Major Industrial Accidents Research Articles

Loss prevention at the startup stage in process safety management: From distributed cognition perspective with an accident case study

Organizational artifacts such as rules, procedures, or codes of practice play important roles in chemical process safety management. The violation of an organizational artifact can lead to major accidents. It is thus essential to understand the underlying significance of violations to coordination of organizational artifacts. Currently, there are rapid changes and development of chemical products which require developing new process in chemical plants. The pre-startup stage in the chemical process is especially prone to errors due to ill-defined work processes and the variety of jobs involved at this stage. However, human errors and understandings in the stage have not been given much of attention it deserves. This paper focuses on human errors in pre-startup stage: (1) An analysis of major industrial accidents in Korea was conducted. (2) A survey of related personnel in chemical plants was carried out to understand conditions of safety management on human error. (3) An accident case study at the pre-startup stage in a Korean chemical plant was conducted by applying the Fault Tree Analysis method to reveal failures of coordination of organizational artifacts. This paper adopted distributed cognition theories to analyze the underlying implications of such failures because these theories have the power to examine the relationship between human operators and artifacts in a system.This study highlights the importance of considering organizational artifacts related to human error in safety management. The results may help people, who are related to a process of pre-startup stage in chemical plants, to improve safety of the work.

Some Considerations on the Definition of Risk Based on Concepts of Systems Theory and Probability

The concept of risk has been applied in many modern science and technology fields. Despite its successes in many applicative fields, there is still not a well-established vision and universally accepted definition of the principles and fundamental concepts of the risk assessment discipline. As emphasized recently, the risk fields suffer from a lack of clarity on their scientific bases that can define, in a unique theoretical framework, the general concepts in the different areas of application. The aim of this article is to make suggestions for another perspective of risk definition that could be applied and, in a certain sense, generalize some of the previously known definitions (at least in the fields of technical and scientific applications). By drawing on my experience of risk assessment in different applicative situations (particularly in the risk estimation for major industrial accidents, and in the health and ecological risk assessment for contaminated sites), I would like to revise some general and foundational concepts of risk analysis in as consistent a manner as possible from the axiomatic/deductive point of view. My proposal is based on the fundamental concepts of the systems theory and of the probability. In this way, I try to frame, in a single, broad, and general theoretical context some fundamental concepts and principles applicable in many different fields of risk assessment. I hope that this article will contribute to the revitalization and stimulation of useful discussions and new insights into the key issues and theoretical foundations of risk assessment disciplines.

The effective control of major industrial accidents by the Major Industrial Accident Prevention Centers (MAPC) through the Process Safety Management (PSM) grading system in Korea

This paper examines effectiveness of a regulatory enforcement organization (Major industrial Accident Prevention Center, MAPC), and a grading system for implementation of the Process Safety Management (PSM) regulation in Korea. A lot of chemical installations have been built in Korea since the 1960s. The frequent occurrence of major industrial accidents had made people's concerns grow. The Korean government enacted PSM regulations in 1996 in order to curb these accidents.However, a key question is how to make sure companies comply with the PSM regulations. In order to improve company’ compliance with PSM regulations the Ministry of Employment and Labor (MOEL) responsible for the regulation introduced a grading management system in 2001 and then established special supervisory centers for enforcement of PSM regulations in 2005. This paper reviews the role and effectiveness of the system in term of PSM enforcement. The author found that the grade-based approach has encouraged employers to implement the requirements of the PSM regulations. MAPCs play an effective role in enhancing enforcement performance. Although the more chemical plants have been established in Korea, the fewer major industrial accidents have occurred since the introduction of the system. The results may be useful for the policy maker to build an effective and efficient enforcement system.

GRA(Generic Risk Analysis) 기법을 이용한 공기분리시설에 대한 준 정량적 위험성 평가에 관한 연구

가스제조 시설들은 불활성 가스공급을 통하여 제조업 시설의 안전한 운영 및 유지하는 역할을 하며, 폭발성, 가연성 및 독성가스를 공급하여 화학제품 제조에 필요한 기초 원료의 공급을 담당하는 역할을 한다. 또한 가스의 제조과정에서 고온, 고압, 초저온 및 촉매반응 등의 운전조건 하에서 시설이 운전되기 때문에 안전하고 신뢰성 있는 운영이 반드시 필요하다. 이러한 공장들은 공정관리가 복잡하며 제조물질의 누출로 인한 화재, 폭발 및 독성가스 누출로 인한 중대산업사고의 위험성이 있고, 불활성가스로 인한 질식재해, 고온 및 초저온으로 인한 화상 등 잠재적인 위험요소를 많이 가지고 있다. 본 연구는 신뢰성 있는 준 정량적 위험성평가 기법인 GRA(Generic Risk Analysis) 모델을 공기분리시설(ASU)에 적용하여 초기위험도(Initial Risk) 산정, 안전방벽(Safety Barriers) 적용, 잔여위험도(Residual Risk) 산정 및 중요안전요소(EIS, Elements Important for Safety)를 도출 하였으며, 위험성 평가 결과로 도출된 중요안전요소에 대한 효과적인 안전관리 및 시행절차의 구축을 제안하였다. The gas production plants supply the inert gas to production plants for maintaining safe operation and also supply combustible, flammable, explosive and toxic gases as functions of basic materials needed for producing chemical goods. In addition, gas plants need to be safe and reliable operation because they are operated under high temperature, high pressure, cryogenic and catalytic reactions. As these plants have a complex process in operation, there has been a risk that major industrial accidents such as a fire, explosion and toxic gas released, also risks of asphyxiations by inert gases and burns caused by high temperature and cryogenic substances. This study is to carry out the semi quantitative risk assesment method which is the generic risk analysis (GRA). This method is applied to air separation unit(ASU) to identify its initial risk, safety barriers, residual risk and elements important for safety(EIS). The result of this study, suggested the management tools and procedures of implementation for EIS management.

Major Industrial Accidents in Korea: The Characteristics and Implication of Statistics 1996–2011

This article describes characteristics of major industrial accidents that occurred in the Republic of Korea from 1996 to 2011. The cases of major industrial accidents have been collected since 1996 after promulgation of process safety management (PSM) regulations. Accident analysis can help to evaluate current compliance to PSM regulations and can help to find effective ways to decrease the number of major industrial accidents that occur. The author analyzed the accident reports. Among 147 cases analyzed, 50% were explosions, 36% were fires, 13% were chemical releases, and 2% were asphyxiations. The most common cause of accidents is “the violation or failure of safety work permit (hot work)” which was 36% of all accidents. 27% of accidents happened during operation. The most common equipment involved accidents where tanks (17%), pipelines (16%), and reactors (15%). The analysis indicates that (i) the number of major industrial accidents has decreased with the introduction of PSM regulations and its enforcement systems and (ii) human failure is a major issue that needs to be addressed. These findings may help to develop a national strategy for PSM in Korea as well as other countries. © 2013 American Institute of Chemical Engineers Process Saf Prog 32: 90–95, 2013

Enhancing resilience: implementing resilience building policies against major industrial accidents

The proper functioning of critical infrastructures (CIs) is vital for society's welfare. A disruption in one of them may lead to a crisis that affects not only the CI where the triggering event occurs but also the whole society. Therefore, it is fundamental to increase the whole system's resilience level. This paper defines resilience as the capacity of a system to prevent a crisis occurrence, to reduce the consequences from failure, and to recover rapidly and efficiently. Although there is much information about the definition of resilience, literature still lacks to provide a detailed holistic prescription about what activities should be carried out to improve the resilience level of the CIs and the society as a whole. This paper defines twelve policies that help to enhance the resilience level of all the stakeholders involved in crisis management, using information gathered from experts and examining several case studies.

Hazardous Workplace Review Program in Taiwan

In Taiwan, relevant mid-term plans and projects of mitigating occupational hazards have been launched in recent years in the hopes of lowering the incidence of occupational hazards. In light of the lack of objective methodologies for researches on issues pertaining occupational safety and health, this research aims to explore the priorities of safety and health issues through focal groups, expert questionnaires and interviews on relevant issues such as hazard installations identified in R181 Prevention of Major Industrial Accidents Recommendation, 1993 proposed during the 18th World Congress on Safety and Health at work in Seoul 2008. Results revealed that distribute reports of major domestic/foreign occupational disasters to relevant sectors for the prevention of major accidents is needed, both from the importance and feasibility analysis. It is the only topic that scored over 4 points in average for expert and focal group consensus. Furthermore, the experts and focal groups came to consensus in the ranking of priority for 4 items, namely: 1) Installations containing/using large quantities of hazardous materials should be prioritized for inspection, 2) Incorporation of hazard installation review/inspection into OSH management system accreditation, 3) Impose operation shutdown as a means of penalty) and 4) Prioritize the promotion of preliminary PHA.

An unwelcome user? Or how to negotiate the use of a risky space

Taking as a starting point the distinction between danger and risk, with the latter being seen as a particular form of the former, in that the probability of its occurrence and the potential damage it causes can be clearly identified (and thus be insured against), questions can be asked about how the shift is made from one to the other, and what events may facilitate this change. This issue is here treated in the context of a sandy beach and cove which were formed as a result of renovation work on a harbor and which, spontaneously, became places frequented for pleasure and leisure activities. Initially, the dangerous industrial sites nearby were neglected as sources of risks, because the only risks identified by the users and the authorities were drowning or traffic accidents. Then, in the 1980s, various major industrial accidents occurred in Europe and the rest of the world, leading to greater awareness among national and European political authorities concerning the risks inherent to industrial production. This awareness led to directives and legislation reinforcing the regulations governing dangerous industrial sites and restricting access to places exposed to such risks. There is thus a shift from dangers that are little known or taken into account, to risks that are socially constructed, which the local authorities must manage according to the law, while also respecting the inhabitants’ great desire to continue frequenting places to which they feel really attached. Over 30 years of history of the seawall and cove thus also show the difficulty in managing a territory when the authorities and users do not have the same perception of what the risks are and how to deal with them.

아크릴산 제조공정 사고사례를 통한 소각 시스템의 안전성 향상 방안

최근 대기환경규제의 강화로 화학공장에서 발생하는 폐가스를 소각 처리하는 경우가 증대되고 있다. 이러한 소각설비는 저장탱크 상부와 배관을 통해 연결되어 화염을 통하여 폐가스를 연소 소각시키기 때문에, 배관을 따라 화염이 역화될 경우에는 치명적인 사고로 연결될 수 있다. 본 연구는 아크릴산 제조공정의 소각시스템에서 발생한 중대산업사고에 대해 폭발의 3요소와 화염의 전파 원인을 분석하여 사고 예방대책 및 안전성 향상 방안을 다음과 같이 제시하였다. 첫째, 소각시스템의 송풍기를 재 가동하기 전에는 공기 또는 불활성 가스로 충분히 희석하여 폭발을 예방하여야 한다. 둘째, 폭굉으로 전이된 화염이 저장탱크로 전파되지 않도록 소각설비의 전단 및 저장탱크 상부에 폭굉용 화염방지기를 설치하는 것이 필요하다. 섯째, 폭연용 화염방지기를 그대로 사용할 경우에는 그 전단에 파열판을 설치하거나 저장탱크 상부와 소각설비의 배관을 후드식으로 연결하여 폭굉으로 전이된 화염을 저장탱크 밖으로 분출시켜야 한다. 마지막으로, 소각설비에 연결된 송풍기의 제어반(MCC)에 순간정전 보상장치인 시간지연계전기(TDR: time delay relay)등을 설치하여 순간정전 후에도 자동으로 재가동될 수 있도록 조치해야 한다. Recently, waste gas incineration is increasing due to strong environmental regulatory system in Korea. These incinerating facilities are usually connected with the top of the storage tank through pipeline and incinerate off gas with the flame. Therefore, the flame originated from these facilities is likely to move back into pipeline and might cause an explosion of the storage tank. Accordingly, the purpose of this study is to suggest the preventive measures and the way to improve the safety of these incineration systems through the cause analysis of a major industrial accident occurred in a acrylic acid manufacturing process in Korea. As a result of the study, the preventive measures are suggested as follows. (1) Air or inert gas inflow facilities should be well designed to dilute flammable gases into air or inert gas sufficiently before the blower is restarted in order to prevent the explosion (2) It is needed for the detonation-type flame arresters to be installed on the top of the storage tanks. (3) In case of using the deflagration-type flame arresters, it is necessary to install a rupture disk before the arresters, or blow off the flame outside tanks by connecting the tank top and the incinerator with hood-type pipe. (4) TDR should be installed to be restarted automatically after the momentary power failure.

Assessment of catastrophe risk and potential losses in industry

This paper describes the potential contribution of near-miss management systems to improving company profitability and reducing the frequency and severity of major industrial accidents. The near-miss concept has long been understood in different industries, as examples in this paper illustrate. However, what has been largely missing is the integration of near-miss management into the culture and day to day operations in a manner that underlines the critical connections between near-misses and behavior. Often, near-miss management has played an ex post forensic role in risk management rather than an alerting one, summarizing leading indicators and precursors of hazardous conditions. This paper describes several strands of recent research that aim to correct this and to make near-miss management an organic element of Enterprise Risk Management. In this respect, a new concept, “potential safety profit loss”, is introduced to calculate the potential monetary losses due to unexpected shutdowns and accidents.

국가산업단지의 석유화학 안전관리 방안에 관한 연구

Major industrial accidents such as fires, explosions and toxic releases have occurred in Ulsan, Yeosu petrochemical complex area every year. In this study, we analyzed the causes of the previous major accidents in order to provide reasonable measures for safety regulations and process safety management. Consequently, It is necessary to make constant revisions of safety regulations and to improve process safety management in other to prevent major industrial accidents in the petrochemical complex areas.

POLITICAS PARA MEJORAR LA RESILIENCIA ANTE GRANDES ACCIDENTES

Society’s welfare is very dependent on the effective performance of Critical Infrastructure (CI). Nowadays, CIs constitutes a network of interconnected and interdependent entities what means that a serious event in one CI can originate cascading events in the rest, leading to a serious crisis. A major Industrial accident can be defined as a crisis which unfolds due to an interruption in a CI. Resilience is the intrinsic ability of a system to reduce the failure probability of the system and once the crisis occurs to react to and recover from disturbances at an early stage causing minimal effect and allowing the continuity of operations. For the case of major industrial accidents, we define two system’s resilience levels: the resilience level of the CI (internal resilience) and the resilience level of the society (external resilience). There are several discussions in the literature about the resilience concept, but there is little information about how we can improve it. The purpose of this paper is to provide a set of policies to improve the resilience level. Through the literature review we analyze the resilience concept and propose the most adequate definition for our research. Twelve mitigation policies in order to increase the level of resilience are identified in the workshops with domain experts and finally these policies were eaffirmed by case studies

Insurance of Techno-Organizational Ventures and Procedural Ethics: Lessons from the Deepwater Horizon Explosion

Hazardous operational consequences of unethical behavior in high-risk projects can be traced back to inadequate relationships between businesses and the insurance industry. The communication of blame, as a consequence of major industrial accidents like the explosion of the Deepwater Horizon drilling rig in the Gulf of Mexico in April 2010, and the relevance of this communication of blame for subsequent insurance litigation, show that the awareness of the relationship between unethical behavior resulting in irresponsible procedural action and deficient loss-prevention practices is a significant component of risk consciousness. The awareness of ethical origins of project risks could alter the methods of design and monitoring of insurance contracts for risky techno-organizational ventures.

Modeling the major accident prevention legislation change process within Europe

The factors giving impulse to changing major accident prevention legislation within Europe, the so-called Seveso Directive, have not been thoroughly studied and molded into an understandable model thus far. For example the exact relationship between major industrial accidents and an ever changing legislation is still unexplored. This paper thoroughly investigates the parameters having influenced the change of the 1996 Seveso II Directive into the 2003 Seveso Directive Amendment 2003/105/EC and develops the accompanying legislation change process. The official major accident reports of Baia Mare, Enschede and Toulouse are studied in-depth, as well as many other official EU documents. Furthermore, experts from academia, government and industry who witnessed and/or participated into the legislation change process were interviewed in-depth. More profound insights into the societal debate following a major accident may help private companies to adapt their safety management system and their prevention policies, and may aid the legislator to develop more efficient and effective regulations. This way, the societal demand to change legislation in an ad hoc manner may be unpressurized.

Quantitative risk assessment: How realistic are those frequency assumptions?

Although much has changed in recent decades in how the consequences are treated in risk assessment of major industrial accidents, estimation of frequencies still appears to be largely based on values from several decades ago. This paper reviews briefly some of the implications of this, drawing on lessons not only from the process industries but also from other not so obviously relevant fields such as aerospace and finance, where the significance of such factors such as organizational culture, normalization of deviance, ownership, demographic change, etc. is becoming increasingly recognized in the analysis and hence the control of risk. Failure to consider such factors and their effects can pose a problem, because risk assessment is not simply an abstract concept but can have a real influence on the level of risk. If protective measures such as the safety culture of the site, etc. can be shown to significantly change the risk zone, this can persuade the risk generator to improve those factors or take other steps to reduce the risk such as reducing the inventory in the process. Conversely, assessments conducted for well-run companies may misrepresent the risk if the site ownership changes to a financial holding company with a focus on maximizing short-term profit and resale of the assets, and it can be difficult even for well-motivated management to justify protective measures if they produce no apparent difference in the risk. This paper introduces these and other issues for consideration in the symposium which follows.

Novel therapeutic strategies for acute lung injury induced by lung damaging agents: The potential role of growth factors as treatment options

The increasing threat from terrorism has brought attention to the possible use of toxic industrial compounds (TICs) and other lung-damaging agents as weapons against civilian populations. The way in which these agents could be used favours the development of generic countermeasures. Improved medical countermeasures would increase survivability and improve the quality of recovery of lung damaged casualties. It is evident that there is a dearth of therapeutic regimes available to treat those forms of lung damage that currently require intensive care management. It is quite possible that mass casualties from a terrorist incident or major industrial accident involving the release of large quantities of inhaled TICs would place a severe burden on already scarce intensive care facilities. The development of effective pharmacological approaches to assist the recovery of casualties suffering from acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) may improve the prognosis of such patients (which is currently poor) and would ideally be used as a means of preventing subjects from developing the pulmonary oedema characteristic of ALI/ARDS. Many promising candidate pharmacological treatments have been evaluated for the treatment of ALI/ARDS, but their clinical value is often debatable. Thus, despite improvements in ventilation strategies, pharmacological intervention for ALI/ARDS remains problematical. A new approach is clearly required for the treatment of patients with severely compromised lungs. Whilst the pathology of ALI/ARDS associated with exposure to a variety of agents is complex, numerous experimental studies suggest that generic therapeutic intervention directed at approaches that aim to upregulate repair of the damaged alveolar blood/air barrier of the lung may be of value, particularly with respect to chemical-induced injury. To this end, keratinocyte growth factor (KGF), epithelial growth factor (EGF) and basic fibroblast growth factor (bFGF) are emerging as the most important candidates. Hepatocyte growth factor (HGF) does not have epithelial specificity for lung tissue. However, the enhanced effects of combinations of growth factors, such as the synergistic effect of HGF upon vascular endothelial growth factor (VEGF)-mediated endothelial cell activity, and the combined effect of HGF and KGF in tissue repair should be investigated, particularly as the latter pair of growth factors are frequently implicated in processes associated with the repair of lung damage. Synergistic interactions also occur between trefoil factor family (TFF) peptides and growth factors such as EGF. TFF peptides are most likely to be of value as a short term therapeutic intervention strategy in stimulating epithelial spreading activities which allow damaged mucosal surfaces to be rapidly covered by epithelial cells.

Underlying causes and level of learning from accidents reported to the MARS database

MARS is the system established and maintained by the European Commission in order to collect information related to major industrial accidents in EU Member States in the context of the Seveso II Directive. One of the main purposes of the MARS database is to provide information for learning from the accidents to avoid similar events. Probably, the most important issue for the learning is the determination of the causes, particularly the underlying causes, of the accidents. One objective was to find possible patterns of underlying causes per industry type and per country. Another objective was to determine the occurrence of weaknesses in safety management systems and in safety culture as underlying causes. A further objective was to determine the level of learning from the accidents, as it appears from the reports, per industry type and per country. A sequential method, presented by us in a previous paper in this publication, was used to make it possible to go beyond the causes given in the original reports and to find more underlying causes. To determine the level of learning from the accidents, using the actions/lessons learned given in the reports, a classification method was developed. This method establishes the level of learning of the lessons learned from each case description, essentially from the organisational point of view. This paper presents the results of an analysis regarding underlying causes of all the accidents of the MARS database reported up to mid 2007. The results are expressed per industry type and per country. The main results are that as much as three times as many underlying causes can be found when applying the method developed compared with what is given in the original reports. The most important underlying causes are found in weaknesses in process analysis (risk assessment) and in procedures, regardless of industry type. Weaknesses in safety management systems and in safety culture contribute as underlying causes in a very high percentage of the accidents. The quality of reporting, measured in terms of analysis of underlying causes, vary considerably between various countries. The level of learning, as determined from the information in the reports, is found to be in general rather low, especially from some of the countries. This study has given rise to ideas of improvement of the MARS system. It has also raised many questions, some of which would be suitable for further research.

Time-Frequency Analysis of Explosions in the Ammunition Factory in Novaky, Slovakia

A sequence of explosions occurred in an ammunition factory in Novaky, Slovakia, on 2 March 2007 and caused a major industrial accident. The origin times and number of explosions were key aspects for the state investigation team to explain the primary cause and development of the accident. An analysis of seismic records was the only way to determine reliable origin times. We were able to identify the two strongest explosions directly from the seismic records. Detailed time-frequency analysis enabled us to identify acoustic waves caused by the explosions. This led to the subsequent identification of two weaker explosions in seismic records and an indication of two even weaker explosions that could not be identified in the records. The seismic analysis is supported by results of the onsite investigation by the state investigation team.

Analytical ecological epidemiology: exposure–response relations in spatially stratified time series

AbstractAn important task of environmental research is the investigation of a possible causal relationship between exposure and the frequency of a biologic trait. Major industrial accidents provide examples where the exposure status of large populations may change considerably within relatively short time intervals of days or weeks (e.g. Seveso herbicide plant explosion, Chernobyl Nuclear Power Plant catastrophe). Therefore, purely temporal change‐points may be tested in time series of appropriate public health indicators (e.g. mortality, morbidity, sex ratio at birth). If, in addition, the spatial contamination is strong and variable enough and can be identified with sufficient precision at the level of regional units (e.g. districts), then a spatial‐temporal approach makes sense. This essentially means that a global time trend model is adjusted for region‐specific trend functions, allowing for local or global temporal jumps or broken sticks (change‐points) at certain points in time. The local jump heights may be tested for associations with local exposure (exposure–response relation), and all other characteristics in the data that vary with locality and in time are automatically accounted for, thus minimizing confounding. Spatial‐temporal approaches may help to strengthen the evidence of possible causal relationships. As an example, the human sex ratio at birth in several European countries before and after the Chernobyl Nuclear Power Plant accident was investigated. A long‐term chronic impact of radioactive fallout on the secondary sex ratio has been found. Copyright © 2008 John Wiley & Sons, Ltd.

Risk management: All stakeholders must do their part

There is always an unexplored ethical dimension over and above the list of causes of major industrial accidents, be them human errors, organizational or technical failures. This results in a cascade of bad decisions being taken at the organizational, human and technical levels, which cause tragic accidents, often with loss of human life. However, no one wants these accidents to occur, and there are often very qualified people who work in these organizations. A myriad of legislation was born from these major industrial accidents, each law or regulation more complex than the last, but they do not seem to be sufficient to cure the outbreak of various errors. Perhaps the prescribed treatment is simply inappropriate or the dose is not well administered! To manage risks properly, it will not only be necessary to develop techniques but also to develop processes, at the personnel level as well as at the organizational level, which will take human nature into account. Appropriate mechanisms will also have to be set up to reconcile “public interest” and “risk management”. It will thus be necessary to define, implement and improve a series of processes and most importantly, provide guidance to managers. It is necessary to continue improving the risk analysis methods, to continue training in the field of risk management for numerous stakeholders, to reinforce legislation on risk management and most importantly, to base risk management on ethical principles.