Factors contributing to US chemical plant process safety incidents from 2010 to 2020

Process safety incidents can result in injuries, fatalities, environmental impacts, facility damage, downtime & lost production, as well as impacts on a company's and industry's reputation. This study is focused on an analysis of the most commonly reported contributing factors to process safety incidents in the US chemical manufacturing industry. The database for the study contained 79 incidents from 2010 to 2019, partly investigated by the Chemical Safety Board (CSB). To be included in the study, the CSB archive of incident investigations were parsed to include only incidents which occurred at a company classified as 325 in the North American Industry Classification System (NAICS), assigned to businesses that participate in chemical manufacturing. For each incident, all of the identified contributing factors were catalogued in the database. From this list of identified contributing factors, it was possible to name the ‘top three’ contributing factors. The top three contributing factors cited for the chemical manufacturing industry were found to be: design; preventive maintenance; and safeguards, controls & layers of protection. The relationship between these top contributing factors and the most common OSHA citations was investigated as well. The investigation and citation history for NAICS 325 companies in the Occupational Safety & Health Administration (OSHA) citations database was then analysed to assess whether there was any overlap between the top reported contributing factors to process safety events and the top OSHA citations recorded for the industry. A database consisting of the inspection and citation history for the chemical manufacturing industry identified by NAICS code 325 was assembled for inspections occurring between 2010 and 2020 (August). The analysis of the citation history for the chemical manufacturing industry specifically, identified that the list of the top contributing factors to process safety incidents overlapped with the most common OSHA violations. This finding is relevant to industry stakeholders who are considering how to strategically invest resources for achieving maximum benefit – reducing process safety risk and simultaneously improving OSHA citation history.     

What can the trove of CSB incident investigations teach us? A detailed analysis of information characteristics among chemical process incidents investigated by the CSB

Understanding the commonalities among previous chemical process incidents can help mitigate recurring incidents in the chemical process industry and will be useful background knowledge for designers intending to foster inherent safety. The U.S. Chemical Safety and Hazard Investigation Board (CSB) reports provide detailed and vital incident information that can be used to identify possible commonalities. This study aims to develop a systematic approach for extracting data from the CSB reports with the objective of establishing these commonalities. Data were extracted based on three categories: attributed incident causes, scenarios, and consequences. Seventeen causal factors were classified as chemical indicators or process indicators. Twelve chemical indicators are associated with the hazards of the chemicals involved in the incidents, whereas five process indicators account for the hazards presented by process conditions at the time of the incident. Seven scenario factors represent incident sequences, equipment types, operating modes, process units, domino effects, detonation likelihood for explosion incidents, and population densities. Finally, three consequence factors were selected based on types of chemical incidents, casualties, population densities, and economic losses. Data from 87 CSB reports covering 94 incidents were extracted and analyzed according to the proposed approach. Based on these findings, the study proposes guidelines for future collection of information to provide valuable resources for prediction and risk reduction of future incidents.     

The prevention of occupational injuries in two industrial plants using an incident reporting scheme

INTRODUCTION: The aim of this study was to examine whether the introduction of an incident reporting scheme with feedback in two industrial plants had an effect on the number of major incidents. METHOD: An intervention design with measurements before the implementation of the incident reporting scheme and two years later was used to examine the relationship between incident rates, safety climate, the willingness to report incidents and perceived management commitment to safety. RESULTS: The results showed that a successful implementation of an incident reporting scheme was followed by a decline in the incidence of major incidents at a Danish metal plant. A key factor in implementing the scheme was top management commitment, which was lacking at another plant, where the implementation of a similar scheme failed. CONCLUSION: Although the study shows some encouraging results concerning the use of incident reporting schemes to prevent occupational accidents, the possibility to draw causal conclusions is limited in the present study, and further studies are needed before the effectiveness of such schemes can be evaluated with certainty.     

Software tools to support incident reporting in safety-critical systems

Incident reporting systems are playing an increasingly important role in the development and maintenance of safety-critical applications. The perceived success of the FAA's Aviation Safety Reporting System (ASRS) and the FDA's MedWatch has led to the establishment of similar national and international schemes. These enable individuals and groups to report their safety concerns in a confidential or anonymous manner. Unfortunately, many of these systems are becoming victims of their own success. The ASRS and MedWatch have both now received over 500,000 submissions. In consequence, the administrators of incident reporting systems increasingly rely upon software tools to support the administration of their systems. In the past, these systems have relied upon ad hoc applications of conventional database technology. However, there are several reasons why this technology is inadequate for many large-scale reporting schemes. In particular, the problems of query formation often result in poor precision and recall. This, in turn, has profound implications for safety-critical applications. Users may fail to identify similar incidents within national or international collections. These ad hoc approaches also neglect the opportunities provided by recent developments in computer assisted interviewing and in the monitoring of retrieval activities to build models of user behavior. These techniques offer a number of potential benefits. For instance, it is possible to automatically detect potential biases in the way that investigators analyze particular incidents.     

Worker-fatigue contributing to workplace incidents in New Zealand Forestry

ProblemReports of incidents in dangerous work environments can be analysed to identify common hazards, in turn aiding in the prevention of future accidents. Whilst studies exist that do this, most focus on causes that involve physical risks. In this paper we propose an alternative approach, and illustrate causes of forestry incidents from the perspective of worker-failure and fatigue. Method This paper outlines the analysis of eight years’ worth of New Zealand forestry incident data, with a focus on the cause of, and time that, incidents occur. Results This has resulted in two main findings. First, 70% of incidents can be attributed, at least in part, to worker-failures. Second, 78% of worker-failure based causes show indications of fatigue. This indicates that a significant number of forestry incidents are caused by worker-fatigue. Finally, this dataset showed inconsistencies in data quality, similar to those that exist in other datasets. This did not affect our analysis. However, these types of errors have the potential to affect the data quality in the national reporting system. Impact on industry The results from this study will be used in a larger project on detecting fatigue in forestry workers for injury and incident prevention. It is also our hope that other researchers may find these results of interest for further fatigue prevention research in hazardous industries.     

Enhancing regional process safety management

As industrial operations expand, major incidents continue to affect people, damage facilities, and impact the environment. In the last 20 years, about 50% of these incidents occurred in facilities that had implemented some form of Process Safety Management (PSM) and 50% came about in smaller facilities that did not include such planning (Demichela et al., 2004). The objective of this article is to use PSM principles to create practical recommendations at the regional level, to complement those previously developed for singular facilities. This article compares Strathcona County Emergency Service (SCES) in Alberta with Technical Standards & Safety Authority (TSSA) in Ontario, with respect to safety, facility licensing, permit requirements, risk assessment procedures and land use planning aspects to determine PSM enhancements for SCES. Furthermore, for a better overview, two supplemental provincial organisations in Alberta, namely Alberta Boiler Safety Association (ABSA) and Safety Codes Council (SCC), were also considered. We proposed that SCES could develop more detailed facility-specific licensing procedures, auditing, and inspection. SCES could also provide details of accredited organisations that carry out inspections and audits on their behalf. When reviewing the quantitative risk assessment processes for SCES and TSSA, we recommend that SCES should update their probability data sources used in their cumulative risk assessment study. Based on the authors’ experience and gathered data, the use of additional facility practices such as safety management system, internal audits, and checklists can enhance incident prevention.     

Severity of emergency natural gas distribution pipeline incidents: Application of an integrated spatio-temporal approach fused with text mining

The transportation of natural gas often relies on pipelines which require constant monitoring and regular maintenance to prevent spills or leaks. Pipeline incidents could pose a huge adverse impact on people, the environment, and society. Numerous efforts have been invested to identify contributing factors to pipeline incidents so that countermeasures could be developed to proactively prevent some incidents and reduce incident severities or impacts. However, the countermeasures may need to vary for different incidents due to the potential heterogeneity between incidents, and such heterogeneity is likely related to the geology, weather, and built environment which vary across space and time domain. The objective of this study is to revisit the correlates of pipeline incidents, focusing on the spatial and temporal patterns of the correlations between natural gas pipeline incident severity and contributing factors. This study leveraged an integrated spatio-temporal modeling approach, namely the Geographically and Temporally Weighted Ordered Logistic Regression (GTWOLR) to model the natural gas pipeline incident report data (2010–2019) from the U.S. Pipeline and Hazardous Material Safety Administration. Text mining was performed to extract additional information from the narratives in reports. Results show several factors have significant spatiotemporally varying correlations with the pipeline incident severity, and these factors include excavation damage, gas explosion, iron pipes, longer incident response time, and longer pipe lifetime. Findings from this study are valuable for pipeline operators, end-users, responders to jointly develop localized strategies to maintain the natural gas distribution system. More implications are discussed in the paper.     

Insights into process safety incidents from an analysis of CSB investigations

Many incidents have helped to define and develop process safety. Each has provided valuable learning opportunities. However, it is even more important to identify insights that can be obtained from an analysis of a large set of incidents that represents those that typically occur. This larger picture illuminates trends and commonalities and provides learning opportunities that are even more important than the causes of any one individual incident.The Chemical Safety Board has published the results of over 60 investigations of process safety incidents. These data have been analyzed to identify commonalities and trends so that measures to help protect against future incidents can be developed. Recommendations are made to address key issues identified.     

Method for evaluating learning from incidents using the idea of “level of learning”

Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be questioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.     

Lessons learned from recent incidents: Facility siting, atmospheric venting, and operator information systems

Recent incidents have focused attention on a number of technical and management systems that need to be addressed by industry. A multiple layer of protection approach is essential for the prevention of incidents and/or reduction of consequences. Safety culture and operational discipline are the overall embracing factors that influence the safety performance of a facility. However, as recent events have indicated, there are a number of technical and engineering issues that must also be developed and implemented appropriately. Some of these issues that could lead to incidents with catastrophic consequences include facility siting and atmospheric relief venting. Impact of operator information systems on the prevention of releases of hazardous materials from their containment is also another significant factor that should be given appropriate attention.

This paper describes these three topics based on the findings from recent incidents and historical data. Engineering standards, regulatory requirements, and industry practices are discussed for facility siting, atmospheric relief venting, and operator information systems. Finally, a summary of gaps and needs in technology, standards, and practices is presented.     

Developing a process equipment failure knowledge base using ontology approach for process equipment related incident investigations

Process equipment failures (PEFs) are one of the most important causes of process incidents occurrences. To investigate and prevent the PEFs, in addition to having the previous data, it is necessary to have some resources of the PEFs domain knowledge. Nowadays, PEFs data are usually retrieved from existent databases. Customary databases present only previously stored data of equipment failures but, for carrying out a comprehensive PEFs management it is necessary to have access to the PEFs desired knowledge and not only stored data. This paper aims to offer a knowledge base for the PEFs through adopting an ontological approach and then to use the proposed knowledge base for further applications particularly, process incident investigation activities. Through adding semantic search capability, the proposed knowledge base could upgrade the data presenting feature of the common databases into a knowledge presenting feature. Using this approach, the user would be able to extract the desired knowledge of the PEFs along the virtual stored data of occurred cases. The knowledge extraction process and the data mining of occurred incidents are both necessary for the PEFs investigation.     

Modeling using dynamic variables – An approach for the design of loss prevention programs

Records from The National Safety Council [National Safety Council, 2007. Safety Intervention Evaluation: A Systematic Approach. <http://www.acgih.org/events/ControlBand/Thomas_SafetyIntervention.pdf> (accessed 10.01.07)] have shown that in 2004 alone, on-the-job injuries to workers constituted 35% of total recorded injuries in the United States. This generated an associated cost of about $142.2 billion. Unfortunately, the safety intervention programs enforced at work places to mitigate such losses are driven mainly by intuition and experience of involved safety personnel. This paper details implementing a computer program to furnish safety personnel with an empirical basis for designing loss prevention programs based on historical safety data. The computer tool is driven by a dynamic mathematical model which adapts itself to variations in data patterns and explains the correlation between historical incident rates and corresponding resources committed to interventions. This study empowers the industry with a tool that is capable of forming the core of optimizing valuable human resource allocation in safety program designs.     

浅析如何制定企业职业安全健康方针

制定适合企业自身发展的职业安全健康方针至关重要,然而目前这方面的研究相对较少。本文收集了国内27家、国外10家知名企业的职业安全健康方针,统计分析了国内外职业安全健康方针在形式和内容上的区别与联系。通过定性分析和定量研究,得出国外企业职业安全健康方针的共性特点和国内企业职业安全健康方针的最常见组合模式。理论联系实际,将我国《职业安全健康管理体系规范（》GB/T28001-2004）中方针的编写要求与研究结论相结合,探讨在新形势下,如何制定企业职业安全健康方针的方法。     

Guidance to improve the effectiveness of process safety management systems in operating facilities

The Process Safety Management (PSM) systems at the operating facilities in the Oil & Gas and in Chemical manufacturing industries have matured over the years and have become, at most facilities, very robust and sophisticated. These programs are administrated by Process Safety (PS) teams at both the corporate business units and plant levels and have been effective in reducing the number and severity of PS events across the industries over the past 25 years or so. Incidents however are occurring at a regular interval and in recent times several noteworthy PS events have occurred in the United States which have brought into question the effectiveness of the PSM programs at play. These facilities have been applying their PSM programs with the expectation that the number and severity of PS events would decrease over time. The expected result has not been realized, especially in context to those facilities that have undergone the recent incidents. Current paper reviews a few publicly available PS performance reports of Oil & Gas and Chemical manufacturing industries. The authors identified a few factors at play that have led to these PS events based on their experience, literature review, and incident investigation reports. Most of the factors are intertwined with multiple PSM elements and it requires a holistic approach to address them. Each of the factors is described and the path forward is proposed to improve the effectiveness of PSM programs.     

A review of hazards associated with primary lithium and lithium-ion batteries

Primary lithium batteries contain hazardous materials such as lithium metal and flammable solvents, which can lead to exothermic activity and runaway reactions above a defined temperature. Lithium-ion batteries operating outside the safe envelope can also lead to formation of lithium metal and thermal runaway. Despite protection by battery safety mechanisms, fires originating from primary lithium and lithium-ion batteries are a relatively frequent occurrence.This paper reviews the hazards associated with primary lithium and lithium-ion cells, with an emphasis on the role played by chemistry at individual cell level. Safety mechanisms to prevent the occurrence and limit the consequences of incidents are reviewed, together with safety tests to monitor compliance with battery safety regulations and standards. Incident information from news accounts and open literature sources are reviewed to extract causal information.It is concluded that the potential severity of incidents during storage, transport and recycling of waste batteries can be significantly higher than in end-use applications. Safe storage, packaging and labelling practices, as well as communication among the parties involved, are essential to ensure safety across the battery lifecycle. It is recommended that a database of lithium battery incidents would be valuable to improve the evidence base for informing accident prevention measures.     

Motor vehicle towing: An analysis of injuries in a high-risk yet understudied industry

Objectives: National fatality rates for commercial tow truck operators exceed those of other first responders who also perform traffic incident management services. The objectives of the current study are to (1) characterize causal factors associated with injuries among commercial tow truck operators engaged in roadside assistance through analysis of coded and free text data obtained from U.S. Occupational Safety and Health Administration (OSHA) investigation files, and (2) utilize supplemental data sources to analyze environmental factors for injuries in which commercial tow truck operators were struck by roadway traffic. Methods: Searches of OSHA’s online IMIS database were performed to identify investigations of incidents in which tow truck operators were injured while performing roadside assistance duties. Freedom of Information Act (FOIA) requests were submitted to obtain full investigation files for each case. Coded and narrative text analyses were performed to identify causal themes across the identified cases. Results: One-hundred and six cases of tow truck operators being killed or severely injured were identified in IMIS; 41 FOIA requests for related investigation documents were fulfilled. Two major event type themes were identified which accounted for 9 in 10 of the cases identified. These were (1) ‘struck-by’ incidents, which were primarily injuries resulting from contact with roadway traffic, rolling vehicles and equipment or other non-motorized objects; and (2) ‘caught-in or -between’ incidents, which were primarily injuries resulting from being pinned beneath and between vehicles and being caught in moving parts. Conclusions: The towing industry should provide initial and refresher safety training on vehicle loading and unloading, defensive techniques when exposed to traffic on roadways, and proper wheel chocking and braking procedures. States should include tow trucks as a first responder vehicle type in their “Move Over” laws and implement public awareness campaigns to protect all first responders, including tow truck operators.     

Reducing non-contact electric arc injuries: an investigation of behavioral and organizational issues

PROBLEM: It is estimated that 5 to 10 arc flash explosions occur in electric equipment every day in the United States. In the mining industry the largest single injury category of electrical injuries are caused by non-contact electrical arcs. METHOD: This investigation progressed in two phases: (a) 836 Mine Safety and Health Administration (MSHA) reports of electric arcing incidents that occurred over a period of 11 years were reviewed, and (b) personal interviews were conducted with 32 individuals. A theoretical Safe Job Performance Model guided the study. RESULTS: Behavioral dimensions were identified and included the effect of worker experience, judgment and decision-making ability, behavioral and organizational controls, and safety culture. SUMMARY: The National Institute for Occupational Safety and Health (NIOSH) conducted an investigation of behavioral components associated with arc flash incidents and developed recommendations for interventions based on findings. IMPACT ON INDUSTRY: This study fills a vacuum in electrical training with a focus on the organizational and behavioral aspects of arc flash incidents. The research is cross-cutting in its scope, in that the results apply not only to mining and construction, but many other industries employing electricians. Although the majority of mine electrical injuries are the results of burns from electrical arcs, few miners are aware that such a hazard exists. A safety training program, which includes a video and an instructor's discussion guide, was developed for electricians based on this study's findings. "Arc Flash Awareness" was released in 2007 (DHHS NIOSH Publication No.2007-116D) and is available through 1-800 CDC INFO. Phone: 1-800 232-4636 or email cdcinfo@cdc.gov. It is also available from MSHA at MSHADistribution@dol.gov or 304-256-3257 (DVD-576). Private industry is producing Portuguese and Spanish language translations.     

境外企业社会安全事件调查分析方法研究

针对我国境外企业在社会安全方面所面临的严峻形势,对境外企业社会安全事件的调查分析方法进行研究.通过对境外中资企业社会安全事件的分类、分级,事件报告和调查的程序,事件统计分析方法等方面的研究,提出境外社会安全事件的分类、分级的标准和原则,境外社会安全事件报告和调查的程序及主要注意事项及统计分析的建议,设计了境外中资企业社会安全事件管理的基本框架,从而加强社会安全事件的调查和统计分析,为科学统计此类事件造成的损失提供依据.