Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Incidents in manual handling activities

More than 20000 handling manoeuvres in loading or unloading trailers in a large transportation company were observed. The aim of the study was to determine the frequency and nature of the incidents occurring whilst handling. The incidents were recorded and interpreted from a double perspective, namely as risk factors and as activity regulation factors. The study showed that on average, one incident occurred in every seven handling manoeuvres: 71% of them were related to the environment, and 29% to the activity. While numerous, the environment-related incidents were generally without consequences. In this respect, the activity incidents appeared more risky; also, the majority of these incidents occurred during the load positioning phase. The study also showed that loads are re-handled twice as often in unloading as in loading, the frequency of re-handlings varying widely from one handler to another. The reasons why so few of the observed incidents are reported in accident studies and their significance in the understanding of handling problems are discussed.     

Factors associated with occupational injury severity in the New South Wales underground coal mining industry

The relationship between a large number of mine and mine worker characteristics and injury severity was examined using multiple regression techniques. The study was based on data extracted from the New South Wales (N.S.W.) Joint Coal Board's computer based accident/incident reporting system describing 21,372 non-fatal, lost-time injurious incidents that occurred in the N.S.W. underground coal mining industry during the 4 year period from 1 July 1986 to 30 June 1990. The number of days lost as a result of an injurious incident was the best available proxy measure of injury severity. Over the study period, the number of days lost per 100,000 tonnes of raw coal production declined by 73%. Over the same period, injurious incidents involving more than 20 days off work, which constituted only 16% of all injurious incidents in underground mines, resulted in 75% of the total days lost for the whole N.S.W. underground coal mining industry. Factors that had practical importance and that were significantly associated with injury severity included mine worker's age, part of the body injured, type of accident, agency of accident, and mine worker activity. Factors not important or not significant in their relationship with injury severity were: time into shift, previous hours worked, mine location of incident, occupation, work experience, frequency of task, shift, and mining region. This study suggests that factors related to the susceptibility of a mine worker's body tissue to damage or repair, and factors related to the concentration of energy on the mine worker by vehicle and environmental characteristics are important determinants of injury severity.     

Self-reported incidents,accidents, and use of protective gear among small-scale forestry workers in Sweden

Self-reported data were collected from 156 self-employed small-scale forestry workers regarding their work, including use of safety gear and number and type of incidents and accidents. About 40% of the respondents reported that during the previous 24 months they had some kind of work-related accident where an injury occurred, and/or experienced in incident, a close call that could have resulted in an injury. Of those injured or involved in an accident, 50% reported that at the time of the accident or incident they were not fully using their safety gear. Sixty-seven percent of the accident victims reported seeking medical attention for their injuries. No significant relationships were found between production level, age, use of safety gear or sensation seeking tendencies and the reports of accidents and incidents. Accidents and incidents were most likely to occur during felling, thinning and transportation activities and were usually caused by unforeseen interactions with falling trees/branches or equipment. Compared to earlier surveys of Swedish small-scale forestry workers, consistent use of all required safety gear was down by 10% to 50%. Protective pants and gloves were the items least likely to be used while ear, eye and foot protection were most likely to be used. The results indicate that better planning during felling processes may be the key to reducing the number of accidents for this population.     

Historical analysis of U.S. onshore hazardous liquid pipeline accidents triggered by natural hazards

Incidents at U.S. onshore hazardous liquid pipeline systems were analyzed with an emphasis on natural hazards. Incidents triggered by natural hazards (natechs) were identified by keyword-based data mining and expert review supplemented by various data sources. The analysis covered about 7000 incidents in 1986–2012, 3800 of which were regarded as significant based on their consequences. 5.5% of all and 6.2% of the significant incidents were found to be natechs that resulted in a total hazardous substance release of 317,700 bbl. Although there is no trend in the long-term yearly occurrence of significant natechs, importance is found to be increasing due to the overall decreasing trend of the incidents. Meteorological hazards triggered 36% of the significant natechs, followed by geological and climatic hazards with 26% and 24%. While they occurred less frequently, hydrological hazards caused the highest amount of release which is about 102,000 bbl. The total economic cost of significant natechs was 597 million USD, corresponding to about 18% of all incident costs in the same period. More than 50% of this cost was due to meteorological hazards, mainly tropical cyclones. Natech vulnerabilities of the system parts vary notably with respect to natural hazard types. For some natural hazards damage is limited possibly due to implemented protection measures. The geographical distribution of the natechs indicated that they occurred more in some states, such as Texas, Oklahoma, and Louisiana. About 50% of the releases was to the ground, followed by water bodies with 28%. Significant consequences to human health were not observed although more than 20% of the incidents resulted in fires. In general, the study indicated that natural hazards are a non-negligible threat to the onshore hazardous liquid pipeline network in the U.S. It also highlighted problems such as underreporting of natural hazards as incident causes, data completeness, and explicit data limitations.     

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.     

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.     

Case study: T2 Laboratories explosion

A tragic explosion resulting from a runaway chemical reaction occurred at the T2 Laboratories, Inc. facility in December 2007. The U.S. Chemical Safety Board (CSB) completed an incident investigation of the T2 explosion, identifying the root cause as a failure to recognize the runaway reaction hazard associated with the chemical it was producing. Understanding the consequences of process upset conditions is critical to determine risk. This paper will focus on lessons learned from this incident including a comprehensive hazard assessment for reactive chemicals as well as proper collection and application of adiabatic calorimetry data to characterize the chemical reaction and determine appropriate mitigation strategies. Examples will be provided to establish safer operating conditions, implement safeguards and reduce the overall risk.     

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.     

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.     

Bayesian estimation and consequence modelling of deliberately induced domino effects in process facilities

Process facilities handling hazardous chemicals in large quantities and elevated operating conditions of temperature/pressure are attractive targets to external attacks. The possibility of an external attack on a critical installation, performed with an intention of triggering escalation of primary incidents into secondary and tertiary incidents, thereby increasing the severity of consequences needs to be effectively analysed. A prominent Petrochemical Industry located in Kerala, India was identified for studying the possibility of a deliberately induced domino effect. In this study, a dedicated Bayesian network is developed to model the domino propagation sequence in the chemical storage area of the industry, and to estimate the domino probabilities at different levels. This method has the advantage of accurately quantifying domino occurrence probabilities and identifying possible higher levels of escalations. Moreover, the combined effect from multiple units can be modelled easily and new information can be added into the model as evidences to update the probabilities. Phast (Process hazard analysis) software is used for consequence modelling to determine the impact zones of the identified primary and secondary incidents. The results of the case study show that such analyses can greatly benefit green field and brown field projects in determining the appropriate safety and security measures to be implemented or strengthened so as to reduce its attractiveness to external threat agents.     

民航不安全事件报告危险源识别模型

为了识别民航不安全事件的发生原因,从民航不安全事件报告出发,提出了一种基于LDA主题模型和Word2Vec模型的民航不安全事件报告危险源识别模型。首先,构建危险源标签分类表,选取民航不安全事件报告与Wiki中文数据库作为数据源,然后利用LDA主题模型得出民航不安全事件报告的主题概率分布与词概率分布,最后利用Wiki中文数据库训练Word2Vec模型得到词向量,进而计算文档主题与不同危险源标签之间的相似度,得出民航不安全事件报告的危险源分类。结果表明,该模型的精准率为77.7%、召回率为86.8%、F为82.0%,能够有效识别各民航不安全事件报告的危险源。     

Non-occupational injuries caused by transport packaging: Residential and retail hazards

BackgroundBackground: Pallets are key components of domestic supply chains, and yet present unique hazards when used by homeowners and retailers for unintended uses. No previous works have investigated non-occupational injuries that occur due to unintentional contact with pallets. This study sought to describe the incidence and epidemiology of non-occupational pallet-related injuries as seen in United States emergency departments (EDs). Method: The National Electronic Injury Surveillance System database was used to derive national, weighted estimates of pallet-related injuries by age, sex, injured body part, and location where injury occurred. Data for the years 2014 to 2018 were analyzed with all relevant narratives reviewed. Results: From 2014 to 2018, there were an estimated 30,493 persons who visited an ED for a pallet-related injury. The yearly incidence of pallet injuries rose during this period. The 35–44 age group (n = 5,481) was most likely to be injured, but about 3,000 children and youth under 18 years of age were injured and more than 4,000 persons 65 years of age or older suffered injuries. The elderly were especially likely to suffer injuries from slip, trip and fall incidents. The lower extremities were the most commonly injured body parts. An estimated 3,964 persons, accounting for approximately 14% of all pallet-related injuries, were treated for injuries incurred while at a retail establishment. African Americans, Hispanics, and the elderly appeared to be disproportionately more likely to have pallet-related injuries in retail locations. Conclusions: Non-occupational pallet-related injuries affect a wide range of patients and cause a variety of injuries, with the elderly being especially vulnerable to tripping incidents. Retailer prevention strategies should focus on the misuse of pallets for merchandising purposes. Industry should maintain control of pallets so they are not used for unintended purposes. Practical applications: Retailers should limit the use of pallets for floor-level merchandising purposes and remove pallets from customer-facing locations where unintentional contact could occur. Owners of pallets should maintain them in a controlled supply chain so that they don’t leak out into the hands of homeowners. Policy-makers should educate the public about the dangers of used pallets.     

Risk management of cost consequences in natural gas transmission and distribution infrastructures

A critical aspect of risk management in energy systems is minimizing pipeline incidents that can potentially affect life, property and economic well-being. Risk measures and scenarios are developed in this paper in order to better understand how consequences of pipeline failures are linked to causes and other incident characteristics. An important risk measure for decision-makers in this field is the association between incident cause and cost consequences. Data from the Office of Pipeline Safety (OPS) on natural gas transmission and distribution pipeline incidents are used to analyze the association between various characteristics of the incidents and product loss cost and property damage cost. The data for natural gas transmission incidents are for the period 2002 through May 2009 and include 959 incidents. In the case of natural gas distribution incidents the data include 823 incidents that took place during the period 2004 through May 2009. A two-step approach is used in the statistical analyses to model the consequences and the costs associated with pipeline incidents. In the first step the probability that there is a nonzero consequence associated with an incident is estimated as a function of the characteristics of the incident. In the second step the magnitudes of the consequence measures, given that there is a nonzero outcome, are evaluated as a function of the characteristics of the incidents. It is found that the important characteristics of an incident for risk management can be quite different depending on whether the incident involves a transmission or distribution pipeline, and the type of cost consequence being modeled. The application of this methodology could allow decision-makers in the energy industry to construct scenarios to gain a better understanding of how cost consequence measures vary depending on factors such as incident cause and incident type.     

A neglected risky behavior among children and adolescents: underage driving and injury in New South Wales,Australia

PROBLEM: Among different causes of injury, roads and traffic-related incidents contributed most to all child deaths. The majority of childhood and adolescent traffic-related deaths are young people killed as pedestrians or bicyclists. Underage driving is a particular risky behavior much neglected. This study aimed to describe some characteristics related to motor-vehicle crashes and crash-related injury in which the vehicle was driven by a young person who was under the legal age of obtaining a learner license in New South Wales, Australia. METHODS: Data used in this study were made available from the Roads and Traffic Authority of NSW for the period between 1996 and 2000. Crash information was collected and reported by NSW police at the scene of these motor-vehicle crash incidents. RESULTS: There were 526 crashes involving an underage driver recorded within the study period. The majority (79.5%) of these underage drivers were males with slightly more than half (58.0%) aged 15 years, and nearly 30% aged 14 years. Among these, 83.6% involved the driver of the vehicle being killed or injured. Among the injured or killed passengers, 128 (73.6%) were nonadult passengers under the age of 18 years. Seventy of these crashes occurred while the car was in pursuit by police. The adjusted relative risk of injury to at least one occupant in the vehicle should a crash occur for female underage drivers was two times (OR=2.01, 95% CI=1.27-3.20) as compared to male underage drivers. DISCUSSION: Underage driving poses a serious problem in terms of crash outcomes. Experimental driving and late-night outings for adolescents should be discouraged. Well-designed studies are required to further investigate the relationship between underage driving and on road risk-taking behavior among licensed adolescents. IMPACT ON INDUSTRY: Data obtained from this study indicate that adults, particularly parents, should discourage underage adolescents from experimenting driving and should actively cultivate a positive attitude toward driving.     

Attributes of Occupational Injury Among Workers in the Chemical Industry and Safety Issues

Case-study research was carried out with a view to find the attributes of occupational injury among workers in the chemical industry and to enhance safety issues. Injury data were collected and processed in terms of different variables, such as age, gender, skills, type of hazard, etc. Pareto analysis was then applied to find a pattern of occupational injury among the workers. The study revealed that 79.52% of the injured workers were in the 40–59 age group; 57.14% of accidents occurred during the 1st shift; 73.26% of accidents caused injury to hands, feet, chest to thigh, arms and eyes; and 70.93% of injuries were caused by pumps, carrying and lifting, vehicles, pipelines, valves, and grinding. Surprisingly, no one was injured in the group of temporary workers. The paper also provides specific suggestions followed by some action plans.     

Attributes of occupational injury among workers in the chemical industry and safety issues.

Case-study research was carried out with a view to find the attributes of occupational injury among workers in the chemical industry and to enhance safety issues. Injury data were collected and processed in terms of different variables, such as age, gender, skills, type of hazard, etc. Pareto analysis was then applied to find a pattern of occupational injury among the workers. The study revealed that 79.52% of the injured workers were in the 40-59 age group; 57.14% of accidents occurred during the 1st shift; 73.26% of accidents caused injury to hands, feet, chest to thigh, arms and eyes; and 70.93% of injuries were caused by pumps, carrying and lifting, vehicles, pipelines, valves, and grinding. Surprisingly, no one was injured in the group of temporary workers. The paper also provides specific suggestions followed by some action plans.     

Study of the severity of industrial accidents with hazardous substances by historical analysis

This paper studies the levels of risk in industrial facilities where hazardous substances are used, evaluating the influence of certain variables on the severity of the accidents that have occurred until now. It makes use of the incidents recorded in the July 2001 version of the MHIDAS database. This study reveals that accidents in developed countries are less severe than those that occur in other geographical areas. Also, it establishes the influence on the severity (number of fatalities) of this kind of incident of certain factors: the type of incident and the type and amount of substance involved. Lastly, the extent to which current facilities comply to the risk tolerance criteria in various countries is evaluated with regards to incidents involving explosions.     

基于TEM模型的民航不安全事件关联规则挖掘与分析*

为了预防民航不安全事件的发生,应用机组威胁与差错管理（TEM）模型分析2014—2020年民航事故/征候的航空安全报告资料,提取事件里存在于民航运行风险中潜在的情况、威胁、机组差错等因素,通过改进的关联规则方法挖掘其中的关联关系,包括挖掘与事件严重程度有关的因素,找到TEM模型中的关键因素和影响航空器结束状态的致因因素,并进行关联网络图分析。研究结果表明:手动操纵/飞行控制差错、缺少/不足的飞行培训和安全管理、飞行员之间沟通差错与程序执行错误是造成事故/征候的显著因素;关联规则能够有效利用航空安全报告信息,通过定量的方法挖掘事故/征候的特征,找到影响民航不安全事件的强关联因素,为民航安全管理人员提供决策依据。