Dynamic accident modeling for high-sulfur natural gas gathering station

Dynamic accident modeling for a gas gathering station is implemented to prevent high-sulfur natural gas leakage and develop equipment inspection strategy. The progress of abnormal event occurring in the gas gathering station is modeled by the combination of fault tree and event sequence diagram, based on accident causal chain theory, i.e. the progress is depicted as sequential failure of safety barriers, then, the occurrence probability of the consequence of abnormal event is predicted. Consequences of abnormal events are divided into accidents and accident precursors which include incidents, near misses and so on. The Bayesian theory updates failure probability of safety barrier when a new observation (i.e. accident precursors or accidents data) arrives. Bayesian network then correspondingly updates failure probabilities of basic events of the safety barriers with the ability of abductive reasoning. Consequence occurrence probability is also updated. The results show that occurrence probability trend of different consequences and failure probability trend of safety barriers and basic events of the safety barriers can be obtained using this method. In addition, the critical basic events which play an important role in accidents occurrence are also identified. All of these provide useful information for the maintenance and inspection of the gas gathering station.     

Development of a database for accidents and incidents in the Greek petrochemical industry

The present paper describes the development of a database that comprises all incidents from the Greek petrochemical industry for the period 1997–2003. This database includes industrial incidents, accidents, operational accidents and near misses from all petrochemical sites in Greece and Cyprus. The design of the database has been conceived in a user-friendly way with additional possibilities for its further use, such as: statistical analysis of the data, calculation of safety indicators, accident reports and human factors analysis. The database allows the various participating industries to compare the analysis of indicators in their own installations with the national average, as the database comprises data from the entire Greek petrochemical industry. Special care has been given to include data from near misses too.     

Identification, analysis and dissemination of information on near misses: A case study in the construction industry

Near misses are well-known for providing a major source of useful information for safety management. They are more frequent events than accidents and their causes may potentially result in an accident under slightly different circumstances. Despite the importance of this type of feedback, there is little knowledge on the characteristics of near misses, and on the use of this information in safety management. This article proposes guidelines for identifying, analyzing and disseminating information on near misses in construction sites. In particular, it is proposed that near misses be analyzed based on four categories: (a) whether or not it was possible to track down the event; (b) the nature of each event, in terms of its physical features (e.g. falling objects); (c) whether they provided positive or negative feedback for the safety management system; and (d) risk, based on the probability and severity associated with each event. The guidelines were devised and tested while a safety management system was being developed in a healthcare building project. The monitoring of near misses was part of a safety performance measurement system. Among the main results, a dramatic increase in both the number and quality of reports stands out after the workforce was systematically encouraged to report. While in the first 4 months of the study – when the workforce was not encouraged to report – there were just 12 reports, during the subsequent 4 months – when the workforce was so encouraged – there were 110 reports, all of them being analyzed based on the four analytical categories proposed.     

The importance of near miss reporting to further improve safety performance

Dealing with accidents implies that such events have in common the potential to affect people and the environment in a significant way. Therefore, all parties involved in industrial risk management processes, i.e. industry, regulatory authorities, public as well as scientific and technical institutions, are well aware of the importance of considering and analysing such type of events for the purposes of accident prevention. Also, the methods of Quantitative Risk Assessment (QRA) have large experience in numerically expressing the various degrees of risk related to accidents. On the other hand, the topic of including `near misses' (i.e. any event which could have escalated to an accident) in safety management systems with the aim to prevent major accidents and the occurrence of similar events in the future is relatively new. Although its importance has more and more been recognised in the last few years, it is not yet a commonly accepted fact that near miss reporting and investigation of near misses should be an integral part of a safety management system in industrial facilities. In the European Council's new `Seveso II Directive' 96/82/EC, there is—in addition to the mandatory requirements of major accident reporting—an explicit recommendation to report near misses to the Commission's Major Accident Reporting System (MARS) on a voluntary basis. In this paper, examples of current experience in the chemical industry with the collection and analysis of data on near misses are presented and discussed with regard to industry-wide conclusions. In addition to this more qualitative discussion, quantitative arguments are put forward regarding the impact of near misses on risk estimates derived from QRA.     

Modelling of BP Texas City refinery accident using dynamic risk assessment approach

Process industries involve handling of hazardous substances which on release may potentially cause catastrophic consequences in terms of assets lost, human fatalities or injuries and loss of public confidence of the company. In spite of using endless end-of-the-pipe safety systems, tragic accidents such as BP Texas City refinery still occur. One of the main reasons of such rare but catastrophic events is lack of effective monitoring and modelling approaches that provide early warnings and help to prevent such event. To develop a predictive model one has to rely on past occurrence data, as such events are rare, enough data are usually not available to better understand and model such behavior. In such situations, it is advisable to use near misses and incident data to predict system performance and estimate accident likelihood. This paper is an attempt to demonstrate testing and validation of one such approach, dynamic risk assessment, using data from the BP Texas City refinery incident.Dynamic risk assessment is a novel approach which integrates Bayesian failure updating mechanism with the consequence assessment. The implementation of this methodology to the BP Texas City incident proves that the approach has the ability to learn from near misses, incident, past accidents and predict event occurrence likelihood in the next time interval.     

Lagging or leading? Exploring the temporal relationship among lagging indicators in mining establishments 2006–2017

Problem: Safety management literature generally categorizes key performance indicators (KPIs) as either leading or lagging. Traditional lagging indicators are measures related to negative safety incidents, such as injuries, while leading indicators are used to predict (and therefore can be used to prevent) the likelihood of future negative safety incidents. Recent theory suggests that traditional lagging indicators also possess characteristics of leading indicators, and vice versa, however empirical evidence is limited. Method: The current research investigated the temporal relationships among establishment-level injuries, near misses, and fatal events using injury and employment data from a sample of 24,910 mining establishments over a 12-year period. Results: While controlling for employee hours worked, establishment-level reported injuries and near misses were associated with of future fatal events across the sample of mines and over the time period studied. Fatal events were also associated with increases in future reported near misses, providing evidence of a cyclic relationship between them. Discussion: These findings challenge the strict categorization of injuries, near misses, and fatal events as lagging indicators. Practical applications: Understanding the KPIs that should be used to manage organizational safety, and how they can be used, is of critical practical importance. The results of the current study suggest that, depending on several considerations, metrics tied to negative safety incidents may be used to anticipate, and possibly prevent, future negative safety events.     

The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.     

The digital representation of safety systems at “Seveso” plants and its potential for improving risk management

At Seveso plants, duty holders must have a complex system for assessing and managing risks. The pillars of this system are the safety report and the safety management system, with a number of underlying documents. The strength of the system is the high standardization of these documents. Regulations, standard codes and guidelines define content, structure and formats. The weakness is the high complexity. Managers and workers perceive documents as difficult to understand and far from actual operations. Major threats for the credibility of documents (and therefore for the safety systems) come from the continuous organizational and technical changes, which in a short time can make most documents obsolete; as well as by near misses, which continuously show the holes in safety systems. A big effort is required to follow up the plant changes and the near misses. In order to help safety managers, a new software has been developed. At Seveso plants, it has been possible build an integrated digital representation, because all documents are perfectly structured. This representation may be used both for updating the relevant documents after a change and to improve documents after a near miss or an accident. In this way, safety documents are always up to date and trustworthy and the huge knowledge, which is usually hidden inside safety documents, is clearly revealed and revived. The approach is basically “knowledge based” and the intention is to provide safety managers with an easy and simple tool. IRISonLine is a software that has been developed by ISPESL to provide safety managers of “Seveso” establishments with a tool for improving the management of change and of near misses.     

From a survey on accidents in the downstream oil industry to the development of a detailed near-miss reporting system

A historical analysis with statistical investigation on accidental events in the oil industry from the beginning of the XX century till now, was performed in order to identify historical trend and go deeper into accident causes. The classification methodology was developed referring to three headings, namely plant/process, environment and organization and trying to go deeper into the analysis of the causes of the accidents reported and understand more of what is probably behind the accidents. The accident types and severity were studied, plotting the accumulated frequency–fatality curve for each item. In the subsequent applicative phase, we applied a similar classification approach to near-misses directly collected over nine years observation in a large downstream oil firm. The historical analysis was extended on each section of the refinery, paying a careful attention to all causes and consequences of the event. Data were structured for analyzing trends and identifying possible precursors of unwanted events. According to the step-by-step approach we try to evidence how immediate causes of a near-miss could be linked in some kind of causal chain to underlying causes that should be controlled by middle or higher management, or are part of the corporate safety culture.     

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。     

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。     

基于循证方法的施工现场安全事故预防体系研究

为提高施工现场安全绩效,构建基于循证方法的施工现场安全事故预防体系。阐明施工现场安全循证预防(EBP)的定义、内涵、核心思想,梳理循证预防解决安全问题的思路,并且提出施工现场安全管理循证预防的流程框架。结果表明:针对施工现场安全事故预防中的不足,循证方法解决问题的思路体现在理论和方法 2个层面;施工现场安全管理循证预防体系分为循证诊断和循证干预2个阶段,具体包括安全检查表、框架表示法、荟萃(Meta)分析等关键步骤。     

重大基坑坍塌事故虚拟仿真系统研究

为预防基坑坍塌事故发生、进行重大事故警示教育,以杭州地铁湘湖站北2基坑坍塌事故为素材,研究构建重大基坑坍塌事故虚拟仿真培训系统。对案例事故涉及的设计、施工、环境三大因素的技术问题进行总结,研究了事故链各致险因素及对推动事故发生所起作用,完成仿真系统平台设计和开发工作。系统应用多种制作技术创建工程场景模型,展示深基坑工程复杂的施工工序和空间关系,再现基坑坍塌事故发生发展过程和贴近实际的灾难场景。研究结果表明:仿真系统成果可丰富地下工程教学、施工现场安全教育和安全监察培训的内容和形式。     

危险化学品生产储存运输安全监控系统研究与应用

提出了基于GIS、GPS、GPRS和无线传感网络技术的危险化学品生产储存运输安全监控系统结构及该系统的软件架构和功能设计,介绍了系统在大连某特种气体有限公司的应用情况。该系统利用无线传感网络技术对危险化学品生产储存场所进行实时监控预警,利用GPS和GPRS技术对运输车辆进行跟踪和监控,利用地理信息系统实现对危险化学品生产储存场所及运输车辆信息的查询检索、综合分析、动态管理等功能,从而为危险化学品储存场所安全监测提供科学依据,对抑制事故发生或减少事故伤损范围具有重要的现实意义。     

Risk assessment of chemical process considering dynamic probability of near misses based on Bayesian theory and event tree analysis

With the development of modern automatic control systems, chemical accidents are of low frequency in most chemical plants, but once an accident happens, it often causes serious consequences. Near-misses are the precursor of accidents. As the process progresses, near misses caused by abnormal fluctuation of process variables may eventually lead to accidents. However, variables that may lead to serious consequences in the production process cannot update the risk in the life cycle of the process by traditional risk assessment methods, which do not pay enough attention to the near misses. Therefore, this paper proposed a new method based on Bayesian theory to dynamically update the probability of key variables associated with process failure risk and obtain the risk change of the near-misses. This article outlines the proposed approach and uses a chemical process of styrene production to demonstrate the application. In this chemical process, the key variables include flow rate, liquid level, pressure and temperature. In order to study the dynamic risk of the chemical process with consideration of near misses, according to the accumulated data of process variables, firstly the abnormal probability of the variables and the failure rate of safety systems associated with the variables were updated with time based on Bayesian theory. On the basis of the dynamic probability of key process variables, an event tree of possible consequences caused by variable anomalies was established. From the logical relationship of the event tree, the probability of different consequences can be obtained. The results show that the proposed risk assessment method based on Bayesian theory can overcome the shortcomings of traditional analysis methods. It shows the dynamic characteristics of the probability of different near misses, and achieves the dynamic risk analysis of chemical process accidents.     

基于AHP-Fuzzy的高处坠落危险性评价研究

高处坠落事故在建筑安全生产事故中所占的比率最大。预防和控制高处坠落事故始终是建筑业应解决的重要问题,高处坠落危险性评价是预防与控制高处坠落事故的重要手段。以高处坠落风险为研究对象,通过对高处作业＂人—机—环境—管理＂复杂系统进行分析,建立生产人员素质因素、生产设备因素、环境条件因素、安全管理因素等4个大类和23个小类的危险性评价指标体系。在层次分析法和模糊综合评价法等研究基础上,构建了高处坠落风险的AHP-Fuzzy评价模型,确定了各层次的权重集。对给出的实例进行评价,评价结果符合实际情况。结果表明,基于AHP-Fuzzy的高处坠落危险性评价方法是可靠与实用的,并对高处坠落危险性的评判有指导意义。     

电动轮自卸车事故分析与监控系统研究

电动轮自卸车是集发动机、发电机、电动机、液压系统、电控系统于一体的大型运输车辆,发生安全事故会造成重大损失。笔者对造成事故的人为因素和设备因素进行了研究,并用故障树对电动轮起火事故作了较详细的分析,确定了造成事故的重要因素。在此基础上设计了基于CAN总线的安全监控系统。该系统以单片计算机为核心,采用模块化结构,组成控制器局域网络,进行分布式控制。监控系统由硬件系统和软件系统两部分构成。对发电机、电动机、发动机进行技术状态监测的同时监测驾驶员的疲劳状态和违章操作情况,可以减少由人为因素和设备因素造成的安全生产事故。对大型工矿设备的安全技术保障有一定的借鉴作用。     

Bi-directional connectivity diagram for accident propagation analysis considering the interactions between multiple-process units

An incident may propagate to an accident with different severity dependent on its propagation scenarios. Since the accident propagation is a two-way process, the current research is focusing on the one-way analysis. This paper aims to analyze the combined effect of multi-units sources and their interactions during the accident propagation. The bi-directional connectivity diagram (BDCD) is applied to visualize the interactions between multiple process units as hazardous sources. The deployed safety barriers interrupt the connection between the hazardous sources and thus minimize the influence of one BDCD node on another. Through which, the accident propagation is reduced. The proposed method can be suitable to the general accidents, and it is applied to a case study of the LNG terminal station to assess the potential consequences of explosion caused by the leakage, in which the cost of the safety barrier is also considered. The BDCD approach is found more effective than traditional single-hazardous source methods for analyzing the accident propagation of multi-units sources in the chemical plant and achieving intrinsic safety.     

建筑安全事故应急措施推理研究

为了加强对建筑安全事故历史案例经验的利用,提高建筑安全事故应急管理的信息化水平,对如何利用智能化技术制定事故应急措施进行研究。将规则推理引入案例推理中,建立了建筑安全事故应急措施推理模型。通过计算综合相似度,在案例库中检索出相似案例的基础上,根据关键属性运用规则推理对相似案例的应急措施进行适用性修改。计算特征属性权重时,利用灰色关联分析法对传统粗糙集方法进行改进,对冗余属性提出了灰色重要度的概念,避免了冗余属性权重为0的情况。选取基坑事故案例对模型进行实例分析,结果表明:建筑安全事故应急措施推理模型具有普遍适用性,可应用于事故应急管理。     

A study of the precursors leading to ‘organisational’ accidents in complex industrial settings

This study aggregates the narrative findings from the investigation of 12 accidents or ‘near hits’ across a wide range of industrial settings to build a catalogue of organisational and cultural precursors to accidents. It was found that many were important factors in multiple events. It is argued that by addressing these potential vulnerabilities using the findings and proposed tools based upon them, organisations undertaking safety related activities will not only develop greater awareness of these deeper-lying issues but should be able to better control the risks associated with them.The precursors have been classified under eight headings and examples of key findings from three of these are presented. Statements providing potential defences against the identified vulnerabilities have been developed which should enable organisations to scrutinise the adequacy of existing expectations or requirements within their business. Probing questions have been developed based on the statements which should allow an assessment to be made as to whether these have been ‘embedded’ in the organisation.It is argued that organisational vulnerability tools should be developed to enable a systematic approach to ‘diagnosing’ incubating precursors. It is also argued that there is the potential for further resilience to be achieved through the use of models of the complex dynamics of socio-technical processes within organisations.