A study of maintenance-related major accident cases in the 21st century

This paper is based on a review of 183 detailed, major accident investigation and analysis reports related to the handling, processing and storage of hydrocarbons and hazardous chemicals over a decade from 2000 to 2011. The reports cover technical, human and organizational factors. In this paper, the Work and Accident Process (WAP) classification scheme is applied to the accident reports with the intention of investigating to what extent maintenance has been a cause of major accidents and what maintenance-related causes have been the most frequent.The main objectives are: (1) to present more current overall statistics of maintenance-related major accidents, (2) to investigate the trend of maintenance-related major accidents over time, and (3) to investigate which maintenance-related major accident causes are the most frequent, requiring the most attention in the drive for improvement.The paper presents statistical analysis and interpretation of maintenance-related major accidents’ moving averages as well as data related to the types of facility, hazardous substances, major accidents and causes. This is based on a thorough review of accident investigation reports.It is found that out of 183 major accidents in the US and Europe, maintenance was linked to 80 (44%) and that the accident trend is decreasing. The results also show that “lack of barrier maintenance” (50%), “deficient design, organization and resource management” (85%) and “deficient planning/scheduling/fault diagnosis” (69%) are the most frequent causes in terms of the active accident process, the latent accident process and the work process respectively.     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

城市煤气网管系统的安全维护及运行

煤气作为一种二次能源,是城市中使用的主要能源之一.燃气行业的生产、输送、使用过程,从某种角度来讲是高危的作业过程.煤气网管系统的施工和维护过程中充满了种种困难和危险,造成了许多重大损失,其主要原因是缺乏有效的组织引导和规范的安全措施.本文着重分析了煤气网管系统发生泄露事故的原因,提出了煤气网管系统的运行和维护过程中应当遵循的安全事项和采取的安全措施,为煤气网管系统的运行和维护工作提供了理论依据.     

基于事故理论的城市轨道交通风险评价模型研究

笔者分析了城市轨道交通事故,在分析我国其他行业事故分类的基础上,确定城市轨道交通事故分类标准,即重大事故、大事故、险性事故和一般事故,并将不同事故分类情况及专家判断评分,按事故的大小不同换算成可以计算的计算尺度,根据事故种类不同计算出事故折算因子,根据风险理论的评价方法,建立了地铁风险评价模型,对地铁的危险性进行量化定级,并通过具体实例进行综合分析评价,该风险评价模型具有一定的工程意义。     

Lessons learned for process safety management in China

A number of chemical accidents have occurred in China over the past two decades with significant impact on humans and the environment. It is expected that lessons will have been learned from these accidents that will help industries to reduce the risk that catastrophic chemical accidents occur in future. In fact, to some extent there is evidence that lessons have been learned, to the extent that the Chinese government has substantially strengthened legislation and regulatory standards. Nonetheless, there remains a concern that much more still needs to be done to reduce chemical accidents risks in China. Important progress in this area requires not only government support but a commitment across all hazardous industries to learn from past accidents that may in many cases require establishment or considerable improvement of their safety management systems. To assist small and medium-sized enterprises (SMEs), in this effort, results of an analysis of common causes of the chemical accidents reported in the Major Accident Information (MAI) website of Chinese State Administration of Work Safety (SAWS) are presented in this paper In particular, inadequate process hazard analysis (PHA), training and emergency response planning (ERP) were identified as the top three process safety management (PSM) elements that contribute to most of the SMEs accidents in China. Seven recommendations are proposed in order to improve the effectiveness of lesson learning for government agencies and SMEs.     

Fired equipment combustion chamber accidents: A historical survey

A historical analysis was carried out on 189 accidents that occurred in gas and oil fuel fired equipment. The variation of frequency as a function of time, the main causes leading to a fire or an explosion, as well as the consequences of the accidents were studied. Explosion was the most frequent accident, followed by fire; in a few cases the final outcome was a release. Accidents in gas fired combustion equipment were significantly more frequent than those in the liquid fired ones. The main causes were tube rupture and/or error in ignition/reignition sequences, followed by loss of flame in the combustion chamber and, with a minor frequency, entrance of non-expected fuel and presence of non-combusted materials. The consequences on people were much more important in case of explosions than in case of fires. Even though the equipment involving combustion chambers can be considered essentially safe, this historical analysis has shown that accidents continue to occur with certain frequency because the number of existing units is quite high and the possibility of human error during its operation and maintenance is still significant.     

Equipment failures and their contribution to industrial incidents and accidents in the manufacturing industry

Accidental events in manufacturing industries can be caused by many factors, including work methods, lack of training, equipment design, maintenance and reliability. This study is aimed at determining the contribution of failures of commonly used industrial equipment, such as machines, tools and material handling equipment, to the chain of causality of industrial accidents and incidents. Based on a case study which aimed at the analysis of an existing pulp and paper company's accident database, this paper examines the number, type and gravity of the failures involved in these events and their causes. Results from this study show that equipment failures had a major effect on the number and severity of accidents accounted for in the database: 272 out of 773 accidental events were related to equipment failure, where 13 of them had direct human consequences. Failures that contributed directly or indirectly to these events are analyzed.     

An analysis of human factors in fifty controlled flight into terrain aviation accidents from 2007 to 2017

Introduction: Controlled Flight Into Terrain (CFIT) account for a considerable amount of fatalities when compared to other accident categories. Human factors are deemed significant contributory causes in these accidents. This paper aims to identify the human factors involved with aviation accidents that resulted in CFIT. Method: The study used the Human Factors Analysis and Classification System (HFACS) framework to determine the factors involved in 50 CFIT accidents from 24 counties over a 10 year period, i.e. 2007–2017. Interviews with five senior aviation safety experts were used to provide a better comprehension of the human factors affecting the flight safety. Results: The study identified 1289 individual causal and contributory human factors with unsafe actions and preconditions for unsafe actions being the main subcategories of the accidents. The study found that CFIT occur across a range of pilot experience and 44% of accidents occurred in cruise flight. Distraction, complacency and fatigue are all elements that flight crews may experience as contributors to CFIT during cruising. Conclusions: Human factors represent a major component of CFIT accidents. The analysis revealed a similar pattern of contributory and causal human factors across the various flight categories, with some noteworthy isolated variations. The prevalent factors were decision and skill-based errors along with communication, coordination and planning issues. Practical applications: Provision of specific CFIT awareness, pilot training focusing on improved decision-making and revision of basic flight skills, development of specific Global Positioning System routes for transiting high terrain areas are necessary to prevent CFIT accidents. Installation of Terrain Avoidance and Warning System and Ground Proximity Warning System and appropriate equipment training, specific CFIT Crew Resource Management training and improvement of organizational knowledge on the elements involved in CFIT are also recommended.     

HAZOP技术在氨合成塔危险辨识中的应用

介绍了HAZOP技术的特点及分析步骤。运用HAZOP方法,对氨合成塔进行危险性辨识。分析了氨合成塔中有意义的偏差、偏差发生的原因、可能导致的后果,并提出相应的对策措施。氨合成塔的HAZOP分析表明,反应温度偏高、反应压力偏高、合成气泄漏是重要的偏差,对氨合成塔的安全运行具有很大的威胁,易引起爆炸事故,应予以特别重视,尤其是控制温度条件是确保氨合成塔安全生产的最重要因素。研究结论是对氨合成塔常见的和可能发生的安全事故的一个系统总结,详细的偏差原因分析、安全对策措施建议,为工程技术人员实现对氨合成塔的安全控制、预防和减少、避免类似事故,提供了具体参考和重要依据。     

基于飞行剖面的航空器试飞活动空管风险研究

为明确空中交通管理风险对航空器适航试飞活动不安全事件的影响,首先,依据航空器试飞科目绘制相应飞行剖面;其次,基于试飞活动飞行剖面,分析管制单位试飞保障流程,提取管制运行风险对试飞活动的影响因素;采用事故树分析法(FTA)分析事故发展过程,将事件和逻辑关系映射至贝叶斯网络(BN),依据国内外民航空管不安全事件分类统计结果...     

A study of storage tank accidents

This paper reviews 242 accidents of storage tanks that occurred in industrial facilities over last 40 years. Fishbone Diagram is applied to analyze the causes that lead to accidents. Corrective actions are also provided to help operating engineers handling similar situations in the future. The results show that 74% of accidents occurred in petroleum refineries, oil terminals or storage. Fire and explosion account for 85% of the accidents. There were 80 accidents (33%) caused by lightning and 72 (30%) caused by human errors including poor operations and maintenance. Other causes were equipment failure, sabotage, crack and rupture, leak and line rupture, static electricity, open flames etc. Most of those accidents would have been avoided if good engineering have been practiced.     

Worker safety and injury severity analysis of earthmoving equipment accidents

Introduction: Research on construction worker safety associated with construction equipment has mostly focused on accident type rather than injury severity and the embedded factor relationships. Significant variables and their effects on the degree of injury are examined for earthmoving equipment using data from OSHA. Four types of equipment, backhoe, bulldozer, excavator, and scraper are included in the study. Accidents involving on-foot workers and equipment operators are investigated collectively, as well as separately. Methods: Cross tabulation analysis was conducted to establish the associations between selected categorical variables, using degree of injury as a dichotomous dependent variable (fatal vs. nonfatal) and a number of independent variables having different values. Odds ratios were calculated to determine how much a certain variable/factor increases the odds of fatality in an accident, and the odds ratios were ranked to determine the relative impact of a given factor. Results: It was found that twelve variables were significantly associated with injury severity. Rankings based on odds ratios showed that inadequate safety training (2.54), missing equipment protective system (2.38), being a non-union worker (2.26), being an equipment operator (1.93), and being on or around inadequately maintained equipment (1.58) produced higher odds for fatality. Conclusion: A majority of the earthmoving equipment accidents resulted in fatality. Backhoes were the most common equipment involved in accidents and fatalities. Struck-by accidents were the most prevalent and most fatal. Non-OSHA compliant safety training, missing seatbelt, operator not using seatbelt, malfunctioning back-up alarms, and poorly maintained equipment were factors contributing to accidents and fatalities. On-foot workers experienced a higher number of accidents than operators, while fatality odds were higher for the operators. Practical applications: Safety professionals should benefit from our findings in planning and delivering training and providing oversight to workers in earthmoving equipment operations.     

Research on 10-year tendency of China coal mine accidents and the characteristics of human factors

The trend of China coal mine accidents in the latest 10 years was studied and the human factors in these accidents were analyzed by multi-dimensional statistic analysis. It shows that the number of major coal mine accidents and the death toll in the accidents were decreasing steadily, while sporadic death accidents still accounted for the largest percentage of deaths. Gas outburst accidents, gas explosion accidents and mine water accidents remained the major part of the whole story and subject to close attention. Among the causes of these accidents, human factors accounted for 94.09%, of which intentional violation, mismanagement and defective design accounted for 35.43%, 55.12%, 3.54% respectively. Improper operational and management practices in which the safety system, procedures and specifications were neglected or broken were still key roots of China coal mine accidents.     

Major accidents in process industries and an analysis of causes and consequences

This paper briefly recapitulates some of the major accidents in chemical process industries which occurred during 1926–1997. These case studies have been analysed with a view to understand the damage potential of various types of accidents, and the common causes or errors which have led to disasters. An analysis of different types of accidental events such as fire, explosion and toxic release has also been done to assess the damage potential of such events. It is revealed that vapour cloud explosion (VCE) poses the greatest risk of damage. The study highlights the need for risk assessment in chemical process industries.     

Developing a risk-based maintenance model for a Natural Gas Regulating and Metering Station using Bayesian Network

During the last decades, the vital role of maintenance activities in industries including natural gas distribution system has cleared up progressively. High costs may induce to reduced maintenance and, in turn, lead to a lower availability and high risk of undesired events. Therefore, a probabilistic model, based on an acceptable level of risk, is required to avoid under and over estimation of maintenance time interval. This paper presents an advanced Risk-based Maintenance (RBM) methodology to optimize maintenance time schedule. Bayesian Network (BN) is applied to model the risk and the associated uncertainty. The developed method can assist the asset managers to work out the exact maintenance time for each component according to the risk level. To demonstrate and discuss the applicability of the methodology, a case study of Natural Gas Reduction and Measuring Station in Italy is considered. Results prove that the most critical components are the calculator and pilots, while the most reliable one is the odorization. Furthermore, the pressure and temperature gauge (PTG), the remote control system (RCS) and the meter are predicted as the components that require less time to transit from minor risk to catastrophic risk.     

我国危险化学品事故统计分析及对策研究

基于2005—2008年我国发生的1565起危险化学品事故,从事故发生时间、发生地点、发生环节等方面分析事故的致因、特点以及规律,可以发现:近3年来我国危险化学品事故呈逐渐下降趋势;石化产业大省是危险化学品事故高发省份;每年3—8月是危险化学品事故高发时期;每天上午10点和下午3点是危险化学品事故高发时间;生产、运输、储存是危险化学品产业链六大环节中的事故高发环节。根据统计结果分析,指出我国危险化学品安全管理存在的问题,并提出预防和减少危险化学品事故的对策。     

Lower explosion limit of hybrid mixtures of burnable gas and dust

Hybrid mixtures – mixtures of burnable dusts and burnable gases – pose special problems to industries, as their combined Lower Explosion Limit (LEL) can lie below the LEL of the single substances. Different mathematical relations have been proposed by various authors in literature to predict the Lower Explosion Limit of hybrid mixtures (LEL_hybrid). The aim of this work is to prove the validity or limitations of these formulas for various combinations of dusts and gases. The experiments were executed in a standard 20 L vessel apparatus used for dust explosion testing. Permanent spark with an ignition energy of 10 J was used as ignition source. The results obtained so far show that, there are some combinations of dust and gas where the proposed mathematical formulas to predict the lower explosible limits of hybrid mixtures are not safe enough.     

基于层次话题模型的煤矿安全事故致因要素研究

为促进安全发展,强化煤矿安全管理的科技支撑,在事故致因理论基础上,利用文本挖掘中的话题模型和创新性构建的层次致因要素话题模型,对我国2000—2015年发生的386起重特大煤矿事故调查报告进行了深入地挖掘、分析和研究。发现事故致因隐含的规律及各类事故之间的关联与共性,并进一步研究发现不同致因要素随时间的演化规律及致灾倾向,为煤矿安全管理找出重点,指导煤矿安全生产管理实践。