Origin of equipment design and operation errors

The paper discusses the origin of chemical process equipment accidents by analyzing past accident cases available in the Failure Knowledge Database (FKD). The design and operation errors of the process equipment that caused the accidents were analyzed together with their time of occurrence. It was found that design errors contributed to 79% of accidents while the rest were only due to human and organizational errors in the operation stage and external factors. The most common types of errors were related to layout, organizational errors in the operation stage, considerations of reactivity and incompatibility, and wrongly selected process conditions (each approx. 13% of total accident contributors). On average there were about 2 design errors per accident. The timing of the errors was quite evenly distributed between various lifecycle stages. Nearly half (47%) of the errors were made in process design-oriented stages, one fourth (26%) in detailed engineering, and one fifth (20%) in operation. In addition, the most frequent design and operation errors for each equipment type were identified. A points-to-look-for list was created for each equipment type, showing also the typical time of occurrence of the error. The knowledge of type and timing of design errors can be utilized in design to focus the hazard analysis in each stage on the most error-prone features of design.     

Antenatal gene tests in low-risk pregnancies: molecular screening for aspartylglucosaminuria (AGU) and infantile neuronal ceroid lipofuscinosis (INCL) in Finland

Approximately one in five subjects in Finland carries some gene defect associated with 30 diseases belonging to the Finnish disease heritage, and about one in 500 children born is affected. Almost all carriers, women and men, are unaware of their condition. Recent advances in molecular medicine have offered the possibility of population-based carrier screening for recessive disorders. We studied acceptance and attitudes to antenatal screening for aspartylglucosaminuria (AGU) and infantile neuronal ceroid lipofuscinosis (INCL). From January 1995 until December 1996 carrier tests were offered at Kuopio City Health Center, free of charge to all pregnant women attending maternity care units. Women found to be carriers of AGU (n=47) or INCL (n=14) underwent detailed genetic counseling, and their male partners were also offered the test. If both partners appeared to be carriers we offered prenatal testing (n=1). No affected fetuses were detected. Attitudes towards the gene test were elicited by means of a questionnaire. Altogether 87% of pregnant women elected to undertake the gene tests. Antenatal screening for gene defects was feasible and well accepted, and it provided an effective way to find carriers of genetic diseases and to incorporate prenatal testing into this process. Copyright © 2001 John Wiley & Sons, Ltd.     

Food chain enrichment of organochlorine compounds and mercury in clean and polluted lakes of Finland

Lakes polluted by pulp mill and urban wastes including chlorobleaching of pulp, semipolluted lakes and reference lakes in nearly natural condition in Central Finland were studied for contents of mercury, methyl mercury and organochlorine compounds in sediment, plankton, roach and pike. Chlorobleaching had caused a 30-fold concentration of Hg in bottom sediment related to that of the purest reference lake. This was not reflected to the mercury levels in fish which were highest at one natural condition (humic) lake and rather high also at semipolluted lake Päijänne. Mercury in fish was shown to be mostly methylated but not completely and its time trends could be estimated. Chloroform showed no but carbon tetrachloride, tetrachloroethylene and chlorinated cymenes significant bioaccumulation in fish. Levels of chlorophenols from bleaching had strongly decreased but pentachlorophenol and 2,3,4,6-tetrachlorphenol levels remained related to earlier results. Using fat basis attenuated the power of estimation of food chain enrichment by a three throphic level model for lipohilic biocides and a strong proof was obtained of the enrichment of hexachlorobenzene. The time trends at Päijänne were decreasing for mercury and DDE but increasing for PCB.     

Alkaline phosphatase activity in amniotic fluid in pregnancies with fetal disorders

Alkaline phosphatase (ALP) activity was determined in 255 amniotic fluid samples collected by amniocentesis between 15 and 39 weeks of gestation. The samples were originally used for chromosomal analysis and/or alpha-fetoprotein measurements. The mean ALP activity in early amniotic fluid from pregnancies with fetal trisomy 18 and 21 syndromes was half of that found in the controls. Highly elevated ALP activity (over 10 times the median level) was found in 14 samples. Two of these pregnancies had normal outcome. Three samples were from pregnancies with intrauterine fetal death. Fetal disorders, including abdominal wall defect (four cases), Meckel's syndrome (two), hydrops fetalis syndrome (two) and genital anomaly (one), were observed in nine cases. Moderately elevated ALP activity (over three times the median) was found in 10 cases, including five pregnancies with a preterm labour shortly after the sample collection. The results indicate that elevated ALP activity in the third trimester amniotic fluid is often associated with fetal disorders.     

Method for identifying contributors to chemical process accidents

The paper presents a new method for identifying contributors to chemical process accidents by exploiting knowledge on causes of past accident cases. Accident reports from the Failure Knowledge Database were analyzed and utilized for hazard identification. The accident information gathered was used as a basis to develop an accidents ranking and points-to-look-for approach for the safe design and operation of chemical process equipment. In the method, accident contributors including technical, design and operation errors of major process equipment types and piping are identified. The method is applicable throughout the process lifecycle, even for process changes in the early design stages. The Bhopal tragedy is used as a case study to demonstrate and test the method. The proposed method can predict on average up to 85% of accident causes and design and operation errors.     

Simple graphical method for inherent occupational health assessment

The concept of inherently safer design was introduced to design a fundamentally safer process so that hazards can be avoided or minimized rather than controlled or managed. The ideology has later been extended to the environmental, but not health criteria due to its complicated underlying principles. Even though health risk methods are already established, majority are for existing plants assessment. Early consideration of health aspect starting from process design stage however, has received much less attention. This paper introduces a simple graphical method to evaluate the inherent occupational health hazards of chemical processes during the R&D stage. A survey was conducted to identify the important health parameters for the graphical method development, involving nine world inherent safety and health experts. Based on their input, process mode, material volatility, operating pressure and chemical health hazard (toxicity and adverse effect) are the significant factors affecting inherent health hazards of chemical processes. The choice of parameters was bounded by the information availability at this stage. The method was applied on six routes to methyl methacrylate and ten routes to acetic acid. The parameters were plotted for each subprocess of the alternative routes. The ‘healthiest’ route was selected based on thorough hazards assessment across all the subprocesses. The first case study reveals the tertiary butyl alcohol as the ‘healthiest’ one as it poses relatively lower, or at least comparable hazards to the other routes due to exposure and health impacts. Meanwhile the acetic acid case study indicates ethanol oxide and ethyl oxide based routes as the inherently healthier as they operate at lower operating pressure besides posing comparable hazards level for the other three parameters, compared to the other routes. The case studies show that the inherent occupational health of a chemical process can already be evaluated easily in the R&D stage with the simple graphical method proposed.