Investigation and Analysis of a Hazardous Chemical Accident in the Process Industry: Triggers, Roots, and Lessons Learned

Abstract

This paper performs an in-depth investigation and analysis on a catastrophic hazardous chemical accident involving domino effects in China based on an emerging accident causation model—the 24Model. The triggers and roots of the incident from the individual and organizational levels have been identified and several useful lessons have been summarized to avoid similar mistakes. This accident began with a leak of vinyl chloride caused by the failure of the gas holder’s bell housing and the operators’ mishandling. Leaked vinyl chloride was ignited by a high-temperature device in the process of diffusion and the fire quickly spread to the illegally parked vehicles. Several organizations were involved in this accident, and the chemical company should bear the main responsibility for it, and shall establish and implement an effective safety management system in its organizational structure and staffing, facilities management, hazards identification, emergency disposal, etc., to improve safety performance in a systematic way. Enterprises in the chemical industry park shall enhance the communication to clarify major hazard installations in their domains, and conduct regular safety evaluation for the plant as the external environment changed. Government agencies shall plan the layout of the chemical industry park scientifically and ensure safety starts with the design stage. The case study provides a practical procedure for accident investigation and analysis, and thus, preventive measures can be made according to the various causations at different levels.

Effects of a Theory-based Educational Intervention on Skills of Emergency Medical Service Personnel for Scene Management in Chemical Accidents

“…Chemical accidents are more critical due to their wide and high diffusion rate [6]. These accidents have multiple domino effects, with widespread casualties, financial loss, and environmental pollution [7]. These accidents, with their high casualties, create an unexpected and sudden demand for medical care, exceeding the normal capacity of service providers and imposing a heavy burden on healthcare systems [8].…”

Classification of Human Failure in Chemical Plants: Case Study of Various Types of Chemical Accidents in South Korea from 2010 to 2017

“…Human factors are classified into workplace and operator factors that positively or negatively affect the performance of workers and act as an important cause of accidents related to hazardous chemicals [ 14 , 15 ]. Several studies have addressed the importance of management of human factors.…”

Bayesian Network-Based Risk Analysis of Chemical Plant Explosion Accidents

“…In order to perform a comprehensive analysis of CPEAs and explore the deeper causes of the accidents, researchers introduced some more widely used models into the analysis of CPEAs, including the 24Model, the human factors analysis and classification system (HFACS), and fault tree analysis (FTA). Wang et al used the 24 Model to research a typical hazardous chemical accident in China, and analyzed the causes of the accident from both individual and organizational levels [ 10 ]. Based on 102 accident cases, Wang et al discussed the main manifestations of unsafe behavior, preconditions for unsafe behavior, unsafe supervision and organizational influence in chemical accidents, and improved the HFACS model to make it suitable for the chemical industry [ 11 ].…”