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IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE
STUDY FOR INTEGRATED SAFETY SUPPORT SYSTEM USING NEAR MISS EVENTAND ACCIDENT DATABASE
M. Wakakura1, K. Suzuki2 and N. Takagi3
1Industrial Technology Center of Kanagawa Prefecture, Masahide Wakakura: Industrial Technology Center of Kanagawa Prefecture
705-1 Simoimaizumi Ebina-city, Japan, zip 243-0435; e-mail: [email protected] University3Yokohama Safety Institute
To backup the safety of the oil refinery plant, Japan Society of Safety Engineering (JSSE) and Pet-
roleum Energy Center (PEC) started the development of the integrated system for the process safety
using original database of near miss event and accident supported by the Ministry of Economy,
Trade and Industry Japan. The system which was named PEC-SAFER consists of near-miss & acci-
dent database, safety education database and equipment management database.
Basic architecture of the near miss & accident database system constitute user interface, data
base, search engine and data input interface.
Near miss and accident data involve kind and/or type of the event, detail and outline of the event,
operating and/or work situation, refining process unit and sub-section, related equipment, initiating
or triggering event, direct, indirect and root cause or lesson learned etc.
To integrate the data and provide effective safety measures simply, many items of input data are
coded originally. As one of the characteristic of the system is to estimate direct and indirect causal
factor and specially defined root cause.
KEYWORDS: accident, oil refinery, safety, near-miss, database, cause analysis
INTRODUCTIONRecently accidents at chemical plant are on the rise in Japan.Following reasons are designated. As many refinery or pet-rochemical plant were constructed during 1970’s, possibili-ties of trouble or accident of peripheral equipments isincreasing, because those equipments are too enormous tofind out the potential hazard easily, even main facilities ofthose plants are well do maintenance. Within few yearsmany veteran engineers and operators retire, then operationor maintenance level or sensitivity for safety of operator arefeared to down by and by in Japan.
As every oil companies use similar facilities andequipments, they can easily share near miss data by com-parison with other process industries such as spetroleumchemistry.
To avoid the future unsafe condition of the oil refineryplant, it is necessarily to share knowledge about processsafety or experience of veteran operators. This near missdatabase will contains not only detail potential hazard ofvarious equipment or direct and indirect causal factor butexperience of veteran and knowledge of authority ofprocess and material safety, human factor, risk analysis etc.
SYSTEM STRUCTUREPEC-SAFER is consist of near miss & accident database,safety education material database and equipment manage-ment database as shown in Figure 1. Those databaseexchange information mutually.
Near miss data, safety and technical educationmaterials and information relevant to maintenance are
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provided from all oil refinery companies and sharedtogether. From 2006 Safety Education Material Databasedisclosed as the first achievement of the project. (PEC-SAFER) (http://safer.pecj.or.jp/)
NEAR MISS & ACCIDENT DATABasic architecture of the near miss (Figure 2) and accidentdata system constitute user interface, data base and searchengine, and data input interface. In this study near missevent which is called “HIyari [in great fear] & Hatto [givena start]” in Japan is defined as follows.
“The events which have possibility to cause fire,explosion, runaway reaction or leak of toxic/flammablesubstances caused by impair or deterioration of facilitiesor failure of equipments or system error, at the oil refineryprocess or the peripheral unit. Injury caused by simplehuman error isn’t included”. The contents of the near missdata are shown below. Main data items were coded,because of convenience of search & statistical analysisand well understanding of item.
. Title� (describe the near miss with what event, where didhappen simply)
. Near miss event�(describe initiating and subsequentevent: corded [Table 1])
. Operating condition�(corded [Table 2])
. Date and time
. Climate Condition (weather, temperature, relativehumidity)
. Related plant/system�(corded)
. Related equipment�(corded [Table 3])
List of experience-based training Center
General basic knowledge
Safety Education Materials DB
Corrosion DB
Plant maintenance
Equipment management DB
Near-miss DB
Accident DB
Near-miss & accidentanalysissystem
Near-miss & Accident DB
Specific knowledge regarding plant operation
Figure 1. Safety support system
Developpreventivemeasures
Protective measureswere ineffective
Accident
Initiating (triggering) event
Direct causal factors
Root cause
Effective measures taken
Near-miss event
Subsequent events
Indirect causal factors
Near Miss Data
Accident Data
Figure 2. Architecture of near miss
Table 1. Cord of
Code of near miss event
Mechanical down, depression, breakage of moving equipment
Start-up failure of moving equipment
False or unexpected of start-up of moving
Mechanical down, depression, breakage of static equipment
Erosion, degradation, breakdown of static
Mechanical failure of down, degradation, breakdown of
instrumentation equipment
Mechanical down, degradation, breakdown of electronics device
Unexpected oscillation or error of process
Others
IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE
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. Main fluid (describe when that fluid concerned the nearmiss event closely)
. Material (describe when that material concerned thenear miss event closely)
. When/How was the near miss detected�(corded)
. Direct and indirect causal factor�(corded [Table 4])
. Root Cause (under consideration)
. Recurrence prevention� (expected to be shared themeasures)
. Lessons learned
. Comment from authority of safety engineering(�essential item)
One of the important purpose of the near miss and theaccident analysis is to estimate the root causes using someanalytical method. Root cause is defined as commoncausal factor that is not easy for individual firm to clearthe problem. They are classified as politics, economics,industrial structure, social situation, etc.
near miss event
Example of event
Mechanical down, of pump
Depression of mechanical seal
Blockage of burner False open of adjustment valve
Eternal corrosion
Mechanical failure of DCS
Mechanical failure of switch
Oscillation of tempreature or
Sinking of land
Table 2. Operation
Normal operation
Maintenance
Under suspension
Start up
Shat down
Others
Table 3. Code
Item Code Sub-Item
Static equipment S Tower, Column
Drum, Vessel
Reactor
Heat Exchanger
Valve
Rotating Equipment R
Instrumentation I
Electrical Equipment E
Table 4. Code of the direct & indirect causal factor
Direct casual factor
Main code Detail code
Material Factor Produce or storage of
hazardous material, etc.
Human Factor Human error, etc.
Communication/Information
Lack of evaluation of
material hazard, etc
Design Factor Inadequate process
design, etc
Procurement &
Inspection
Inadequate
inspection, etc.
Construction Inadequate
material, etc.
Maintenance Inadequate
maintenance, etc
External factor Natural disaster, etc.
IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE
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If the root cause can be estimated, it will be goodinformation to discuss the safety culture of process industry.
As usually the near miss and accident data searchedby unit process/section or equipment. In addition to theclassified equipment list, process flow sheets were standar-dized and provided.
Oil refinery plant was classified to 13 unit processes(atmospheric distillation process, vacuum distillationprocess, reforming process, desulfurization process, etc.),and unit process is divided to sections (heating section,
of equipment
Code Equipment Code
S1 Distillation Column, Fractionator, etc. S11
Regeneration Tower S12
Conveter S13
Other Tower S14
S2 Drum, Vessel S21
S3 Reactor S31
S4 Shell & Tube Heat Exchanger S41
Air Fin Cooler S42
Plate Type Heat Exchanger S43
Other Type Heat Exchanger S44
S5 Control valve S51
Shut-off Valve S52
Manual Valve S53
Check Valve S54
Indirect causal factor
Main code Detail code
Organization
factor
Kink of decision making system
Cut down of equipment management
division
Cut down of operation management
division
Cut down of safety division
Laxness of responsibility etc.
Management
factor
Inadequate change management system
Inadequate safety management system
Inadequate safety management system
Inadequate safety education system
Inadequate information management system
Inadequate operation standards of manuals
etc.
Figure 3. Data search from process flow
IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE
distillation section, etc.). User can search from flow sheet ofthe process shown in Figure 3.
UTILIZATIONFollowing utilizations of the near miss data are expected byoil companies.
a. Clear up weak point about safety of own process equip-ment or management etc. compare their near miss datawith total data statistically.
Figure 4. Image of eve
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b. Find out potential hazard of certain unit by the nearmiss data of other company even if trouble did notoccurred at the unit till then.
c. Young operators or managers can learn the knowledgeof veteran (especially know why) from lesson learnedor comment of authority.
d. Verify own preventive measures compare with themeasures of other companies relevant to similar event.
To use the near miss and the accident data moreeffectively, we have been developing acquisition of new
nt-based retrieval (1)
Event: temperature rise of tank
Retrieved information
retrieval code< tank/temperature rise >
Event: temperature rise of tank
retrieval code< tank/temperature rise >
Retrieval code allow to get the information which has same event
Near-Missdatabase
Same retrieval code
Same event !
Accidentdatabase
Event-based retrieval
Figure 5. Image of event-based retrieval (2)
IChemE SYMPOSIUM SERIES NO. 153 # 2007 IChemE
knowledge by event based retrieval. Figure 4 and 5 showsthe image of the event based retrieval system.
Using the retrieval search method following effectsare expected
a. Classification of the near miss data according toimportance for safety measures.
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b. Use the near miss data as the risk management tool.c. Screening and detection of the preventive measures of
the major accident from the near miss data (note thatnear miss is a successful experience)