DUTCH CHEMICALS

Handling Chemicals Safely, 2nd ed., Dutch Assoc, of Safety Experts, Dutch Chemical Industry Assoc., and Dutch Safety Inst., 1980. 

December 13, 1991, a benzoic acid tairk exploded causing six deaths and three injuries at the Dutch chemical firm DSM s chemical complex in Rotterdam Harbor. Shipping traffic was halted for an hour in the world s busiest port while the fire was controlled. 

Association of the Chemical hidustry of Austria (FCIO), 256 Association of the Dutch Chemical hidustry (VNCI), 262 ASTA Medica AG, 160 Astaris LLC, 218... 

He is also a member of the Royal Society of Chemistry, Royal Dutch Chemical Society, Society of Plastic Engineers and The Institute of Materials. 

Stamicarbon [Staatsmijnen carbon] Stamicarbon bv is the licensing subsidiary of the Dutch chemical company DSM. It offers a number of processes, including HPO and HSO. Historically, the process for which the company was best known was a coal carbonization process today, a urea-manufacturing process is probably its most important one. 

To verify the developed concepts underlying the structured 7-stage protocol in a reactive way, they were applied to an analysis of recent accidents in the Dutch chemical process industry. Despite the limitations in the information available from the accident database, it could be deduced that all accidents were preceded by precursors, and even that similar precursors had led to similar accidents, implying that companies had failed to learn from these re-occurring deviations which were in fact pre-warning signs of impeding accidents. 

In Chapter 5 the conceptual approach from the previous Chapter will be tested and evaluated and finally applied to a single case study in the Dutch chemical process industry. This exercise is performed to test the conceptual approach in practice. The findings of the case study will be evaluated and will lead to refinements in the conceptual approach. Finally a structured protocol will be derived and applied to the same case study to ascertain if the structured protocol is effective and suitable for practical use and leads to answering the research questions posed in Chapter 1. 

In Chapter 7 the derived structured protocol will be applied to multiple case studies in the Dutch chemical process industry. Three case studies will be conducted to derive the answers on the posed research questions and to confirm or reject the results from the case histories in the previous Chapter. The case studies will be carefully selected so that the outcomes of the analysis are predictable for all three cases. This replication strengthens the generalization and overall validation of all case studies and the research in general. 

In this Chapter further evidence is provided that precursors exist long before they escalate into an accident. It will be demonstrated that the existence of precursor information could have been used to foresee and even prevent recent accidents with hazardous substances. Moreover, a set of precursors retrieved from 17 recent accidents in the Dutch chemical process industry is used to validate the 7-stage protocol developed in the previous Chapter. In spite of the limited accident information it is shown that if a proper control action had been initiated, all of these 17 accidents could have been prevented. 

Are accidents always unforeseeable , Proceedings of the annual Loss Prevention Symposium AIChE, New Orleans, pp. 483-492. The remainder of this Chapter is based on a paper by Sonnemans P.J.M., Korvers P.M.W., Brombacher A.C., Beek van P.C., Reinders J.E.A., 2003. Accidents, often the result of an uncontrolled business process — a study in the (Dutch) chemical industry, Quality Reliability Engineering International 19(3), pp. 183-196. 

The results from the study into identical accidents show that precursors often do exist prior to accidents. The existence of precursors prior to accidents creates the opportunity to derive indicators for accidents. To actually obtain a better understanding of how and why accidents can occur in spite of the presence of precursors prior to accidents, in the next Section 17 recent accidents from the Dutch chemical process industry will be analysed using the 7-stage protocol. 

That precursors are frequently observed in accident trajectories was stated in the previous Section. In this Section 17 recent accidents in the Dutch chemical process industry are taken and their accompanying precursors and ineffective control processes in the companies identified. This study is executed from hindsight using limited accident information which is the reason for adapting the analysis protocol so that the results of most stages can still be retrieved. 

The next Chapter will apply the 7-stage protocol pro-actively in three different case studies in the Dutch chemical process industry, identifying why hazardous situations still exist in the companies in spite of the enormous number of safety measures present. 

The protocol developed in Chapter 5, which was applied on accidents as shown in Chapter 6, is applied on three cases in the Dutch chemical process industry. First, the cases are selected according the criteria stated in Chapter 5. Secondly, the developed protocol of analysis is applied on these selected cases, to identify why and how it is still possible that accidents may occur despite precursors and several existing safety barriers. Thirdly, the results from the analysis are further elaborated on, indicating the problems in current safety management systems, allowing accidents to occur. 

The selection criteria for the case studies are taken from Chapter 5, i.e. presence of hazardous substances, batch industry, large company, located in The Netherlands. The selection criteria narrowed the search for suitable cases down to large Dutch companies in the batch industry falling under the Dutch Seveso-II directive (BRZO, 1999). To increase the generalizability to Dutch chemical companies in the batch industry, from the around 80 selected companies falling under the previous selection criteria, different companies and different product types were selected. 

Apart from this thesis, the PhD work resulted in a number of papers that have been presented at international conferences and published in various international journals. The research was performed in co-operation with various companies in the Dutch chemical industry and the department of industrial safety at TNO. While TNO will continue with the results of this research, Patrick starts working for SABIC Euro Petrochemicals B.V., from the 1st of March onwards. 

The project Human Error in the Process Industry within the Ergonomics Section of the Technology Work Department at the Graduate School of Industrial Engineering and Management Science was started in 1985. In order to get acquainted with the world of chemical process control two exploratory investigations were carried out in the first two years at Dutch chemical companies. This led to the development of a prototype classification model of system failure (see Chapter 5 for the most recent version). 

Ail of the insights and suggestions mentioned in this dissertation are primarily based on two major sources an international workshop on near miss reporting, held in Eindhoven in 1989, and a three-year contract research project (1988-1991) to design and implement an actual near miss management system for a chemical plant in Rotterdam, Furthermore, the thesis describes a first step towards validation through a series of discussions with safety managers in the Dutch (chemical process) industry. 

The near miss presented here is loosely based on an actual near miss in the Dutch chemical process industry, but it has been both simplified and somewhat extended to serve as an useful example for an audience not familiar with that specific process. 

The Netherlands Highly developed national chemicals strategy - Dutch chemicals strategy available in English - Dutch strategy considered when devising the Systems Framework (Chapter 6)... 

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