Industry, accident analysis

Kartam, N. A., Bouz, R. G. (1998). Fatalities and injuries in the Kuwaiti construction industry. Accident Analysis and Prevention, 30, 805-814. 

Mohr, D.L. and D. Clemmer. 1989. Evaluation of an occupational injury intervention in the petroleum industry. Accident Analysis and Prevention 21 (3) 263—271. 

State intervention in man s activities to protect the health of the inhabitants goes back to prehistory. The motivation may not have been altogether altruistic the king acted to protect his subjects because he regarded them as his property. Public health protection began for disease control. With industrialization, came the need for control of even more hazardous forces and substances. This extended protection became technological in accident analysis and response. Present efforts in controlling risk, such as from nuclear power, are a continuation of this development. 

Leplat,]., Rasmussen, J. (1984). Analysis of Human Errors in Industrial Incidents and Accidents for Improvements of Work Safety. Accident Analysis and Prevention 16(2), 77-88. 

Keywords reliability / safety management / accident analysis / operational control processes / chemical industry... 

Yonemitsu K, Tsunenari S, Kanda M. 1983. [An industrial accident due to Freon 113 poisoning. Toxicological analysis of the cause of death.] Nippon-Hoigaku-Zasshi 37 428. (Japanese)... 

The analysis of industrial accidents provides an indication of the damage potential in an RPT, but, in many instances, data are fragmentary and definitive conclusions are difficult to draw. Whenever possible, the RPT criteria, developed from laboratory tests, are compared to conditions existing in industrial accidents. 

Concern over dioxins originally arose over one particular dioxin, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). This was found to produce clinical effects (chloracne) in workers exposed to it through industrial accidents.35 It is also toxic to some species of laboratory animals. A few PCBs have been shown in experimental systems to exert a number of toxic responses similar to those observed for TCDD. In consequence, the total concentrations of both dioxins and PCBs in environmental media, including food, are now commonly determined as part of the same chemical analysis, and each cannot be discussed now without reference to the other. 

Individuals exposed through industrial accidents or environmental contamination. Very extensive residential contamination by 2,3,7,8-TCDD occurred in Seveso, Italy, when a 2,4,5-TCP reactor exploded in 1976 (Mocarelli et al. 1991). The contaminated area was divided into three zones based on the concentration of 2,3,7,8-TCDD in the soil. Families in zone A, the most heavily contaminated area based on soil 2,3,7,8-TCDD levels, were evacuated within 20 days of the explosion and measures were taken to minimize exposure of residents in nearby zones. A recent analysis of 19 blood samples from residents of zone A, which were collected and stored shortly after the accident, showed serum lipid levels of 2,3,7,8-TCDD that ranged from 828 to 56,000 ppt. These serum lipid levels are among the highest ever reported for humans (Mocarelli et al. 1991). 

Svenson, 0. (1991), The Accident Evolution and Barrier function (AEB) model applied to incident analysis in the processing industries. Risk Analysis, J/, 499-507. 

Organization for Economic Coordination and Development (OECD), Guidance on Safety Performance Indicators related to Chemical Accident Prevention, Preparedness and Response for Industry, 2nd Edition, OECD Environment, Health and Safety Publications, Series on Chemical Accidents No. 19, Paris, 2008 Phimister, J. et al., Near-Miss Incident Management in the Chemical Process Industry, Risk Analysis, Vol. 23, No. 3,2003... 

Improve the accident investigation philosophy The philosophy and aim orientation of the accident investigation shall focus on improvement of safety and avoidance of accidents, analysis of the radical causes of the accidents, and learning of experiences and lessons. These measures serve as the important grounds for relevant department, industry and enterprise to formulate standards. Their implementation is supervised and tracked, so as to avoid reoccurrence of similar accidents. 

In some cases, general requirements and policies for an industry are established by the government or by professional associations. These can be used during an accident analysis to assist in comparing the actual safety control structure (both in the plant and in the community) at the time of the accidents with the standards or best practices of the industry and country. Accident analyses can in this way be made less arbitrary and more guidance provided to the analysts as to what should be considered to be inadequate controls. 

The analysis of past accidents may provide lessons learned to avoid the recurrence of accidents and to improve emergency response in future accidents. In order to obtain data about the vulnerability of the equipment items and to get a possible correlation between the lightning severity and the possible damage states, the historical analysis of past accidents was used as a starting point. In fact, the review of records on industrial accidents triggered by lightning events may allow the identification of ... 

It has a sound theoretical basis, being derived from a proven accident analysis tool. Reason s Swiss Cheese Model is now a familiar concept in numerous industries, which enables this derivative process to be readily explained to users. 

The results from synthesis and structure proof studies demonstrate that the product resulting from a TATP synthesis may be a complex mixture. Furthermore, the products are rich in peroxide functionality and make them relatively unstable, and therefore, unsafe. The thermal-induced decomposition of TATP has been studied and is reported to produce primarily acetone, carbon dioxide, and ozone as decomposition products [22-25], TATP from syntheses catalyzed with sulfuric acid, methanesulfonic acid, and perchloric acid was reported to spontaneously decompose over time to yield DADP, even at low temperatures (i.e., 0°C) [26]. While it may be sufficient in many cases to simply identify the presence of TATP, forensic examination may profit from a more complete analysis of the product mixture that comprises unpurified synthetic TATP. Unpurified TATP may be encountered in terrorism investigations, industrial accidents, and other events that involve the possible formation of organic peroxides from acetone and related ketones. 

A recent application involved a quick phenol analysis from an industrial accident at a pulp and paper mill near Temiscaming, Quebec. Ottawa river samples were collected and analyzed on-site by quick test kits (Hach DR2000, method 470). Additional water samples were brought back and confirmational analyses were performed by SPME, using a polar acrylate fiber and GC/MSD. The water samples were modified with salt addition and PH adjustment. A target list of 18 phenol compounds can be detected at 10 ppb level. None of the water samples had any deteetable amounts of phenol as found by the quick screening tests. There were, however, traces of trichlorophenol (1 ppb or less) and pentachlorophenol (30 ppb or less), both well below the Quebec provincial criteria of 3 ppm (Lambert, 1999). 

This analysis is broadly applicable to industrial accidents as well. There are both latent (system) factors and active (individual) factors which can be identified in most if not all accidents. It is thus quite misleading to suggest that a certain proportion of accidents can be attributed to unsafe acts by workers and another proportion to unsafe conditions or systems in which the work is carried out. 

This is a systematic approach to accident analysis and is particularly good for trying to determine where hazards exist in technologically complex operations. The space industry would be well suited to this type of analysis as there are maity millions of operations which must come together to produce a successful mission launch. 

Xadnto, C., Canoa, M. Guedes, C. 2009. Workplace and organizational factors in accident analysis within the Food Industry. Safety Science 47(5), 626-635. 

The systems approach seeks to identify situations or factors likely to contribute to human error. James Reason s analysis of industrial accidents revealed that catastrophic safety failures almost never result from isolated errors conunitted by individuals. Most incidents result from smaller and multiple errors in components and environments with underlying system flaws. Reason s Swiss Cheese Model describes this phenomenon. Errors made by individuals can result in disastrous consequences due to flawed systans that are represented by the holes in the cheese. Reason believed human error would happen in complex systems. Striving for perfection or punishing individuals who make errors does not appreciably improve safety. A systems approach stresses efforts to catch or anticipate human errors before they occur. Reason used the terms active errors and latent errors to distinguish individual errors from system errors. Active errors almost always involve frontline personnel. They occur at the point of contact between a human and some element of a larger system. Latent errors occur due to failures of the organization or designs that allow inevitable active errors to cause harm. The terms sharp end and blunt end correspond to active error and latent error. The systems approach provides a framework for analysis of errors and efforts to improve safety. 

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