Analysis of underlying causes of investigated loss of containment incidents in Dutch Seveso plants using the Storybuilder method

In the Netherlands there are around 400 “Seveso” sites that fall under the Dutch Major Hazards Decree (BRZO) 1999. Between 2006 and 2010 the Dutch Labour Inspectorate's Directorate for Major Hazard Control completed investigations of 118 loss of containment incidents involving hazardous substances from this group. On the basis of investigation reports the incidents were entered in a tailor-made tool called Storybuilder developed for the Dutch Ministry of Social Affairs and Employment for identifying the dominant patterns of technical safety barrier failures, barrier task failures and underlying management causes associated with the resulting loss of control events. The model is a bow-tie structure with six lines of defence, three on either side of the central loss of containment event. In the first line of defence, failures in the safety barriers leading to loss of control events were primarily equipment condition failures, pre start-up and safeguarding failures and process deviations such as pressure and flow failures. These deviations, which should have been recovered while still within the safe envelope of operation, were missed primarily because of inadequate indication signals that the deviations have occurred. Through failures of subsequent lines of defence they are developing into serious incidents. Overall, task failures are principally failures to provide adequate technical safety barriers and failures to operate provided barriers appropriately. Underlying management delivery failures were mainly found in equipment specifications and provisions, procedures and competence. The competence delivery system is especially important for identifying equipment condition, equipment isolation for maintenance, pre-start-up status and process deviations. Human errors associated with operating barriers were identified in fifty per cent of cases, were mostly mistakes and feature primarily in failure to prevent deviations and subsequently recover them. Loss of control associated with loss of containment was primarily due to the containment being bypassed (72% of incidents) and less to material strength failures (28%). Transfer pipework, connections in process plant and relief valves are the most frequent release points and the dominant release material is extremely flammable. It is concluded that the analysis of a large number of incidents in Storybuilder can support the quantification of underlying causes and provide evidence of where the weak points exist in major hazard control in the prevention of major accidents.     

An optimal level of dust explosion risk management: Framework and application

The current research provides guidance on the prevention and mitigation of dust explosion using a Quantitative Risk Management Framework (QRMF). Using concepts drawn from previous studies, the framework consists of three main steps: (i) a new combined safety management protocol, (ii) the use of DESC (Dust Explosion Simulation Code) and FTA (Fault Tree Analysis) to assess explosion consequences and likelihood, respectively, and (iii) application of the hierarchy of controls (inherent, engineered and procedural safety). QRMF assessment of an industrial case study showed that the original process was at high risk. DESC simulations and Probit equations determined the destructive percentages. FTAs revealed high probabilities of explosion occurrence; in addition, detailed individual and societal risks calculations were made, before and after the framework was applied. Based on the hierarchy of controls technique, the framework showed significant risk reduction to the point where the residual risk was acceptable for the process.     

我国煤矿安全生产事故的致灾因素分析

煤矿安全不仅关系到广大煤矿工人的生命财产安全、煤炭的安全开采,还关系到煤炭企业的和谐稳定.煤矿安全工作是党和政府管理社会、为人民服务的基本任务,是全面落实科学发展观、建设和谐社会的重要组成部分.首先对我国煤矿安全形势进行了分析,随后介绍了事故致因理论的发展,结合我国煤矿事故的特点运用现代事故致因理论对一起煤矿事故进行了分析,最后得出提高煤矿安全监管的措施.     

信息化在海外油气项目HSE管理中的应用

伴随着中国石油企业走出去的步伐不断加快,海外油气项目的规模迅速扩大,相较于国内而言,海外油气项目面临的环境更加复杂,HSE管理难度更大。探索一种科学、高效并且符合现代化管理要求的先进管理手段,与企业的HSE管理有机融合,从而确保企业HSE管理体系良好运行,对于企业具有重要意义。中国某石油企业海外项目（A公司）在此方面进行了大量、有益的实践,其将自身的信息管理系统与HSE体系有机融合,从而实现了HSE管理的信息化。选取A公司的事故预防应急系统作重点介绍,将A公司的事故预防管理与传统事故预防管理进行对比,同时将A公司的应急管理与传统应急管理进行对比,最后提出了针对HSE管理信息化的思考,以期对石油企业海外项目的HSE管理提供帮助。     

基于人因失误分析的医院电气安全管理研究

医院是重点用电单位,用电的安全性和供电可靠性都比较高,但因不可抗力、供电系统故障、医院管理问题、人为失误等方面的原因,仍存在发生各类电气突发事件的风险。其中,由人的误操作或不安全行为因素而诱发的电气方面的突发事件已成为医院非医疗事故的主要原因。文章针对医院电气安全操作方面的人因失误,从个人和组织两个角度进行了失误原因的分析,认为人的失误既受个体因素的影响,也受环境、制度和管理水平的影响。在此基础上,提出完善相关规章制度建设、加强教育与培训等,从组织制度建设、人员技术素质提高等方面,提出预防与减少人因失误的措施与方法,提高供配电质量,为医院医疗工作提供有效的电气安全后勤保障。     

在煤矿构建人因安全测评室的探索

人因安全管理是煤矿安全管理中的重要内容,而其中的一项重要内容则是人员测评.参考已有研究经验,并结合煤矿生产的特点,基于测评方法和侧重点的异同、企业实施检测的条件与环境等因素,对煤矿安全人因测评指标进行重新归纳,提出了一套系统性好、针对性强、且具有较高可操作性的煤矿人因安全测评室的构建方案.总结出三类与煤矿安全生产紧密相关的人因指标模块:心理素质、生理机能和认知能力,并给出了每个模块的具体测评指标及检测方法.最后还给出了测评室建设实施及完善推广的相关建议.     

企业安全生产信息化建设存在的问题及对策

在对我国安全生产信息化建设现状调研的基础上,结合国内外相关资料文献及笔者多年为企业提供安全生产信息化建设解决方案的工作经验,分析了目前我国安全生产信息系统的分类和应用方向,以及企业在安全生产信息化建设过程中存在的问题,如缺乏统一规范和总体规划、投入结构不合理等。针对企业安全生产信息化建设中存在的诸多问题,提出了建设应对措施及建议。对指导企业开展安全生产信息化建设,保证系统科学性、实用性等方面具有重要意义。     

潘一矿西翼通风系统调整与预测研究

针对潘一矿采掘布局高度集中,导致西三采区需求风量大幅提高,引起中央风井风机负压高的问题,提出了西翼通风系统调整与优化方案;并结合矿井未来发展规划,提出了加快二水平巷道掘进、提前准备大巷煤柱工作面顺槽的方法,制定了西三采区进风段和回风段的降阻措施。模拟结果表明:从采区的进风段和回风段同时采取措施,并在采区内部进行扩巷,能有效改善西三采区通风阻力较高的状况,主要通风机负压能降至合理范围。     

提高基层班组JSA质量的管理实践

工作安全分析(简称JSA)作为有效的危害识别和风险控制工具被广泛使用,但基层班组员工所做JSA的质量一直不高,具体表现为员工虽然清楚JSA的各个环节,却不能高质量的完成.尽管这在一定程度上与基层员工文化素质低,文字表达能力差有关,但也是管理者缺乏具体和优秀的指导所致.针对实施JSA的各个环节,分析制约质量提升的具体原因,以标准规范为基础提出具体可行的改进措施,实施效果良好.     

基于物联网技术的特种设备监检移动办公系统开发

为了使特种设备监察、检验、作业过程更加规范、高效,提出了将物联网技术应用于特种设备监管办公的方案,开发了实际可用的便携式电梯监检移动办公系统.该系统利用射频卡标识电梯和作业人员,实现了和管理对象的直接交互;采用无线通信网络建立手持终端机与管理系统后台服务器之间的通信,实现特种设备现场与特种设备监察检验管理系统的实时交互.运行测试结果显示,利用监检移动办公系统手持机可以在现场认证作业人员资质、现场查询设备详细信息和现场出具检验报告,并且运行稳定可靠,实现了特种设备监察、检验、作业过程的自动识别和实时、远程管理.