Texas City refinery accident: Case study in breakdown of defense-in-depth and violation of the safety–diagnosability principle in design

Saleh, Joseph H.; Haga, Rachel; Favaró, Francesca; Bakolas, Efstathios

doi:10.1016/j.engfailanal.2013.09.014

Cited by 53 publications

(30 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Correspondingly, in our study we found that several authors include sensemaking as a general notion and do not provide any associated definition (e.g. Favarò & Saleh, 2018;Saleh et al, 2014;Sanne, 2012). Some provide references to the work of others, but without reproducing the actual definition (e.g.…”

Section: The Use Of the Term 'Sensemaking'mentioning

confidence: 60%

“…Sensemaking has often been limited to an organisational context, seldom discussing issues such as system design. Saleh et al (2014), point out that safety science seems to have drifted from the engineering and design side of system safety towards organisational and social sciences or refinement of probabilistic models. To improve safety and resilience in safety-critical operations, we must have a broad based approach involving the socio-technical system, and also how cues and prospective sensemaking can be enabled from the design phase on.…”

Section: Sensemaking As a Basis For Change Innovation Creativity Anmentioning

confidence: 99%

See 1 more Smart Citation

Sensemaking and resilience in safety-critical situations: A literature review

Kilskar¹,

Danielsen²,

Johnsen³

2018

Safety and Reliability – Safe Societies in a Changing World

View full text Add to dashboard Cite

Recent accidents and near-accidents, such as the capsizing of the anchor handling vessel Bourbon Dolphin in 2007 and the unintended list of the drilling rig Scarabeo 8 in 2012, underline the need for addressing sensemaking in safety-critical situations within the maritime domain. This paper is a literature review to answer the research question: What are the characteristics of sensemaking and resilience in safety-critical situations? The aim was to establish more knowledge on sensemaking in safety-critical situations and the relationship between sensemaking and resilience. The majority of authors provide definitions based on Weick's work on sensemaking, describing sensemaking as a social process, involving the extracting of cues and enactment to create meaning to events retrospectively. Few authors provide descriptions that characterise sensemaking in safetycritical situations. There is a lack of literature regarding sensemaking in safety-critical situations in the maritime domain that addresses the issues of training and human-machine interactions.

show abstract

Section: The Use Of the Term 'Sensemaking'mentioning

confidence: 60%

Section: Sensemaking As a Basis For Change Innovation Creativity Anmentioning

confidence: 99%

Sensemaking and resilience in safety-critical situations: A literature review

Kilskar¹,

Danielsen²,

Johnsen³

2018

Safety and Reliability – Safe Societies in a Changing World

View full text Add to dashboard Cite

show abstract

“…The Three Mile Island and the Texas City refinery accidents as noted previously are examples of such situations. Details of these accidents and other similar cases can be found in (Saleh et al, 2014;Favarò and Saleh, 2013).…”

Section: The Observability-in-depth Principlementioning

confidence: 72%

“…Intuitively, the hazard level can be conceived of as the closeness of an accident to being released (Saleh et al 2014). It is thus related to the extent an accident sequence has advanced: the further the sequence has escalated, the more hazardous the situation is.…”

Section: Background Information: Accident Sequence and Hazard Levelmentioning

confidence: 99%

System safety principles: A multidisciplinary engineering perspective

Saleh

Marais

Favaró

2014

Journal of Loss Prevention in the Process Industries

Self Cite

View full text Add to dashboard Cite

System safety is of particular importance for many industries. Broadly speaking, it refers to the state or objective of striving to sustainably ensure accident prevention through actions on multiple safety levers (technical, organizational, and regulatory). While complementary to risk analysis, it is distinct in one important way: risk analysis is anticipatory rationality examining the possibility of adverse events (or accident scenarios), and the tools of risk analysis support and in some cases quantify various aspects of this analysis effort. The end-objective of risk analysis is to help identify and prioritize risks, inform risk management, and support risk communication. These tools however do not provide design or operational guidelines and principles for eliminating or mitigating risks. Such considerations fall within the purview of system safety.In this work, we propose a set of five safety principles, which are domain-independent, technologically agnostic, and broadly applicable across industries. While there is a proliferation of detailed safety measures (tactics) in specific areas and industries, a synthesis of high-level safety principles or strategies that are independent of any particular instantiation, and from which specific safety measures can be derived or related to, has pedagogical value and fulfills an important role in safety training and education. Such synthesis effort also supports creativity and technical ingenuity in the workforce for deriving specific safety measures, and for implementing these principles and handling specific local or new risks. Our set of safety principles includes: (1) the fail-safe principle; (2) the safety margins principle; (3) the un-graduated response principle (under which we subsume the traditional "inherently safe design" principle); (4) the defense-in-depth principle; and (5) the observability-in-depth principle. We carefully examine each principle and provide examples that illustrate their use and implementation. We relate these principles to the notions of hazard level, accident sequence, and conditional probabilities of further hazard escalation or advancement of an accident sequence. These principles are a useful addition to the intellectual toolkit of engineers, decision-makers, and anyone interested in safety issues, and they provide helpful guidelines during system design and risk management efforts.

show abstract

“…The core idea is as follows: A set of technical, operational, and organizational provisions are designed to enable the monitoring and identification of emerging hazardous conditions and accident pathogens in real time and over different time scales. OiD also requires monitoring the conditions of all confinement barriers that implement DiD (62). OiD not only improves the traditional DiD principle but is also of great significance to the implementation of online risk monitoring in the future (59).…”

Section: Wuli-shili-renli-based Thought Achieves Reasonable Control Ofmentioning

confidence: 99%

Nuclear safety in the unexpected second nuclear era

Chen

Wang

et al. 2019

Proc. Natl. Acad. Sci. U.S.A.

View full text Add to dashboard Cite

Nuclear energy development has entered an unexpected second nuclear era, which is mainly driven by developing countries. Despite major efforts to pursue a safe nuclear energy system in the first nuclear era, severe nuclear accidents occurred. A basic problem is that we do not have an adequate understanding of nuclear safety. From the viewpoints of risk and the close coupling of technical and social factors, this paper reexamines the nature of nuclear safety and reviews how previous experts understood it. We also highlight the new challenges that we are likely to confront in the unexpected second nuclear era and clarify some of the refinements that need to be made to the concept of nuclear safety from a sociotechnical perspective. These include the following: 1) Risk decisions should be made based on integrating social and technical elements (i.e., “social rationality”); 2) risk needs to be controlled based on the “Wuli–Shili–Renli” framework; 3) systems thinking should be substituted for reductionism in risk assessment, and social mechanisms need to be combined to address uncertainties; and 4) public-centered risk communication should be established. This contribution can provide a theoretical foundation for improving our understanding of the nature of nuclear safety and for transforming the concept of nuclear safety in the unexpected second nuclear era.

show abstract

Texas City refinery accident: Case study in breakdown of defense-in-depth and violation of the safety–diagnosability principle in design

Cited by 53 publications

References 19 publications

Sensemaking and resilience in safety-critical situations: A literature review

Sensemaking and resilience in safety-critical situations: A literature review

System safety principles: A multidisciplinary engineering perspective

Nuclear safety in the unexpected second nuclear era

Contact Info

Product

Resources

About