A Methodology for Learning Lessons in the Chemical Industry

Industrial chemical accidents can have a major impact on society not only because of the immediate harm they can cause to man and property (Toulouse , Enschede ), but also because of their potential adverse long-term effects on the environment (Baia Mare ). This has clearly been recognised through the development of legislation such as the "Seveso II Directive" and its amendment, and by work carried out by international organizations such as the European Commission (EC) and the Organisation for Economic Co-operation and Development (OECD). Approaches to tackling this problem have been put forward such as appropriate land-use planning, risk assessment (safety reports), emergency planning etc. However, it is also acknowledged that learning from history is very important in order to avoid making the same mistakes, and many accidents that materialise now have occurred previously possibly with less severe consequences, possibly in another country or another industry. It has been clearly stipulated within the Seveso Directives that the operators, competent authorities, and the European Commission all have obligations to investigate, collect and report information concerning ¿major accidents¿ and share and implement lessons learned. A thorough examination of the causes, circumstances, evolution, consequences and responses to these past accidents generates valuable lessons that can contribute towards future accident prevention and/or mitigation. Before an examination can take place however it is necessary to collect and organise accident information into a suitable format for analysis. The Joint Research Centre of the European Commission supports this goal by ensuring that the information available throughout Europe (and from the OECD) on the occurrence of technological accidents is systematically collected. More specifically, it maintains the Major Accident Reporting System (MARS), which manages information on ¿major accidents¿ in the chemical industry in accordance with the provisions of the European Seveso directives. This chapter outlines a methodology for learning lessons and introduces the European Community¿s MARS database to demonstrate the methodology in practice. One of the reasons why accidents keep occurring is that the lessons from past events have either not been learned or communicated in a systematic way, or they have not been translated into existing risk-management practices. Therefore it is important that the lessons learned are incorporated into all phases of safety management systems. The importance of Safety Management Systems has long-since been recognized , but the author would like to emphasis in particular the role of chemical process design in learning and preventing accidents.JRC.G.7-Traceability and vulnerability assessmen

Guidelines on Post-Accident Investigation/Evaluation

During the work performed within the SafeT project a clear lack of validated information on tunnel accidents was identified. Consequently, with insufficient data to provide the information necessary to detect trends or point towards possible prevention and mitigation measures, the lessons to be learned - in particular with respect to the identification of accident root causes - are very limited. This finding fed into the development of recommendations for the collection of data on tunnel accidents for use by authorities, tunnel operators or owners. By its very nature the template development also guided the formulation of recommendations for the investigation of accidents as the accident-investigation report should be the primary source for data collection via the template and should drive the template's regular updating. Article 15 on Reporting of the EU Directive, to which the results of Work Package 4 are most pertinent, is very specific in contents without, however, spelling out how the objectives of the Article should be achieved. Therefore, based on the findings of Work Package 4 guidelines have been developed to support the effective implementation of Article 15 by providing guidance to the actors responsible for reporting or sharing information under the EU Directive.JRC.G.7-Traceability and vulnerability assessmen

Learning lessons from tunnel accidents - Recommendations in support of the implementation of Article 15 on Reporting of the EU Directive 2004/54/EC

Tunnels in the trans-European road network (TEN) facilitate the transport of persons and goods on European roads. Following a series of major tunnel accidents European Union Directive 2004/54/EC was adopted to support the achievement of uniform and high tunnel safety levels. With future accident prevention and mitigation in mind and in support of the effective implementation of Article 15 on Reporting of the Directive we outline a procedure for learning lessons and discuss every step in the process with specific regard for its implications on Article 15. This includes accident investigation, reporting, data collection and analysis, learning lessons and their implementation. The realization that validated information on tunnel accidents is not easily available or accessible, or suffers from a lack of detail or accuracy fed into the development of a data-collection template. By its very nature the template development also guided the formulation of recommendations for accident investigation and reporting as the main information source. In addition, recommendations on data analysis, learning lessons and implementation were also made to assist the actors responsible for reporting or sharing information under the EU Directive.JRC.DG.G.7-Traceability and vulnerability assessmen

A Methodology for Learning Lessons - Experiences at the European Level

In Europe, efforts to protect both the citizen and the environment face a continuing challenge from a wide range of risks that arise from both natural and technological hazards. The lessons learned from the systematic analysis of the evolution of past events and the circumstances that facilitated their occurrence are of paramount importance for future risk reduction and priority setting in terms of vulnerability management. This paper proposes a methodology for learning lessons that addresses the following steps: accident and disaster investigation and reporting, data collection and analysis, generation and implementation of lessons learned. The methodology is demonstrated by introducing the MARS and NEDIES knowledge bases, which are two of the European Community’s systems for collecting existing and producing new lessons learned, and exchanging information on the management of technological accidents and natural disasters.JRC.G.4-Maritime affair

Underlying Causes and Level of Learning from Accidents Reported to the MARS Database

MARS is the system established and maintained by the European Commission in order to collect information related to major industrial accidents in EU Member States in the context of the Seveso II Directive. One of the main purposes of the MARS database is to provide information for learning from the accidents to avoid similar events. Probably, the most important issue for the learning is the determination of the causes, particularly the underlying causes, of the accidents. One objective was to find possible patterns of underlying causes per industry type and per country. Another objective was to determine the occurrence of weaknesses in safety management systems and in safety culture as underlying causes. A further objective was to determine the level of learning from the accidents, as it appears from the reports, per industry type and per country. A sequential method, presented by us in a previous paper in this publication, was used to make it possible to go beyond the causes given in the original reports and to find more underlying causes. To determine the level of learning from the accidents, using the actions/lessons learned given in the reports, a classification method was developed. This method establishes the level of learning of the lessons learned from each case description, essentially from the organisational point of view. This paper presents the results of an analysis regarding underlying causes of all the accidents of the MARS database reported up to mid 2007. The results are expressed per industry type and per country. The main results are that as much as three times as many underlying causes can be found when applying the method developed compared with what is given in the original reports. The most important underlying causes are found in weaknesses in process analysis (risk assessment) and in procedures, regardless of industry type. Weaknesses in safety management systems and in safety culture contribute as underlying causes in a very high percentage of the accidents. The quality of reporting, measured in terms of analysis of underlying causes, vary considerably between various countries. The level of learning, as determined from the information in the reports, is found to be in general rather low, especially from some of the countries. This study has given rise to ideas of improvement of the MARS system. It has also raised many questions, some of which would be suitable for further research.JRC.G.7-Digital Citizen Securit

A sequential method to identify underlying causes from industrial accidents reported to the MARS database

This paper presents a method designed to identify underlying causes leading to industrial accidents. The method developed intends to facilitate the learning process from accidents by identifying possible causes related to the accidents that were not directly stated in an accident report, but that can be deduced following the description of the event, in particular with regard to the quality of the safety management systems in place at the industrial establishment at the time of the accident. The method has been prepared following a sequential approach, although a combination of the philosophy behind other existing accident models has been taken into consideration. The starting point to develop the model is the causes for accidents included in the MARS database of the European Commission. These causes have been extended by considering typical operational or organisational failures that are normally related to the original reported cause. The extension of causes has been performed by adding three follow-on levels of possible underlying causes. The first level could be considered as a direct cause of the accident and, the last level being more applicable to the foundation of establishing safety: "Safety Management System or the Safety Culture". In order to check the applicability of the method developed, it has been validated by a group of experts of the European Federation of Chemical Engineering, in order to reinforce the strategy adopted by the authors. Moreover, the method has been used to analyse the total set of accidents reported to the MARS database. The objective is to determine the efficiency of the method in identifying underlying causes, and to establish a link between the results obtained and the actual causes stated in the reports. In this way, it is possible to establish a system to go deeper into the analysis of past accidents, in order to obtain lessons learned, and to avoid recurrence of similar accidental scenarios in the future, as well as to give directions for a better reporting system of industrial accidents. (C) 2009 Elsevier Ltd. All rights reserved

Study of Major Accidents Involving Chemical Reactive Substances: Analysis and Lessons Learned

The objective of this paper is to present the results of the analysis performed on a selection of accidents included in the MARS database. This is a database of past accidents that occurred in Europe maintained by the European Commission, in order to help the Member States to meet the requirements of the Seveso and Seveso II directives. The study is focused on those accidents that involve reactions between chemical substances, whether wanted or unwanted, that generated a hazardous situation by loss of control of such reactions.JRC.G.4-Maritime affair

Application of the HarsMeth Methodology as a Tool for Analysing the Chemical Accidents Reported to the MARS Database

This paper presents a comparative analysis between the causes that lead to accidents in the chemical industries, and the issues covered by the hazard assessment methodology HarsMeth. The objective of the report is to identify possible synergies between lessons learned from accident analyses and the requirements that an efficient hazard assessment tool must meet to be reliable. The analysis has been performed on a selection of accidents reported to the MARS database involving chemical reactivity. The main causes have been identified and linked to the different topics included in HarsMeth, referring to specific management or technical issues, in an attempt to identify what areas of a chemical process are more critical as potential causes of accidents.JRC.G.7-Traceability and vulnerability assessmen

Identification of reference accident scenarios in SEVESO establishments

In the frame of the ESREL special session on ARAMIS project, this paper aims at presenting the work carried out in the first Work Package, devoted to the definition of accident scenarios. This topic is a key-point in risk assessment, and serves as basis for the whole risk quantification. A first part of the work aims at building a Methodology for the Identification of Major Accident Hazards (MIMAH), which is carried out with the development of generic fault and event trees based on a typology of equipment and substances. This work is coupled with an historical analysis of accidents. In a second part, influence of safety devices and policies will be considered, in order to build a Methodology for the Identification of Reference Accident Scenarios (MIRAS). This last one will take into account safety systems and lead to obtain more realistic scenarios.JRC.G.4-Maritime affair