Trends in accidents,disasters and risk sources in Europe

Most of the adverse impacts on man and/or the environment result from routine human activities such as the process industry, electricity generation and use, transport and agriculture (hazards, i.e. sources of risk). Apart from such essentially technological hazards, possibly resulting in “accidents”, human health and the environment can also be affected by natural hazards, possibly resulting in “disasters”, such as earthquakes or floods. This paper examines current trends in the risk sources and occurrences of four classes of such types of undesired events, entailing largely involuntary risk (e.g. neither car-driving nor smoking):

• •major accidents at fixed installations in the process industry,
• •incidents/accidents at nuclear installations,
• •marine transport and offshore installation accidents,
• •disasters caused by natural hazards and their potential exacerbation by human activities.

It aims to provide an integrated overview of such events in Europe (≡ 15 EU Member States, 4 EFTA, 13 PHARE, 7 TACIS and 5 other South and South Eastern European countries) during the last decade, estimating and interpreting trends in the number of risk sources and accidental events. For each type of event, specific “accident” definitions are given, illustrating the differences in the perception of the respective risk.     

Investigations of flame front propagation between interconnected process vessels. Development of a new flame front propagation time prediction model

For the case where a dust or gas explosion can occur in a connected process vessel, it would be useful, for the purpose of designing protection measures and also for assessing the existing protection measures such as the correct placement, to have a tool to estimate the time for flame front propagation along the connecting pipe. Measurements of data from large-scale explosion tests in industrially relevant process vessels are reported. To determine the flame front propagation time, either a 1 m³ or a 4.25 m³ primary process vessel was connected via a pipe to a mechanically or pneumatically fed 9.4 m³ secondary silo. The explosion propagation started after ignition of a maize starch/air mixture in the primary vessel. No additional dust was present along the connecting pipe. Systematic investigations of the explosion data have shown a relationship between the flame front propagating time and the reduced explosion over-pressure of the primary explosion vessel for both vessel volumes. Furthermore, it was possible to validate this theory by using explosion data from previous investigations. Using the data, a flame front propagation time prediction model was developed which is applicable for:

• •gas and dust explosions up to a K value of 100 and 200 bar m s⁻¹, respectively, and a maximum reduced explosion over-pressure of up to 7 bar;
• •explosion vessel volumes of 0.5, 1, 4.25 and 9.4 m³, independent of whether they are closed or vented;
• •connecting pipes of pneumatic systems with diameters of 100–200 mm and an air velocity up to 30 m s⁻¹;
• •open ended pipes and pipes of interconnected vessels with a diameter equal to or greater than 100 mm;
• •lengths of connecting pipe of at least 2.5–7 m.

     

Human factors integration – Bridging the gap between system designers and end-users: A case study

Within any high hazard industry such as chemical, oil and gas, rail or nuclear, it is necessary to involve system end-users within the design process if system design is to be optimised. To facilitate the identification and assessment of end user requirements it is necessary to integrate human factors (HF) into design from the start of the design lifecycle.During 2004, the author facilitated the integration of HF into a development project being implemented at a major gas processing facility on mainland Britain. The approach taken to HF integration on the project is commonly applied across the high hazard industries. This paper will provide information on this process and the benefits that this provided to the operator. Details will be provided on the approach taken in terms of:

• –Liaison between HF and other design disciplines.
• –Analysis undertaken and tools used.
• –HF topic areas covered.
• –Specific issues raised and how these were resolved.

It will demonstrate the advantage of the early integrated approach as compared to the later auditing or assurance approach sometimes taken in relation to HF.     

The oil and gas industry,the Offshore Installation Manager (OIM) and the management of emergencies - Changes necessary to achieve effective competence assessment of OIMs in controlling emergencies

Within the UK offshore oil and gas industry all installations require to be under the charge of a ‘competent’ installation manager in accordance with the Offshore Installations and Pipeline Works (Management and Administration) Regulations (MAR) 1995. The Offshore Installation Manager (OIM) is responsible for the safety of all persons onboard and within 500 m of an installation. Should an incident arise, the OIM performs one of the most critical roles within the offshore industry - management of the response to the emergency to mitigate and make safe the installation to secure a place of safety for persons onboard or organise their safe evacuation. The emergency response also includes limiting the loss of hydrocarbons to the environment.Research at the University of Aberdeen has identified 8 potential barriers to the effective competence assessment of OIMs in controlling emergencies. These underlying barriers are a consequence of current UK legislation and industry practices in the assessment of OIM competence and result from:

• •multiple definitions of competence,
• •competence assessment predominantly by observation,
• •lack of specific and unambiguous competence requirements for trainers and assessors,
• •complexity in UK legislation and complicated interpretation of terms,
• •lack of statutory competence requirements for OIMs in controlling emergencies,
• •lack of ownership of OIM competence and competence assessment,
• •complex interactions across multiple UK Government departments, and
• •lack of regulation and independent audit of the competence assessment process of OIMs in controlling emergencies.

The potential barriers were identified by qualitative analysis of key documentation, including legislation, using a critical hermeneutic approach. Hermeneutics has historically been used to analyse texts within the domains of theology, business and law. It arguably, however, represents a powerful approach to the study of documents within the engineering domain and the offshore oil and gas industry.This paper discusses the identified potential barriers, research conclusions and recommendations and represents the culmination of three years of doctoral research investigating the competence assessment of OIMs in controlling emergencies within the offshore oil and gas industry. The research, in particular, is relevant to Duty Holders within the offshore industry, safety engineers and UK Government departments.     

How the management aspects can affect the results of the QRA

This paper describes a procedure to include into the quantitative risk assessment (and namely in the construction and solution of the Fault Trees) the Safety Management System (SMS) aspects.The parameters used for probabilistic assessment of the Expected Number of Failures (ENF) of a Top Event are parameterised depending on:

• 1.a weight assigned to each SMS section with reference to the parameter;
• 2.a judgment about the correct application of the same SMS section.

Each probabilistic parameter (e.g. failure rates, mean time to repair, and so on) is thus modified using a mathematical algorithm, where an overall parameter including all the SMS sections influencing each single parameter is defined.The application of the procedure to a formaldehyde plant allowed the validation of the method and is here entirely reported.     

Problems with identifiying a standard procedure for determining KG values for flammable vapors

Assessing the effect of potential confined fuel–air explosions involves the examination of several essential parameters. These include the limits of combustion, maximum pressure and the deflagration index or K_G. Accurate measurement of these parameters can be influenced by numerous experimental conditions. This paper describes the sensitivity of one of these parameters (K_G) to several experimental influences. The deflagration index, K_G, is important since it is the main design parameter for explosion protection systems. These studies used a highly automated 20 liter combustion sphere, with a 10 mm fuse wire igniter. Our results for methane combustion show that the deflagration index, K_G, is very sensitive to

• •the gas composition; a 1% change in nitrogen composition changed the index value by 12 bar-m/s along the stoichiometric line. Our studies also identified some problems with mixing gases to the desired composition.
• •the moisture content of the gas, which can change the index by 13 bar-m/s.

For some combustion gas compositions, it was difficult to describe a K_G value due to significant fluctuations in the pressure vs time data. Finally, an extensive study of fuse wire igniter dynamics identified a means to provide a consistent energy delivery to the igniter. All of these problems contribute significantly to specifying a standard procedure for determining the deflagration index.     

The relationship between speeding behaviour (as measured by violation convictions) and crash involvement

While it seems rational to assume that crash involvement risk and outcome are influenced by the way one drives, nevertheless there is continuing controversy over the validity of certain categories of traffic law infractions as true measures of such behavior. Specifically, does the accumulation of tickets for speeding identify drivers as high risk for becoming culpably involved in speed-related crashes? Further, does a proclivity for exhibiting speeding behavior in the presence of police translate into a greater risk for involvement in high-severity collisions?The research reported in this paper attempted to address these issues. Several years of crash and conviction data were utilized to examine

• 1.(a) the risk of culpable crash involvement by severity of outcome during a 2-year period following 3 years of conviction record,
• 2.(b) the degree to which an increasing level of speeding convictions per driver relates to an increasing propensity for speed to be a factor in drivers' crash involvements.

The results of the research identified a clear distinction between the conviction categories of “exceeding the speed limit” and “excessive speed” in terms of these accident-violation relationships.     

Chemical plant innovative safety investments decision-support methodology

Introduction

This article examines the extent to which investing in safety during the creation of a new chemical installation proves profitable.

Method

The authors propose a management supporting cost-benefit model that identifies and evaluates investments in safety within a chemical company. This innovative model differentiates between serious accidents and less serious accidents, thus providing an authentic image of prevention-related costs and benefits. In classic cost-benefit analyses, which do not make such differentiations, only a rudimentary image of potential profitability resulting from investments in safety is obtained.

Results

The resulting management conclusions that can be drawn from such classical analyses are of a very limited nature. The proposed model, however, is applied to a real case study and the proposed investments in safety at an appointed chemical installation are weighed against the estimated hypothetical benefits resulting from the preventive measures to be installed at the installation.

Conclusion

In the case-study carried out in question, it would appear that the proposed prevention investments are justified.

Impact on industry

Such an economic exercise may be very important to chemical corporations trying to (further) improve their safety investments.     

The impact of the BP Baker report

Introduction

This study examined the impact of the British Petroleum (BP) Baker Panel Report, reviewing the March 2005 BP-Texas City explosion, on the field of process safety.

Method

Three hundred eighty-four subscribers of a process safety listserv responded to a survey two years after the BP Baker Report was published.

Results

Results revealed respondents in the field of process safety are familiar with the BP Baker Report, feel it is important to the future safety of chemical processing, and believe that the findings are generalizable to other plants beyond BP-Texas City. Respondents indicated that few organizations have administered the publicly available BP Process Safety Culture Survey. Our results also showed that perceptions of contractors varied depending on whether respondents were part of processing organizations (internal perspective) or government or consulting agencies (external perspective).

Conclusions

This research provides some insight into the beliefs of chemical processing personnel regarding the transportability and generalizability of lessons learned from one organization to another.

Impact on Industry

This study has implications for both organizational scientists and engineers in that it reveals perceptions about the primary mechanism used to share lessons learned within one industry about one major catastrophe (i.e., investigation reports). This study provides preliminary information about the perceived impact of a report such as this one.     

Translation of falls prevention knowledge into action in hospitals: what should be translated and how should it be done?

Introduction

Falls prevention evidence has changed and evolved over time with positive and negative studies revealing that a “one-size fits all” approach is not the solution. Care must be taken to critically appraise the evidence and the potential applicability of that evidence to the specific hospital setting.

Method

A narrative account of the evolution of research evidence in this field is first presented. How this evidence should be applied in clinical practice is challenging, with a lack of translational evidence for the hospital setting we draw on broader theory of translating knowledge to action.

Conclusions

The journey should begin with formation of a management and engagement committee. A review of existing practices and the difference between existing practice and evidence-based practice should be undertaken to identify the “evidence-practice gap.” Engagement with staff is recommended to inform a plan for practice change. Plans for resourcing, targeting, and evaluating these strategies should also be undertaken.

Impact on Industry

This paper will assist hospitals to identify and implement evidence based falls prevention strategies leading to an improvement in patient safety.     

Safety in construction – a comprehensive description of the characteristics of high safety standards in construction work, from the combined perspective of supervisors and experienced workers

Introduction

The often applied engineering approach to safety management in the construction industry needs to be supplemented by organizational measures and measures based on how people conceive and react to their social environment. This requires in-depth knowledge of the broad preconditions for high safety standards in construction. The aim of the study was to comprehensively describe the preconditions and components of high safety standards in the construction industry from the perspective of both experienced construction workers and first-line managers.

Method

Five worker safety representatives and 19 first-line managers were interviewed, all strategically selected from within a large Swedish construction project. Phenomenographic methodology was used for data acquisition and analysis and to categorize the information. Nine informants verified the results.

Results

The study identified four main categories of work safety preconditions and components: (1) Project characteristics and nature of the work, which set the limits of safety management; (2) Organization and structures, with the subcategories planning, work roles, procedures, and resources; (3) Collective values, norms, and behaviors, with the subcategories climate and culture, and interaction and cooperation; and (4) Individual competence and attitudes, with the subcategories knowledge, ability and experience, and individual attitudes.

Discussion

The results comprehensively describe high safety standards in construction, incorporating organizational, group, individual, and technical aspects. High-quality interaction between different organizational functions and hierarchical levels stood out as important aspects of safety. The results are discussed in relation to previous research into safety and into the social-psychological preconditions for other desired outcomes in occupational settings.

Impact on Industry

The results can guide construction companies in planning and executing construction projects to a high safety standard.     

An empirically derived taxonomy of pilot violation behavior

Violations occur when pilots deliberately break safety rules; they are a serious and vexing problem in aviation. Study one engaged cluster analysis, multidimensional scaling and Pathfinder network analysis on an experimentally derived similarity matrix of violation causes to discover the structure of violation reasoning. Using the insights so gained, a classification was constructed based on actor intent with four categories:

•

Improvement. The intention is to increase safety or production, a desire to do better.

•

Malevolent. The intention is to cause harm or reduce production, a desire to do damage.

•

Indolent. The intention is to increase operator ease, a desire for lethargy.

•

Hedonic. The intention is to increase operator excitement, a desire for sensation.

Study two tested the taxonomy for reliability by having aviation experts assign categories to six accident reports. The taxonomy was found to have a free-marginal multirater kappa of 0.82, which is considered excellent.     

[Case Study] CityCenter and Cosmopolitan Construction Projects, Las Vegas, Nevada: Lessons learned from the use of multiple sources and mixed methods in a safety needs assessment

Problem

The present study describes a response to eight tragic deaths over an eighteen month times span on a fast track construction project on the largest commercial development project in U.S. history.

Methods

Four versions of a survey were distributed to workers, foremen, superintendents, and senior management. In addition to standard Likert-scale safety climate scale items, an open-ended item was included at the end of the survey.

Results

Safety climate perceptions differed by job level. Specifically, management perceived a more positive safety climate as compared to workers. Content analysis of the open-ended item was used to identify important safety and health concerns which might have been overlooked with the qualitative portion of the survey.

Discussion

The surveys were conducted to understand workforce issues of concern with the aim of improving site safety conditions. Such efforts can require minimal investment of resources and time and result in critical feedback for developing interventions affecting organizational structure, management processes, and communication.

Summary

The most important lesson learned was that gauging differences in perception about site safety can provide critical feedback at all levels of a construction organization.

Impact on the Industry

Implementation of multi-level organizational perception surveys can identify major safety issues of concern. Feedback, if acted upon, can potentially result in fewer injuries and fatal events.