Anatomy of a domino accident: Roots,triggers and lessons learnt |
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| Authors: | Bahman Abdolhamidzadeh Che Rosmani Che Hassan Mahar Diana Hamid Sajjad FarrokhMehr Naser Badri Davood Rashtchian |
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| Institution: | 1. Department of Chemical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia;2. Centre for Process Design, Safety and Loss Prevention (CPSL), Department of Chemical and Petroleum Engineering, Sharif University of Technology, Tehran, Iran;1. Safety and Security Science Group, Delft University of Technology, The Netherlands;2. Australian Maritime College, University of Tasmania, Australia;3. Centre for Risk, Integrity, and Safety Engineering (C-RISE), Memorial University of Newfoundland, Canada;1. Safety and Security Science Section, Faculty of Technology, Policy, and Management, TU Delft, The Netherlands;2. Antwerp Research Group on Safety and Security (ARGoSS), Faculty of Applied Economics, Universiteit Antwerpen, Antwerp, Belgium;3. Research Group CEDON, Campus Brussels, KULeuven, Brussels, Belgium;1. Dipartimento di Ingegneria Chimica, Mineraria e delle Tecnologie Ambientali, Alma Mater Studiorum – Università di Bologna, via U. Terracini 28, 40131 Bologna, Italy;2. Institute for the Protection and Security of the Citizen, European Commission, Joint Research Centre, via E. Fermi 2749, 21027 Ispra (VA), Italy |
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| Abstract: | On July 24th, 2010, several explosions and fires devastated a hydrocarbon processing plant in Kharg Island, Iran. Four workers were killed and many others were severely injured. The plant became out of service for 80 days. The way the accident happened and its sequence was representing as a domino accident. In this paper, events leading up to the disaster have been analyzed in details. Graphic presentation techniques such as Fish Bone Analysis and Event Sequence Diagram (ESD) have been utilized to enhance the understanding of the accident mechanism. Finally major lessons learnt from this domino accident have been addressed. |
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