协和客机坠毁事故调查始未

事故调查是通过收集事故发生后所表现出来的各种现象、信息、痕迹与特征，并加以分析、鉴别与判断，从而揭示引起事故的原因。因此，事故调查是一个从果求因的逆向思维过程。在这种逆向认识客观事物的过程中，正确的思路与思维方法显得特别重要。以严谨的态度去收集、核实、分析与鉴定事故发生后所呈现出来的各种纷繁的现象、信息和面目全非的残骸，查找出事故的可能原因，通过科学的分析，逐一排除，最终认定引起事故的原因，这是国外事故调查工作的程序。客观、公正、实事求是，是调查人员应当遵循的准则。查找事故的可能原因，广泛吸取事故教训，切实改进安全工作，有效预防未来事故，才是事故调查最根本的目的。从本期开始，我们将陆续编辑一些国外重大事故调查案例。研究和借鉴其思想理论和实践经验，或许能够对我国事故调查工作的开展起到促进作用。     

事故调查的哲学原理

进行事故调查的一个根本目的,就是预防事故以致最终消灭事故。为实现这一目的,事故调查必须遵循基本的哲学原理。事故调查的各个环节表现为相互联系相互依存的紧密关系事故调查的主要任务是,查找事故原因,总结事故教训,制定和落实预防事故、改进工作的措施。这是事故调查的精髓所在,是事故预防的根本途径。事故原因是按照事故致因理论,采用取证、实验、推理以及其他科学方法,     

对一起丙酮回收塔爆炸事故的分析

2006年8月中旬,某制药厂发生一起丙酮回收塔爆炸事故,所幸未伤人,只是将回收塔（蒸馏塔）的封头崩出,飞跨4层高厂房,降落在离爆炸地点水平距离约50m的平地上。爆炸事故发生后,该厂停止了生产,立即进行事故调查和分析,查找原因。     

对建立第三方事故调查机制的探讨

事故调查的根本目的在于查找事故的可能原因并提出事故的预防措施,而事故调查的独立性对此根本目的起关键作用。我国安全生产管理体制建设起步较晚,事故管理机制发展不成熟,与国外先进事故调查理念相比,我国事故调查机制缺乏独立性的保障,主要表现在技术调查与司法调查未能分离、事故调查报告未能完全公开、事故调查的客观性保障不足,限制了我国事故调查水平的进一步提高。通过分析国外第三方事故调查的机制的优势并结合我国国情,从第三方事故调查的任务、人员编制、人员培训、责任与权利、法律义务等方面提出我国第三方事故调查机制的框架,并规划了构建第三方事故调查的三阶段进程及其主要内容,以逐步实现第三方事故调查的公正、客观、高效,更好地促进我国安全生产管理水平的提高。     

中小学校园拥挤踩踏事故致因机理探究

为预防校园拥挤踩踏事故,同时进行校园安全事故致因推理和情景演化分析,本文利用事故致因“2-4”模型和情景演化理论,构建中小学校园拥挤踩踏事故致因分析模型,并运用该模型对某校园拥挤踩踏事故进行分析,还原事故发展全过程,针对性提出“情景—应对”和“事故—预防”的事故双重干预对策。结果表明:该模型能够为校园拥挤踩踏事故开展原因调查提供新的思路,同时可供学校对拥挤踩踏事故开展情景推演与针对性安全教育培训工作。     

协和客机坠毁事故调查始末

编者按:事故调查是通过收集事故发生后所表现出来的各种现象、信息、痕迹与特征,并加以分析、鉴别与判断,从而揭示引起事故的原因.因此,事故调查是一个从果求因的逆向思维过程.在这种逆向认识客观事物的过程中,正确的思路与思维方法显得特别重要.以严谨的态度去收集、核实、分析与鉴定事故发生后所呈现出来的各种纷繁的现象、信息和面目全非的残骸,查找出事故的可能原因,通过科学的分析,逐一排除,最终认定引起事故的原因,这是国外事故调查工作的程序.客观、公正、实事求是,是调查人员应当遵循的准则.查找事故的可能原因,广泛吸取事故教训,切实改进安全工作,有效预防未来事故,才是事故调查最根本的目的. 从本期开始,我们将陆续编辑一些国外重大事故调查案例.研究和借鉴其思想理论和实践经验,或许能够对我国事故调查工作的开展起到促进作用.     

中欧事故报告与调查处理比较研究

事故调查是安全生产工作中的重要环节,是对生产安全事故及时处理、发现问题的重要手段,其目的在于找出导致事故发生的可能原因,进而提出防止类似事故再次发生的对策措施。从法律依据、事故分级、事故调查程序、事故调查主体、调查组组成、事故调查期限、责任追究、事故调查经费来源、信息公开等方面开展了我国与欧盟的事故报告与事故调查处理对比分析,剖析了我国目前事故报告与调查处理的工作存在的一些问题,研究和借鉴了欧盟的一些先进理念和做法,并提出改进我国事故报告与调查处理的若干对策建议。     

基于屏障理论的安全事故原因分析方法研究

本文系统介绍了基于屏障理论的事故原因分析方法,编制事件时间链图,完整还原事故发生经过,并通过屏障辨识及分析,确定事故的直接原因、间接原因和根本原因,为事故原因分析提供参考方法和工具。最后通过实际案例进行了应用和验证。     

事故调查报告和事故处理批复的法律属性

依照《生产安全事故报告和调查处理条例》的规定,事故调查组应当提交事故调查报告,有关人民政府应当作出事故处理批复。这是在事故调查阶段和事故处理阶段形成的重要法律文书。确认调查调查报告和事故处理批复的法律属性,对于查明事故原因、认定事故性质、分清事故责任、实施责任追究,减少行政复议和行政诉讼,具有重要意义。     

尾矿库事故隐患及风险表征与防控方法*

为解决尾矿库安全隐患及风险,应用基于证据(Evidence-based)方法和事故树分析模型,辨识并表征尾矿库事故影响因素、隐患及耦合状态,根据事件发生可能性、潜在后果严重性和受体暴露程度相关独立参数,给出尾矿库事故风险表征方法,建立尾矿库事故多情景、多阶段（3段）、多层次和多等级（4级）风险防控框架。结果表明:对尾矿库5类事故（溃坝、漫顶、渗流、输送冒漏、库区扬尘）进行分析,得出基本事件或蛰伏隐患对尾矿库事故结构重要度或影响程度,给出尾矿库事故风险3维表征方法,并结合巴西布鲁马迪尼奥尾矿库进行实例应用,确定尾矿库风险等级（最高级4级）,验证方法可行性与有效性。研究结果可为尾矿库减灾防灾提供理论支撑与实践指导。     

Root cause analysis of an old accident in an explosives production plant

Twenty-six years ago, a massive accident occurred in the Semtin explosives plant in Czechoslovakia. The results of investigations which were carried out (but kept confidential at the time) were made available after 1989, but have not been published in a summarized form to date. Reopening of the results of old investigations and application of root cause analysis deepens our understanding of accident causes and leads to the conclusion that, according to today’s standards, the analysis was not completed at the time of the accident and therefore neither some of the practical aspects of the event nor the social, professional, and political climate it should have exposed have ever been fully understood. New analysis shows that plant safety management had decayed. The results demonstrate as well how substantial a shift has occurred in the understanding of causes and in performing and organizing their analyses during the elapsed quarter-century. The new examination employs a few innovations of root cause analysis. A tight connection between the analysis and the assumptions about the structure of safety management of investigated processes will be underlined. Suitable illustration will be proposed. Detail requirements on the form and content of a root cause map will be specified. Finally it is shown that even the root cause analysis has its limitations and that it may not be sufficient to finish the investigation of causes satisfactorily. This motivates for the identification of levels of causes which underlie the root causes.     

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.     

Totalitarian loss of responsibility in an explosives production plant

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

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.     

硝基苯精馏再沸器安全分析与评估

为了明确硝基苯精馏再沸器装置爆炸事故发生的原因,有针对性的采取预防措施,综合运用英国帝国化学工业公司的IC I蒙德评价法和事故树分析（FTA）法对精馏再沸器进行安全分析研究,确定了该装置生产过程中的物料物质系数,计算相关的物质危险性、工艺危险性和毒性指数,经过安全措施补偿系数修正后,得出了硝基苯精馏再沸器总危险性系数和危险等级;定性地分析了各危险因素的大小;定量地得出装置的危险程度,并提出了安全措施。结果表明,该装置的危险等级属中等,高温下漏入空气、阀门失效和法兰密封不严是导致该事故的3个最主要的原因,因此,应从以上几方面采取措施,加强安全生产管理。控制精馏再沸器的加热温度,防止局部积累热量,从而降低危险等级,确保安全生产。     

Systems thinking in a gas explosion accident – lessons learned from Taiwan

On July 31, 2014, at around 23:57, several huge explosions occurred that lasted for 2 h in Kaohsiung City, Taiwan. As a result of a gas leak from a ruptured underground pipeline, the catastrophic incident destroyed more than 6 km of roads, killed 32 people, injured 321 people, and damaged 3259 buildings. Pipeline explosions have been reported as a repeatedly occurring problem, indicating that (1) complex systems are difficult to manage and control, and (2) humans are unable to effectively learn from experiences of accidents. Initial analyses results reveal that root causes of this incident were a combination of a series of complex chain reactions, which eventually led to propylene leakage and explosion. This is a systematic problem, which can hardly be investigated or analyzed by traditional research approaches. Based on the investigation reports and “systems thinking” method, this study develops causal loop diagrams for the Kaohsiung gas explosion to explore the root causes of the disaster. The research results indicate that (1) this pipeline explosion incident was the result of the chain reactions and was the output of a complex system; (2) the mental model of “production first” and “experience gap” were the root causes of the disaster; and (3) to achieve a higher safety standard, continuous education to improve the mental model of “safety first and safety over production” are essential. The findings of this study may contribute toward the improvement of the standard operating procedure for disaster management and preventing similar incidents in the future.     

Fault propagation behavior study and root cause reasoning with dynamic Bayesian network based framework

The Bhopal disaster was a gas leak incident in India, considered the world's worst industrial disaster happened around process facilities. Nowadays the process facilities in petrochemical industries have becoming increasingly large and automatic. There are many risk factors with complex relationships among them. Unfortunately, some operators have poor access to abnormal situation management experience due to the lack of knowledge. However these interdependencies are seldom accounted for in current risk and safety analyses, which also belonged to the main factor causing Bhopal tragedy. Fault propagation behavior of process system is studied in this paper, and a dynamic Bayesian network based framework for root cause reasoning is proposed to deal with abnormal situation. It will help operators to fully understand the relationships among all the risk factors, identify the causes that lead to the abnormal situations, and consider all available safety measures to cope with the situation. Examples from a case study for process facilities are included to illustrate the effectiveness of the proposed approach. It also provides a method to help us do things better in the future and to make sure that another such terrible accident never happens again.     

Learning from Tabasco’s floods by applying MORT

Natural disasters are increasing alarmingly worldwide in recent years. They have killed millions of people, and adversely affected the life of at least one billion people. Given this, natural disasters present a great challenge to society today concerning how they are to be mitigated so as to produce an acceptable risk is a question which has come to the fore in dramatic ways recently. In 2007, the state of Tabasco, Mexico, was flooded and it is believed that al least one million people were left homeless. The paper addresses the following question: what can be learnt from flood disasters? The paper presents some preliminary results of the analysis of the Tabasco’s flooding by applying the Management Oversight Risk Tree (MORT). The MORT technique may be regarded as a structured checklist in the form of a complex ‘fault-tree’ model that is intended to ensure that all aspects of an organization’s management are looked into when assessing the possible causes of an incident. One of the key conclusions of the present analysis is that the approach to decision making in relation ‘flood management’ at the time of the disaster has not been based explicitly on ‘flood risk assessment’. It is hoped that by conducting such analysis lessons can be learnt so that the impact of natural disasters such as the Tabasco’s flooding can be mitigated in the future.     

Common operations failure modes in the process industries

The Abnormal Situation Management^® (ASM^®) Consortium (This research study was sponsored by the Abnormal Situation Management (ASM) Consortium. ASM^® and Abnormal Situation Management^® are registered trademarks of Honeywell International, Inc.) funded a study to investigate common failure modes and root causes associated with operations practices. The study team analyzed 20 public and 12 private incident reports using the TapRoot^® methodology to identify root causes. These root causes were mapped to operations practice failures. This paper describes the top ten operations failure modes identified in the analysis. Specific recommendations include how to analyze plant incident reports to better understand the sources of systemic failures and improve plant operating practices.     

Duty hours and incidents in flight among commercial airline pilots

Introduction. Working long duty hours has often been associated with increased risk of incidents and accidents in transport industries. Despite this, information regarding the intermediate relationship between duty hours and incident risk is limited. This study aimed to test a work hours/incident model to identify the interplay of factors contributing to incidents within the aviation industry. Methods. Nine hundred and fifty-four European-registered commercial airline pilots completed a 30-item survey investigating self-report attitudes and experiences of fatigue. Path analysis was used to test the proposed model. Results. The fit indices indicated this to be a good fit model (χ²?=?11.066, df?=?5, p?=?0.05; Comparative Fit Index?=?0.991; Normed Fit Index?=?0.984; Tucker–Lewis Index?=?0.962; Root Mean Square of Approximation?=?0.036). Highly significant relationships were identified between duty hours and sleep disturbance (r?=?0.18, p?r?=?0.40, p?r?=?0.43, p?Discussion. A critical pathway from duty hours through to self-reported incidents in flight was identified. Further investigation employing both objective and subjective measures of sleep and fatigue is needed.