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.     

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.     

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.     

Global process safety incidents in the pharmaceutical industry

The objective of this research is to analyse global process safety incidents within the pharmaceutical industry in terms of their consequences and factors contributing to the incidents. There were 73 process safety incidents leading to 108 fatalities found between 1985 and 2019. Trends between the number of incidents, number of fatalities, location, and contributing factors were identified and summarized. The most reported fatalities occurred in 2018 & 2019. 83% of fatalities occurred in China and India. Explosions were associated with 71% of incidents, which resulted in 89% of fatalities. For most of the international incidents, incident investigations were not available and thus insufficient details were available to determine the causes. Contributing factors were available or estimated from available data for about half of the incidents, with the following most common: hazard awareness & identification; operating procedures; design; safeguards, controls & layers of protection; safety culture; and preventive maintenance. These findings can be used as a basis to improve process safety performance in the pharmaceutical industry.     

Analysis of laboratory incident database

With the growth of academic institutions, the number of labs handling hazardous chemicals has increased. Although the chemicals used in academic institutions are well-known, the dosage, usage, and management of these chemicals pose significant threat to researchers at all levels. As a step towards incident prevention, a laboratory incident database was developed to record incidents at universities and secondary schools. The data consisted of 128 entries occurring during the years 2012–2015. Incidents were classified by institution type, hazard type, consequences, substance type, body parts injured and direct causes. Of 128 incidents, 65% of the incidents were taking place in universities. Chemical spills were observed to be the most recurrent hazard type contributing to 45% of the incidents following by explosions (23%) and fires (21%). The consequence which most frequently occurred in incidents was personal injury and hazmat response contributing to 22% each. It was observed that in 41% of the incidents, the body parts injured in the incident was not known or reported. Of the total 128 incidents, about 50 incidents occurred due to improper storage and handling.     

Fires, explosions and related incidents at work in Great Britain in 1996/97 and 1997/98

Incidents in Great Britain reported to the Health and Safety Executive during 1996/97 and 1997/98 involving fires, explosions, runaway chemical reactions and unignited releases of flammable materials are reviewed. Statistical comparisons are made against previous years based on the materials involved, and a number of common themes and causes are identified.