年的安全生产事故,按照严重程度、伤残等级、事故类型等分别进行统计与分析,查找事故发生规律。统计表明,冬瓜山铜矿死亡事故按类别主要以车辆伤害和中毒窒息死亡为多,其次是片帮冒顶;从原因分析看,排在第一的是事故隐患,其次是管理缺陷和违章。针对事故发生的原因,提出了一系列的改进措施,目前这些改进措施已经逐步在冬瓜铜矿得到落实,取得了明显的效果,2012年以来,事故率明显下降,员工安全意识和安全操作技能一定程度得到提高,矿山安全管理环境得到显著改善。     

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。     

Subsea pipelines incidents prevention: A case study in Brazil

There are more than 4000 subsea pipelines in Brazil. These pipes include umbilicals, drilling risers, flexible risers, rigid risers, hybrid risers, flowlines, and export pipelines. Despite all standards, regulations, guides, and risk management tools designed to avoid events, subsea pipeline incidents still occur, revealing possible failures in companies' risk control. Identifying similarities between different subsea pipeline failure events is crucial to improving the design, risk management practices, and regulation requirements, besides promoting accident prevention. This paper proposes applying the life cycle and management practices combined to analyze subsea pipeline incidents from the RDI (Detailed Incident Report) and investigations reported to ANP (Brazilian National Agency of Petroleum, Gas, and Biofuels), the Brazilian safety regulatory agency. Furthermore, subsea pipeline incidents data were analyzed: correlated circumstances, consequences, and causes. The results show that most riser and flowlines causal factors are related to equipment failures, and recurrent root causes are design errors and integrity control. Based on the proposed approach, it was possible to identify gaps in most riser and flowlines accident investigations since there are few causal factors, root causes, and the absence of riser and flowlines failure mode and mechanisms. Therefore, the development of accident recommendations can be compromised. Thus, this paper proposes improvements to current Brazilian regulations to clarify the minimal subsea pipeline accident investigation requirements.     

公路工程施工安全事故致因模型构建

为了探究公路施工安全事故诱因及其影响关系,基于"4M"理论和事故致因"2-4"模型,识别公路工程施工安全事故致因因素并确定模型框架,运用SPSS Modeler软件对2007~2017年426起事故进行关联规则挖掘,采取路径分析与重要度分析,构建出公路工程施工安全事故致因模型。结果表明:施工单位内外部原因共同引发公路工程施工安全事故,外部原因来源于建设单位、监理单位和勘察设计单位的安全管理缺失,而施工单位内部影响因素中,人的不安全动作、物的不安全因素、不良的生产环境和自然环境是事故发生的直接原因,无效的安全监管和作业层安全素质及能力不强是间接原因,根本原因是施工程序和技术方案存在缺陷,根源原因是决策层和管理层的安全素质及能力有待提高。该模型系统展现了工程施工项目安全事故致因因素的影响关系和重要程度,为公路工程施工安全事故预防提供指导。     

在役工业厂房建筑维护管理分析评价

在调研了全国各区域各行业工业厂房结构安全的基础上,提出工业厂房后期运营阶段的结构安全性和可靠性需要通过科学的维修制度来保证。分析了引起工业厂房结构失检、误判的因素,建立了相应的评价指标体系,以评价企业厂房结构安全的维护管理水平。理论分析和实例评价表明,通过提高维护管理水平可以减少厂房结构失检、误判事件的发生,加强厂房的检测、维护,可以有效预防工业厂房结构渐发性事故发生,在有限成本内实现对工业厂房结构安全管理的效益最大化。     

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.     

The context and habits of accident investigation practices: A study of 108 Swedish investigators

The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the ‘human factor’ was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices – particularly those conducted as part-time work in organizations.     

核电厂人因事故预防的定量化决策

人因事故的分析与预防是核电厂安全运行和管理的重要内容。笔者提出的系统安全性层次分析法主要从两种角度考虑系统的安全性:专家能力权值和安全性矩阵的建立。采用专家判断矩阵确定事故原因对系统安全性的重要度排序。举例某核电厂事故定量分析进行说明,在对事故进行原因分析基础上,构建事故影响因素层次模型,利用层次分析法分析得出事故原因重要度排序由高到低依次为组织管理、操作人员、人机界面、培训与设备状态,并据此提出了相应的预防与改进措施,为安全性要求较高的复杂工业系统提供事故预防的定量化决策依据。     

基于24Model-AHP的建筑施工高处坠落事故原因研究

为预防建筑施工高处坠落事故,本文采用事故致因“2-4”模型,研究2012-2018年50起高处坠落事故案例,对导致事故的根源原因、根本原因、间接原因和直接原因进行定性分析,并使用SPSS软件分析原因之间的相关性,同时根据事故原因构建递阶层次模型,计算出其权重值并进行排序,从而得到影响事故发生的关键因素。结果表明:安全管理制度和操作规程不健全、员工的安全意识不高和违章操作以及安全防护措施不到位是导致事故发生的主要因素,也是事故预防重点。研究成果对确保施工过程安全,制定相应防范措施有重要意义。     

烟花爆竹生产事故概率分析与对策

近年来 ,烟花爆竹事故频频发生 ,通过事故概率分析 ,掌握某些规律 ,认为“事故难免论”是错误的 ,但也不提倡没有根据的“事故可以杜绝论” ,应该时刻牢记“事故有随时可能发生”这一严厉的事实 ,提倡“不怕一万 ,只防万一”安全生产的正确、谨慎、有科学根据的态度 ,并提出相应的基本安全对策     

基于层次话题模型的煤矿安全事故致因要素研究

为促进安全发展,强化煤矿安全管理的科技支撑,在事故致因理论基础上,利用文本挖掘中的话题模型和创新性构建的层次致因要素话题模型,对我国2000—2015年发生的386起重特大煤矿事故调查报告进行了深入地挖掘、分析和研究。发现事故致因隐含的规律及各类事故之间的关联与共性,并进一步研究发现不同致因要素随时间的演化规律及致灾倾向,为煤矿安全管理找出重点,指导煤矿安全生产管理实践。     

Overcoming the blame game to learn from major accidents: A systemic analysis of an Anhydrous Ammonia leakage accident

This article aims to demonstrate the need for changing the methods with which accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the sociotechnical principle of understanding the real operating conditions in which accidents take place. In order to demonstrate the benefits of the theoretical framework, we compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic approach. The results favor the latter since it tends to be more reliable and offering useful recommendations to safety management processes, thus helping to prevent accidents, especially in complex systems.     

事故树-风险矩阵评估高校实验室火灾风险

为了使高校实验室安全管理科学化、精准化,应用事故树-风险矩阵法进行风险评估。首先采用事故树法对实验室火灾事故进行分析,得出导致事故发生的基本事件,然后依照事故致因理论,得出事故隐患三级原因,采用层次分析法对事故发生的频率和后果严重度及安全措施补偿系数的等级赋值,得到四级风险矩阵模型,对基本事件调查并由专家评估得出其风险值。评估结果表明导致实验室火灾事故的主要原因为:燃烧反应失控、加热、人员消防素质、操作不当、实验室管理水平、火灾报警系统缺陷、电气火花、灭火材料不足、消防系统缺陷、木制品、反应放热、存放不当。根据基本事件风险值高低针对性采取相应预防措施可以一定程度上提升实验室安全管理水平。     

安全降变原理及C-S-R事故致因新模型

为发展安全科学原理和给事故防控与调查提供新的方法,根据变化对系统安全的影响机制,开展安全降变原理及事故致因新模型研究。首先,提出安全降变原理并解析其内涵及研究意义。其次,基于安全降变原理,给出不同层级安全系统变化的分类实例,并对作业场所事故及其致因重新定义和分类。再次,构建基于安全降变原理的C-S-R事故致因新模型。最后,基于事故案例分析,验证所提出的C-S-R事故致因新模型与安全降变原理的有效性。结果表明,各级安全系统中自发或是受联动的变化超出系统的变化承受水平时,将导致事故的发生。经事故案例分析验证可知,安全降变原理及C-S-R事故致因新模型具有充分的实用性。     

石油企业生产安全事故致因模型探讨

事故致因理论是企业安全管理工作首要研究的理论问题,是所有安全具体工作背后的理论依据。本文以中国石油天然气集团公司安全管理体系—HSE管理体系为样本,探讨了基于风险管理思想下的石油企业事故成因问题,并得出相对完善的石油企业事故致因模型,可对其它石油企业或其它工贸企业的安全管理工作提供借鉴。     

Not drowning, waving!: Safety management and occupational culture in an Australian commercial fishing port

An ethnographic study of safety management was conducted in a commercial lobster fishing industry, in a small fishing town in Southern Australia. The objectives were to test the utility of the ethnographic method for exploring the nature of the relationship between occupational culture, workplace social organization, and safety management.Available accident data suggests this particular fishery may not have the same high incidence of occupational trauma normally attributed to commercial fishing. Changes in licensing laws and improved management of fish stocks have significantly reduced risk exposure. Participants in this study had a good understanding of their physical workplace risks, but accepted some of these with too few defences. Wear rates of personal flotation devices (PFDs) were below 1% for the study period.The paper suggests that participants do not have a strong learning culture, and links this to occupation-wide cultural assumptions, other external issues and safety management issues. Assessment of the social and cultural context of safety management can offer policy makers a ‘road-map’ to guide their interventions. The utility of ethnographic methods for this type of analysis is significant, and will be enhanced by improving the transparency of the research method.