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.     

Arabian,Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives

Introduction. Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. Method. A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. Results. Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p?<?0.05). Conclusion. Although not given much consideration, national culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.     

旋转压缩机油路系统仿真与试验研究

压缩机泵油系统对滚动转子压缩机性能和可靠性非常重要.为了了解压缩机泵油特性.本文应用CFD软件,采用VOF模型对滚动转子压缩机整个泵油系统进行数值模拟,搭建试验台进行试验,并将模拟和试验结果进行对比,结果表明上法兰螺旋槽处润滑油流量结果吻合很好,误差在10％以内,证明了该仿真方法的可行性.     

电磁辐射测量仪对测量结果的影响分析

目前国内外对环境电磁波的测量仪器主要分为两类,分别是选频式和非选频式。选频式仪器由各类测量接收机或频谱分析仪和接收天线组成,其不适于非周期信号测量。非选频式仪器由各类全向型探头和主机组成,适用于周期和非周期信号的环境电磁波测量,但这类仪器动态范围不高。本文采用了两种不同的测量仪器,分别以单频连续波和调制脉冲为激励信号进行比较分析。结果表明：随着测量信号电平增加,两种仪器测量结果数据趋于一致。而在用两种标准的不同方法计算某一频段的复合场强时,其数值有较大差异。     

航空维修差错模式及差错成因的灰色关联分析

提出一种基于HFACS-ME框架和灰色关联分析法的航空维修差错模式和差错成因之间关系的分析方法。利用该方法分别从"模式—成因"和"成因—模式"2个方向,以"技能差错"和"身体状态差"为例,对差错模式和差错成因之间的关系进行分析,得到影响"技能差错"的主要差错成因依次为空间狭窄、培训不足、工具损坏、身体状态差、精神状态差、空间阻碍,以及"身体状态差"主要影响的差错模式为记忆差错、决策差错、技能差错。结果表明,灰色关联分析法对航空维修差错模式和差错成因之间关系的分析是有效的、可行的。     

基于人因失误理论的安全文化评价指标体系构建——以建筑企业为例

为构建一个科学的建筑企业安全文化评价指标体系,实现对企业安全文化水平的客观评价。通过问卷调查及信息沉淀的方式获取影响建筑企业安全文化水平的各种因素,并基于人因失误理论对建筑企业安全文化影响因素进行分析和归类。在构建的建筑企业安全文化评价概念体系的基础上,采用因子分析的方法构建建筑企业安全文化评价指标体系。研究结果表明:该指标体系不仅可以描述指标的重要程度,而且可以明确各指标之间的因果关系,对建筑企业安全文化的构建具有一定的指导意义。     

基于APJE-SLIM的海运人因失误概率的确定

安全是海运行业永恒的主题,调查研究表明,人因失误是造成海事的主要原因。为了对海运人因失误进行研究,探讨引起人因失误的行为形成因子(PSF),确定在PSF影响下的人因失误概率。在调查海上避让行为的人因失误和这些失误的行为形成因子的基础上,采用APJE和SLIM相结合的方法对航海人员避让行为中的可靠性进行分析。结果表明,航海人员疲劳与健康程度、知识、经验与培训水平、任务复杂程度、安全管理水平与组织有效性等PSF对人因失误概率有着不同程度的影响,相应提高PSF水平,可极大地减少人因失误概率。利用APJE确定端点绝对失误概率,解决了SLIM方法中难以获得参考点概率的问题,获得了在不同种类不同水平PSF影响下的海运人因失误概率。     

大气颗粒物“二重源解析”技术的误差分析

"二重源解析"模型计算结果的误差是采样误差、样品处理误差、化学组分分析误差、数据处理误差以及数学模型误差等所有误差的积累。提出了"二重源解析"解析结果的相对误差和标准偏差表达式,并用之计算了某市利用"二重源解析"模型计算的源贡献值的相对误差和标准偏差,还针对从源排放出来的初始态颗粒物在传输过程中发生的扬尘态变化提出了扬尘转化率的概念和计算方法。     

SAMPLING FRAME FOR IMPROVING PEBBLE COUNT ACCURACY IN COARSE GRAVEL‐BED STREAMS1

ABSTRACT: Improved sampling techniques are needed to increase the accuracy of pebble‐count particle‐size distributions used for stream studies in gravel‐bed streams. However, pebble counts are prone to operator errors introduced through subjective particle selection, serial correlation, and inaccurate particle‐size measurements. Errors in particle‐size measurements can be minimized by using a gravel template. Operator influence on particle selection can be minimized by using a sampling frame, 60 by 60 cm, in which sampling points are identified by the cross points of thin elastic bands. Serial correlation can be minimized by adjusting the spacing between the cross points and setting it equal to the dominant large particle size (=D₉₅). In a field test in a cobble‐bed stream, the sampling frame developed in this study produced slightly coarser size distributions, particularly in the cobble range, than the traditional heel‐to‐toe walk that selects particles with a blind touch at the tip of the boot. The sampling frame produced more similar sampling results between two operators than heel‐to‐toe walks. The difference between the two sampling methods is attributed to an unbiased selection of fine and coarse particles when using the sampling frame.     

Cost-Effective Suppression and Eradication of Invasive Predators

Abstract: Introduced predators can have pronounced effects on naïve prey species; thus, predator control is often essential for conservation of threatened native species. Complete eradication of the predator, although desirable, may be elusive in budget‐limited situations, whereas predator suppression is more feasible and may still achieve conservation goals. We used a stochastic predator–prey model based on a Lotka‐Volterra system to investigate the cost‐effectiveness of predator control to achieve prey conservation. We compared five control strategies: immediate eradication, removal of a constant number of predators (fixed‐number control), removal of a constant proportion of predators (fixed‐rate control), removal of predators that exceed a predetermined threshold (upper‐trigger harvest), and removal of predators whenever their population falls below a lower predetermined threshold (lower‐trigger harvest). We looked at the performance of these strategies when managers could always remove the full number of predators targeted by each strategy, subject to budget availability. Under this assumption immediate eradication reduced the threat to the prey population the most. We then examined the effect of reduced management success in meeting removal targets, assuming removal is more difficult at low predator densities. In this case there was a pronounced reduction in performance of the immediate eradication, fixed‐number, and lower‐trigger strategies. Although immediate eradication still yielded the highest expected minimum prey population size, upper‐trigger harvest yielded the lowest probability of prey extinction and the greatest return on investment (as measured by improvement in expected minimum population size per amount spent). Upper‐trigger harvest was relatively successful because it operated when predator density was highest, which is when predator removal targets can be more easily met and the effect of predators on the prey is most damaging. This suggests that controlling predators only when they are most abundant is the “best” strategy when financial resources are limited and eradication is unlikely.