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.     

A Framework of Lessons Learned from Community-Based Marine Reserves and Its Effectiveness in Guiding a New Coastal Management Initiative in the Philippines

Community-based coastal resource management has been widely applied within the Philippines. However, small-scale community-based reserves are often inefficient owing to management inadequacies arising because of a lack of local support or enforcement or poor design. Because there are many potential pitfalls during the establishment of even small community-based reserves, it is important for coastal managers, communities, and facilitating institutions to have access to a summary of the key factors for success. Reviewing relevant literature, we present a framework of lessons learned during the establishment of protected areas, mainly in the Philippines. The framework contains summary guidance on the importance of (1) an island location, (2) small community population size, (3) minimal effect of land-based development, (4) application of a bottom-up approach, (5) an external facilitating institution, (6) acquisition of title, (7) use of a scientific information database, (8) stakeholder involvement, (9) the establishment of legislation, (10) community empowerment, (11) alternative livelihood schemes, (12) surveillance, (13) tangible management results, (14) continued involvement of external groups after reserve establishment, and (15) small-scale project expansion.These framework components guided the establishment of a community-based protected area at Danjugan Island, Negros Occidental, Philippines. This case study showed that the framework was a useful guide that led to establishing and implementing a community-based marine reserve. Evaluation of the reserve using standard criteria developed for the Philippines shows that the Danjugan Island protected area can be considered successful and sustainable. At Danjugan Island, all of the lessons synthesized in the framework were important and should be considered elsewhere, even for relatively small projects. As shown in previous projects in the Philippines, local involvement and stewardship of the protected area appeared particularly important for its successful implementation. The involvement of external organizations also seemed to have a key role in the success of the Danjugan Island project by guiding local decision-makers in the sociobiological principles of establishing protected areas. However, the relative importance of each component of the framework will vary between coastal management initiatives both within the Philippines and across the wider Asian region.Published on line     

Database for accidents and incidents in the fuel ethanol industry

The purpose of the present research is to collect information about accidents and incidents that have occurred at fuel ethanol facilities from 1998 to October 2014, and to keep complete unified records of them in a database. The developed database contains general information about the accident or incident, its sequence, mitigation measures, its causes and consequences for humans, environment and for the plant. Until now, this information is not available. The work consisted in gathering information from different documental sources and subsequent organization in a database. It complements the previous work made for biodiesel industry and fills the existing gap in the field of ethanol. Knowledge about this information enables us to manage plant risks, since the accidents that are more likely to occur and the main sources of risk can be easily identified. Also, it makes it possible to exchange information with interested third parties. Statistical analysis shows that accident frequency has an oscillatory behavior, rising in the last year. Fire is the most common type of accident, while equipment mechanical failure is the main cause of accident. Partial material loss has been identified as the most common consequence. Finally, some conclusions are obtained concerning to the importance of having an updated and complete accident and incident database.     

Defensive secretion of a flightless grasshopper: Failure to prevent lizard attack

Summary We tested the role of a grasshopper defensive secretion in deterring lizard predation. Adults, but not young larvae, of the chemically defended lubber grasshopperRomalea guttata (=microptera) froth a volatile secretion when attacked by predators. The lizardAnolis carolinensis failed to strike juvenile lubbers (which lack secretion) in laboratory trials. Survivorship of palatable crickets loaded with secretion offered toA. carolinensis was not significantly different from survivorship of control crickets. In experiments designed to investigate if lizards learn an aversion to the secretion, striking times forSceloporus undulatus fed wax worms coated with secretion were not significantly different over three days of trials. Three primary conclusions are drawn from these data. First, the secretion may not be necessary for lubber protection from lizards. Second, lubber secretion does not appear to deter lizards from attacking or eating prey items. Third, lizards do not appear to develop an aversion to the secretion.     

Tired of innovations? Learned helplessness and fatigue in the context of continuous streams of innovation implementation

The business environment faced by contemporary organizations is highly uncertain and constantly changing. Thus, organizations have adopted and implemented a continuous stream of innovations to achieve sustainable growth and survival. Considering the demand for additional resources to implement innovations, the present study explores organizational conditions that may lead to innovation‐targeted burnout and fatigue among employees, which impede their active participation in a subsequent innovation. To this end, we propose a theoretical framework that elucidates the effects of previous innovations on the subsequent implementation behavior of employees. We identify two dimensions of the cognitive appraisal of previous innovations (i.e., intensity and failure) that shape employees' beliefs regarding innovations, such as innovation‐targeted helplessness, which ultimately results in innovation fatigue. Data collected from 84 managers and 397 employees of Chinese and Korean organizations prove the significant role of employee perceptions of previous innovations in shaping the innovation‐targeted helplessness and fatigue of employees, which ultimately affect employee behavior toward a subsequent innovation. The present conceptual and empirical analyses suggest that given continuous streams of innovation implementation, managers should carefully consider employee's perceptions of previous innovations (i.e., intensity and failure) for successful implementation of a subsequent innovation. Copyright © 2017 John Wiley & Sons, Ltd.     

Learning lessons from incidents: A paradigm shift is overdue

Drawing on historical data we show that the international community of process engineers has not been good at learning lessons from their past accidents. We call for a paradigm change in the way we approach this and the creation of a single new, multi-national, multilingual accident database that is free at the point of use and that includes immediate and underlying causes as well as “lessons learned”. It must be user-friendly and provide links to key source documents. The purpose of this paper is to challenge those in authority, and with the power to do so, to make this happen. We give some preliminary views on what may be required. In countries that so choose this could include an element of compulsion to consult the database in specific circumstances and a sign-off procedure to verify that this has been done.     

Water, sanitation and sustainability: lessons from a community project

This paper captures the lessons learned from the implementation of water supply and sanitation interventions in Mayiwane community in the rural northeastern region of the Kingdom of Swaziland, relating to water system rehabilitation, water quantity and quality improvements, and the promotion of latrine construction. The issues examined include both the dimensions of implementation efficiency and project effectiveness: first identifying the inputs, activities and final outputs and, then, tracking the entire project cycle, from design to implementation and monitoring. To draw meaningful lessons for the sustainability of similar interventions, project evaluation involved extensive fieldwork, water sampling and testing, review of documentation, and interviews with community members and officials of governmental, civil society and collaborating external agencies. Readers should send their comments on this paper to BhaskarNath@aol.com within 3 months of publication of this issue.     

Accident data for the Semantic Web

This paper describes concerns about the documentation, dissemination and use of lessons learned from mishap investigations, impediments posed by current practices, and opportunities for improvement. Lessons are presently developed, documented and stored primarily in narrative form and relational databases, and disseminated in many forms and media, including the Internet. Current practices pose many impediments to maximized development, dissemination and use. Investigation process research and new data concepts behind the Semantic Web, exploited elsewhere, offer potential opportunities to overcome these impediments. To exploit these opportunities, formation of a working group to develop an improved Semantic Web-friendly mishap investigation lessons learning system is proposed. An example illustrating an alternative approach is described to support a reasonable expectation that an alternative lessons learning system could be developed.     

Safety issues related to the maintenance operations in a vegetable oil refinery: A case study

The present work was focused on maintenance hazards related to vegetable oil refining. An incident occurred in an Italian vegetable oil refinery was presented to evidence this safety criticality. The incident took place during a maintenance shut down, and was associated to the ignition of the solid residual in a packed column. No fatalities or injuries were reported, but the column was strongly damaged and removed from the plant. A specific experimental characterization of the solid residues accumulated in the column, sampled both from the damaged and undamaged parts of the column, was carried out in order to determine the conditions leading to unwanted combustion of the residues. At the same time, samples taken from the damaged column steelwork were subjected to metallurgical analysis aimed at the thermal and mechanical characterization of the steel, obtaining information about the incident duration and temperature reached during the combustion phenomenon. The study evidenced the need of adequate maintenance procedures and safety management in the generic framework of food industry, identified as key lessons learned.     

Method for evaluating learning from incidents using the idea of “level of learning”

Learning from incidents is considered a very important source for learning and improving safety in the process industries. However, the effectiveness of learning from reported incidents can often be questioned. Therefore, there is a need to be able to evaluate the effectiveness of learning from incidents, and for that purpose we need methods and tools. In this paper, a method is described for evaluating the effectiveness of learning, based on the idea of “level of learning” of the lessons learned. The level of learning is expressed in terms of how broadly the lesson learned is applied geographically, how much organizational learning is involved and how long-lasting the effect of learning is. In the 6-step method, the incidents reported in a typical incident learning system are evaluated both for the actual and the potential level of learning in a semi-quantitative way with different tools. The method was applied in six process industries on a large number of incidents. The method was found to be very useful and to give insights of aspects that influence the learning from incidents.