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: waka@kanagawa-iri.go.jp2Okayama 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)