A perspective on Seveso accident based on cause-consequences analysis by three different methods

Fabiano, Bruno; Vianello, Chiara; Reverberi, Andrea P.; Lunghi, Erika; Maschio, Giuseppe

doi:10.1016/j.jlp.2017.01.021

Cited by 38 publications

(9 citation statements)

References 35 publications

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“… Shrivastava (1987) , Chapter 3 Seveso 1976 Low safety culture; bad design; serious management errors; not learning from previous incidents with serious consequences elsewhere; ignoring concerns from unexplained accidents in the sector. Fabiano et al, 2017 Three Mile Island 1979 Due to insufficient training operators had wrong mental image of process; shift supervisor ignored/wrongly interpreted signals providing warning; superintendent technical support appeared not familiar with this reactor. Rogovin & Frampton (1980) Chernobyl 1986 Bad safety culture; in principle unstable design; insufficient insight in reactor complexities; procedures not followed; ad hoc change of plans; late response top management, at first trying to downplay consequences.…”

Section: Organizational Culture and Structurementioning

confidence: 99%

Early warning signals noticed, but management doesn't act adequately or not at all: a brief analysis and direction of possible improvement

Pasman

2021

Journal of Loss Prevention in the Process Industries

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History has taught us that quite disastrous events with much human loss, injuries and asset damage could have been prevented or at least mitigated, if top management had recognized early warning signals in some form as urgent and had decided to take timely preventative measures. It turns out to be a rather common phenomenon in various sectors of life and some process industry examples are presented. The problem is further analyzed from a leadership point of view, from organizational structure and culture aspect, and what modern technology developments can help to improve the situation. Research in the latter directions is encouraged.

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Section: Organizational Culture and Structurementioning

confidence: 99%

Early warning signals noticed, but management doesn't act adequately or not at all: a brief analysis and direction of possible improvement

Pasman

2021

Journal of Loss Prevention in the Process Industries

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“…A generic control process consists of multiple control levels and the system integrity depends on ensuring the interactions between components do not lead to loss or hazard [36]. In STPA framework, this process is modeled with a hierarchical control structure, as shown in Fig.…”

Section: B) Develop Control Structurementioning

confidence: 99%

Operational Vulnerability Identification Procedure for Nuclear Facilities Using STAMP/STPA

et al. 2020

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The nuclear facilities are operated to give safety the utmost priority and all possible scenarios that may lead to hazardous states must be evaluated. To date, the probabilistic safety assessment has been used as one of the standard tools for the safety evaluation; however, concerns have been raised about its capability to treat the complex interaction between human operators, digital systems, and diverse plant processes. This paper proposes an operational vulnerability identification procedure based on STAMP/STPA (System Theoretic Accident Model and Process/Systems-Theoretic Process Analysis) which allows us to derive unsafe control action (UCA) leading to the unwanted consequence of a system, such as a spurious reactor trip. The effectiveness of the proposed procedure is demonstrated with the case study of a cold neutron source system installed in High-Flux Advanced Neutron Application Reactor (HANARO). In result, 127 UCAs were derived for 51 control actions regarding spurious trip scenario. The UCAs were reviewed by the HANARO operators and found new scenarios that requires further investigation for reducing the possibility of a spurious trip. The proposed procedure is expected to provide a holistic viewpoint for operational vulnerability identification and further used to suggest recommendations for the safety enhancement of nuclear facilities.

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“…At present, accident investigation in China abides by the principle of “four musts”: causes must be found out, responsible person(s) must be dealt with, responsible person(s) and by‐passers must be well educated, and corrective measures must be implemented. However, in investigating the accident, the accident model selected for cause analysis will affect the perspective of the investigators in attending the accident , and will affect the subsequent affixing responsibility and effective proposing corrective suggestions. According to domestic and overseas data, present cause analysis models can be mainly classified into: causal‐sequence model, process model, energy model, logical tree model, and SHE‐Management model .…”

Section: Background Of the Studymentioning

confidence: 99%

A new insight into the accident investigation: A case study of Tianjin Port fire and explosion in China

Zhou

Fan

2017

Process Safety Progress

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By figuring out the cause and learning the lessons, accident investigation serves to avoid the like accidents effectively. Incident Management is one of the twelve key factors among China's process safety management system (PSMS), while accident investigation is central to Incident Management. This paper selected “Tianjin Port 8.12 fire and explosion accident” (“Tianjin 8.12 Accident”) as an investigation case. Three core components: cause analysis, affixing the responsibility and corrective suggestions, were unfolded. Problems were analyzed from process safety and accident development point of view. A process analysis approach, which is based on event sequence‐barrier failed, was employed for accident investigation. Affixing responsibility process based on failed analysis was used for accident investigating and affixing. In order to give corrective suggestions, safety information‐based corrective suggestions are proposed by starting from systematic and interconnected perspective and combining with finding failed behaviors and an in‐depth analysis of the causes behind the behaviors. Subsequently, an integral accident investigation approach, which consists of cause analysis based on event sequence‐barrier failed, affixing responsibility process based on failed analysis and systematic corrective measures based on safety information, can effectively render scientific theoretical guidance to investigation and analysis of an accident. © 2017 American Institute of Chemical Engineers Process Saf Prog 36: 362–367, 2017

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A perspective on Seveso accident based on cause-consequences analysis by three different methods

Cited by 38 publications

References 35 publications

Early warning signals noticed, but management doesn't act adequately or not at all: a brief analysis and direction of possible improvement

Early warning signals noticed, but management doesn't act adequately or not at all: a brief analysis and direction of possible improvement

Operational Vulnerability Identification Procedure for Nuclear Facilities Using STAMP/STPA

A new insight into the accident investigation: A case study of Tianjin Port fire and explosion in China

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