Recent accidents

Locate newspaper mid/or news magazine articles in the library New York Times, Newsweek, Time, etc.) about a recent accident lliat involved evacuation of populations due to risk to llicir heallli and/or safety. From lliese sources, write a brief essay describing what liappcned, where tlie incident took place, the nmnber of people killed and/or injured, the iiiunediate impact in the community, etc. 

To obtain an answer to the research questions posed, pro-active safety indicators used in today s chemical process industry were analysed and the deviations upon which they are based were compared with deviations present in the accident trajectories of 70 recent accidents. By comparing these two sets of deviations, it was observed that although re-occurring deviations with no direct perceived safety related consequences were present in the majority of accident trajectories they were nevertheless not addressed by the commonly used pro-active safety indicators. These so-called indirect perceived safety related deviations may therefore be more important indications of a possible accident than was thought previously. 

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. 

Chapter 1 provided a general research area, where the problem of measuring safety pro-actively was identified in literature and in practice. This was done by sketching a recent accident and discussing how safety was measured in the past and currently. Moreover, it highlighted that the pro-active measurement of safety is still a problem in the chemical process industry. The development of substantially more understanding of how to pro-actively indicate accidents in the chemical process industry, was finally derived as the scope of this study and will be discussed in the remaining Chapters of this thesis. 

To analyse the problem posed in Chapter 1 an overview of current literature on tools, methods, and standards concerning safety indicators will be presented in Chapter 3. With this overview a better understanding of the signs currently used to indicate safety will be obtained. These signs will be compared with the signs present prior to recent accidents (1995-2002). From both literature and case histories a hypothesis will be derived that will be especially tested in Chapter 6. Moreover, in Chapter 4, the conclusions will be used to develop some generic concepts and a conceptual practical approach. The approach will consist of several steps and models derived from organizational science and safety literature. 

From Chapter 1 it appeared that all the existing safety management systems and tools cannot prevent accidents with hazardous substances in the chemical process industry. In this Chapter, the most commonly used safety indicators will be analysed to derive the set of deviations used for indicating. These deviations are then compared with deviations present in an accident trajectory prior to recent accidents. The differences between the two sets of deviations are then discussed to indicate why accidents still occur. These differences show shortcomings in current safety indicators and are used to set the criteria for a new safety indicator. 

The definition of risk from Chapter 1 is used to set up an analysis tool to find a possible link between Sis and recent accidents. The following sub-Section will therefore introduce this analysis tool before analysing current safety indicators and accidents. 

In the next Section the risk coverage area of events present in recent accident trajectories will be identified. 

In this Section the risk coverage area of events preceding recent accidents is determined. To construct this risk coverage area a number of recent accidents (1995-2002) are discussed. The events present in recent accident trajectories are identified and their risk coverage area is determined. 

When identifying the events present in recent accident trajectories, conditions regarding the availability of information must be considered. In this case, as with... 

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. 

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. 

Hughes, W.F. Importance of mustard burns of the eye as judged by WW I statistics and recent accidents. IN National Research Council, Division of Medical Sciences, Committee on Treatment of Gas Casualties. Fasciculus on Chemical Warfare Medicine, Volume I Eye. Prepared for the Committee on Medical Research of the Office of Scientific Research and Development. 

Erythritol tetranitrate (ETN) (Figure 1) is an explosive first prepared in 1849 [1] with similar properties to pentaerythritol tetranitrate (PETN). ETN is melt-castable, has impressive performance, and is not difficult to prepare, which increases the necessity for understanding its properties from a homemade explosive threat determination perspective [2]. Due to its handling sensitivity, ETN has been involved in recent accidents [3] and should not be handled outside of a dedicated explosives facility. We have recently reported the first X-ray crystal structure of ETN [4], and discussed the influence of crystal packing on the sensitivity of the material, relative to PETN [5]. Another recent publication also discusses basic characterization of ETN [6]. 

The most recent accident occurred at Dugway Proving grounds in July 2013 a detonation occurred while a chemist was grinding the material. 

Mixtures of Black Powder with titanium, used to produce fountains with white sparks, have not been considered to be particularly dangerous. However, two recent accidents (one fatal) while loading gerbs have caused these mixes to be examined closer. 

R.K. Wharton, Areas for Future Safety Research Identified by Recent Accidents in the Pyrotechnic Industry , Proceedings of the /(S International Pyrotechnics Society, JbnkOping, Sweden, 1991. 

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