The use of the Pareto shape parameter as a leading indicator of process safety performance

Metrics addressing process safety incident performance typically focus on frequency and severity statistics. Often, these lagging metrics are not overly sensitive to actual performance, making trending and forecasting difficult. This article presents the results from a statistical study of a large incident dataset where changes in the Pareto shape parameter were observed as a function of time. This approach has been found to give far better insight into process safety performance than traditional incident metrics and readily relates back to concepts such as the “incident triangle” and “layers of protection.” Through the application of this approach, trends within process safety incident performance have been observed earlier, and more accurate forecasting has allowed for the identification of anomalies. In turn, these critical observations have allowed for the better structuring and targeting of process safety programs. Although incident data are generally considered as a lagging indicator, this approach has clearly reduced the lag time associated with this type of data and has given valuable insight into the current status of process safety performance. © 2009 American Institute of Chemical Engineers Process Saf Prog 2009     

Consequences of solvent ignition during a drum filling operation

This paper describes an incident in a pilot plant designed to make specialty chemical products based on oxime chemistry. The requirements of the process include handling fairly large amounts of flammable liquids. With this in mind the plant was built within an existing building and was provided with a properly designed sprinkler system, an adequate drainage system, ventilation system, and electrical equipment appropriate to the occupancy.     

第七届中国玩具展（7th CHINA TOY EXPO）：玩具产区优势明显 中国制造齐展风采——中国玩具行业大会同期在上海举行

金秋十月,对于玩具行业来说是一个举足轻重的月份。虽然去年玩具重大召回事件的影响已渐渐远去,国内玩具企业在抓质量重品牌上的策略越来越清晰明了,但受全球经济形势不景气的影响,我国玩具行业目前遇到的挑战仍然巨大。已经成功举办了六届的中国国际玩具、模型及婴儿用品展览会（以下简称中国玩具展）依托强大的组织机构和其在世界专业玩具展览会中的重要地位，已经成为亚洲地区仅次于香港玩具展的第二大玩具展览会。在世界经济不景气及玩具行业面临巨大挑战的情况下，第七届中国玩具展于10月9日-11日在上海新国际博览中心顺利举行，为世界玩具行业同仁提供了在打好最后一季营销战的巨大平台。     

中国食品大企业的可持续发展研究

食品行业是我国国民经济发展的支柱产业,对国民经济运行和市场经济发展都有非常重要的影响。加快食品工业的发展,确保食品安全,是国家可持续发展战略的重要选择。2008年以“三鹿奶粉事件”为导火索,食品行业出现了很多问题,对食品企业的可持续发展产生了不良影响。作为食品企业该如何做到可持续发展,本文在阐述我国食品大企业发展现状的基础上分析了食品行业面临的问题,对此从企业、政府、社会三个层面提出了相应的解决对策和建议。     

The importance of reliable inertisation and grounding of ignition sensitive powder handling systems

A fire occurred in a powder handling facility handling highly ignition sensitive organic powders used as antioxidants for the plastics industry. Fortunately little damage was done and no one was injured. The incident was investigated and the facts examined with conclusions made as to the possible causes. The incident may have been prevented had production management set in place a set of regular controls, carried out by the process operators themselves, to ensure integrity of equipment designed to ensure the safety of the system. This article describes the basics of such a Safety Maintenance and Control (SAMACO) system. © 2009 American Institute of Chemical Engineers Process Saf Prog, 2009     

Loss prevention features perform in fired heater loss incident

An incident at a small manufacturing site is described. Minimum impact resulted because of proper maintenance and the loss prevention features.     

Sleeping giants? Fired workbloggers and labour organisation

This paper argues that the Waterstone's fired blogger incident performed a labour organising function in terms of garnering pro‐labour media attention and encouraging critical discourse. Looking at the blog's distinctive features and evolution, it evaluates the strengths, limitations and potential for recurrence of similar high‐profile incidents.     

Brittle fracture of a high pressure heat exchanger

The lesson from the E-440 incident is that we must establish minimum pressurizing temperatures for all heavy-wall equipment, not just reactors. We must also exercise care in the design of new equipment and modifications plus repairs to existing equipment.     

Learning value from a blown fuse

The following loss incident is one that would not typically be recognized before it occurs. When investigating safety and loss prevention incidents, failure to execute operating procedures is most often the cause of the problem.     

Preventing fires with high temperature vaporizers

In 1986 one of Du Pont's plants experienced a damaging fire in and around a vaporizer containing a high-temperature heat transfer medium (HTHTM). There were no injuries, but there was considerable property damage and lost production. A review of HTHTM history showed other plants and companies had experienced both damaging fires and incidents of severe damage to the vaporizer with no accompanying fire. This suggested a study in more depth than usually associated with one specific incident.     

Procedures for preventing pilot plant runaways

During the nitration of a substituted benzoic acid, a runaway reaction occurred. The reaction had been run without incident many times in the laboratory and once in the pilot plant on a 50 gallon scale. As a result of the runaway, the procedures for running reactions in the pilot plant were thoroughly reviewed. The review resulted in eliminating some practices, reemphasizing some existing procedures, establishing a new review system, and formalizing a standard operating procedure for all reactions to be run in the pilot plant.     

Carbon disulfide incidents during viscose rayon processing

Two incidents occurred in a viscose rayon manufacturing process about a month apart during the same step of a semi-monthly cleaning operation in a carbon disulfide recovery box. The operation removes sulfides that accumulate on equipment surfaces during the week. In both incidents, carbon disulfide was released from the recovery box into the vapor exhaust system and the area surounding the recovery box. Ignition occurred and the resulting vapor flash propagated throughout the vapor exhaust system and the operating bay. Both incidents caused extensive equipment and building damage and minor injuries to personnel. Investigation and recommendations after the first incident, although appropriate, did not eliminate the root cause of the problem. Additional information obtained during the investigation of the second incident showed that a combination of several modifications and subtle changes in that particular process line, in conjunction with the colder temperatures of fall and winter, resulted in the incidents. The changing of the critical balance of temperature, pressure in the closed system, and sudden volatilization of accumulated carbon disulfide in an unlikely location were triggered by startup of the cleaning operation. Once the carbon disulfide vapor pressure vented from the closed system numerous ignition sources were available. The discussion will focus on the importance of management of change for seemingly small, logical changes, and on the importance of attention to small details in an accident investigation.     

Case history of a deflagration involving an organic solvent/oxygen system below its flash point

A deflagration occurred in a pilot scale vessel containing an oxygen atmosphere and an organic solvent well below the flash point. This was unexpected since the experiment had been carried out on a smaller scale over 50 times. Further investigation of the incident showed that the loading of the vessel and agitation system produced a flammable mist which was capable of explosion at temperatures below the flash point. Simulation studies of the mist conditions in a controlled flammability system were also conducted. Ignition sources were also investigated and at least two were shown to be feasible.     

事故致因理论的煤矿安全管理研究

完善煤矿生产安全管理工作,提高预警和事后搜救效率,确保矿工生命安全,是煤炭工业发展的重中之重.为了有效控制和预防煤矿事故的发生,改善内蒙古自治区煤矿安全生产状况,保证煤矿职工的生命安全,本文认为,我们有必要对煤矿事故的发生机理进行系统性研究,探讨充实适合内蒙古自治区煤炭工业发展的事故致因理论.     

Safety in multistream ammonia plants utilizing common utility services

A multistream plant has a definite advantage of achieving an overall lesser downtime as compared to a single-stream plant based on Partial Oxidation because the outage of individual stream does not necessarily put the plant out of operation. But the safety considerations in the design, operation and maintenance of a multistream plant should be all the more elaborate and well defined. Usually the multistreams have common utility sources and a number of interconnections provided for the side streams. The present paper is a case study of an incident that occurred in the Ammonia Plant when the maintenance work was in progress in one stream and the other two were under operation.     

Representational predicaments at work: How they are experienced and why they may happen

Representational predicaments reflect unfavorable perceptual or attributional incongruence between subordinates and superiors about the employees’ work, and adversely affect morale. Critical incident interviews were held with 63 Hong Kong Chinese employees from over 50 organizations. Stories about undervaluation of contextual performance were compared with stories about duly appreciated contextual performance, and stories about negative spotlighting (disproportionate emphasis on shortcomings or mistakes) were compared with stories about fair treatment of mistakes. Subordinates attributed undervaluation of contextual performance to: the superior’s unfamiliarity with the employee’s work, the superior’s perception that the work was of marginal importance, the subordinate’s lack of empowerment to report contextual performance, the lack of considerate attention by the superior, and the subordinate’s felt need to keep a low profile. Underlying factors were inhibitions against employee voice, leadership styles characterized by lack of benevolence and lack of individualized consideration, and absence of close subordinate-superior relationships. Subordinates attributed negative spotlighting to: the superior’s abusive behavior, prejudicial and hostile attitudes, or insistence on one “right way”; rivalry between the superior and the subordinate; and the absence of legitimate channels for upward feedback. Underlying factors were absence of just grievance procedures, and leadership styles characterized by authoritarianism, which could be compounded by lack of benevolence and lack of moral restraint, leading to abusive supervision. Cross-cultural research could establish whether large power distance and other cultural and institutional factors render Asian employees especially vulnerable to representational predicaments.     

Safety of exothermic reactions a UK strategy

The paper deals with research projects initiated by HSE to resolve certain technical issues which arose out of a study of incident histories. In addition guidance is discussed which is being published by HSE, or to which HSE is contributing. This will help industry to meet their obligations under the Health and Safety at Work etc. Act 1974 with respect to the safety of exothermic reactions having the potential for thermal-runaway. Finally the question of to vent or not to vent' is considered.     

Continuing studies of hazardous material vapor mitigation using aqueous foams

Earlier work [1, 2, 3] has shown that aqueous foams can be used successfully to suppress vapors and/or fumes and mitigate reactivity of many hazardous materials. Chubb National Foam, in concert with numerous major chemical manufacturers and users, is committed to a continuing hazardous materials control program which provides experimental data from actual field tests. Studies of this nature produce valuable information on techniques used to apply special foams, types of equipment required and the courses of action to avoid in a hazardous material incident. The tests covered in this report were conducted at the Department of Energy Nevada Test Site, Mercury, NV.     

Building a high-integrity ammonia storage tank—1988

In late 1984, initial work began on preparing a project to install atmospheric ammonia storage at DuPont's Victoria, Texas plant. This storage was to supplement the existing ammonia spheres. In the aftermath of Bhopal and, in light of DuPont's response to that incident, the project focus was changed to one of replacing all pressurized ammonia storage and rail car unloading at the site and installing atmospheric ammonia storage of the highest possible integrity. This paper discusses the various phases of the project and the high-integrity design of the storage facilities.     

Flashback from waste gas incinerator into air supply piping

A waste gas incinerator experienced a flashback with a pressure wave in the Suction Vent Gas (SVG) system. Extensive damage resulted to the SVG flame arrestor, SVG fan, SVG valves, and incinerator piping. There were no injuries. The primary cause of the incident is believed to have been a fuel rich SVG stream that was rapidly introduced into the incinerator creating a “puff.” This “puff” allowed flame from the natural gas ring burner to blow back into the windbox igniting the fuel rich SVG. The combustion of gas in the ducting then created a pressure wave that blew apart the flame arrestor and caused the remainder of the damage.