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Lessons from Esso''''s Gas Plant explosion at Longford

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... According to National Transportation Board Safety, US 2010, eight casualties and more than 50 injuries were reported at Pacific Gas and Electric Company Natural Gas Transmission Pipeline Rupture and Fire in California [2]. In 1998, two fatalities and multiple injuries were reported at the Esso Longford Gas Plant explosion in Australia [3]. According to a case study by the European Commission's Joint Research Centre (EC-JRC), at Tianjin Explosions, China, in 2015, 173 people died while 798 people were injured [4]. ...
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The prompt and accurate detection of gas leakages is essential for the safe operation of gas pipelines and cylinders. Early detection mitigates environmental hazards, safeguards human lives, reduces repair costs, and prevents catastrophic disasters. Optical fiber cables with temperature sensing capabilities present a cost-effective solution for near real-time gas leak detection. This study investigates the efficacy of optical fiber as a reliable sensor for detecting gas leakages through temperature variations. The temperature change, caused by a gas leak, is analyzed by measuring the change in light intensity. An Infrared (IR) Light Emitting Diode (LED) transmits infrared light through the fiber, and a photodiode receiver at the opposite end captures the transmitted light. Experimental results indicate a rapid temperature drop near the leakage point, with greater temperature drops observed under higher leakage pressures. Consequently, for optimal detection, the optical fiber must be positioned proximate to the pipeline or gas container. This approach is vital for timely and accurate gas leakage detection, thereby preventing potential harm to the environment, human lives, and property.
... These maps help in understanding the complex interactions between human operators, technology, organizational factors, and external influences that can lead to accidents. Andrew Hopkins, an Australian sociologist and safety researcher, extensively used Accimaps in his work, particularly in his book "Lessons from Longford: The Esso Gas Plant Explosion (Hopkins, 2000). He used Accimaps to explore the complex interactions and failures that led to the catastrophic incident. ...
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Modelling Complex Systems to try to understand and predict their behaviour is a challenge that is becoming increasingly important as our modern-day systems become more and more opaque to discerning how they actually work in practice. Classic MBSE (Model Based Systems Engineering) seems to duplicate Business Intelligence software as a bespoke means of organising data and information flows. So, this paper sets out to select the most appropriate solution from the currently available approaches attempting to analyse the behaviour of complex systems. It does this by systematically reviewing the most relevant modelling methodologies and their application; and setting criteria for the requirements of a practical approach which is appropriate for our needs. The criteria chosen include the requirement for:-• a solution based on system thinking. • sufficient resolution or granularity of the representations, • the nonlinear, non-predetermined nature of the process models • the ability to predict dynamic behaviour. • The ability to model unexpected outcomes-(resonance and emergence) • The ability to follow the propagation of variability through the system. • and the ability to optimise the performance and resilience of the system. This appraisal found that currently there seems to be only one methodology that satisfied all the criteria. That was Hollnagel's FRAM (Functional Resonance Analysis Method) approach, enhanced with the latest developments to the web based, open-source software.
... In addition, the utilization of Accimap contributes to the comprehension of the dynamics among various societal strata during the occurrence of accidents [78]. Accimap has been utilized in a range of sectors, such as chemical [79], public health [80], transportation [81,82], and aerospace safety [83,84]) to undertake SAA studies. Accimap provides an objective examination of safety accidents and aids in the discovery of causative relationships across many societal levels. ...
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... Rasmussen identified these influences as notional hierarchical organograms, (Svedung & Rasmussen (2002), Debrincat & Clark), which were instrumental in showing the bigger picture. Longford (Hopkins, 2000) is perhaps the best example of their use in teasing out all the factors involved in inducing sharp end miscalculations. Leveson (2004) formalised this model and showed clearly the controls that are necessary and assumed to be in place to ensure safe operation. ...
... In addition, the API 581 and RIMAP standards are extremely complicated, very comprehensive, and very time and financially demanding to implement (Jovanovic, 2004;Kauer et al., 2004;Khan & Abbasi, 1998), so they pose a challenge in the case of smaller process plants and factories. The analysis of the history of accidents also shows that the mechanical integrity of the equipment is a significant indicator and in that sense, the risk analysis of such a system focuses on a given direction (Baker et al., 2007;Golubović et al., 2021;Hopkins, 2000;Nivolianitou et al., 2006). However, a more detailed analysis makes it clear that in most cases there would be no equipment failure or the consequences would be significantly less if there were no omissions in the organization (Pate-Cornell & Murphy, 1996;Skogdalen & Vinnem, 2011;Smith et al., 2013). ...
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In recent decades, process safety control and process safety risk assessment have become very attractive topics. The way control is carried out, using tools such as HAZOP, FMEA, FTA, and similar is not sufficient to adequately prevent or control accidents with serious consequences in the process industry. The need to analyze the causes of the causes themselves, with special emphasis on the impact of organizational factors has arisen. This research results in the development of an original, reliable, and valid measuring instrument for assessing organizational factors important for risk assessment methodologies in working with pressure equipment. The initial instrument was designed based on the previous research and then checked by statistical analysis, using the Kaiser-Meyerto-Olkin test, exploratory factor, and reliability analysis. The proposed instrument has reduced 71 to 48 dimensions, describing 10 organizational factors important for risk management of pressure equipment. Providing a valid and reliable measurement instrument is essential for a proactive approach, which enables managers employed in the organization to mitigate the risks of pressure equipment operation, and prevent accidents. The proposal of further research is the application of confirmatory factor analysis or/and structural equation modeling on data collected.
... Rasmussen identified these influences as notional hierarchical organograms, (Svedung & Rasmussen (2002), Debrincat & Clark), which were instrumental in showing the bigger picture. Longford (Hopkins, 2000) is perhaps the best example of their use in teasing out all the factors involved in inducing sharp end miscalculations. Leveson (2004) formalised this model and showed clearly the controls that are necessary and assumed to be in place to ensure safe operation. ...
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The very ideas that underpin our traditional understanding of organization and workplace are being critically explored by an increasingly large number of people. Equally, the discussion is also embracing new ways of thinking about organization, through a range of perspectives. It is as if a new school of organizational thought and practice is appearing and is crying out for closer investigation, as there are, apparently, no easy solutions as to how it can be remedied so that those similar incidents do not continue to occur at regular intervals. It seems too superficial to simply hold the entire organization to "blame". More recently attempts to address the fallibility of such organizations has tended to focus on their "culture" and style of leadership. Given human frailties, are very large, dispersed organizations then doomed to fail? Hopkins argues that a good organisation should not allow these deviations to get out of control. A number of other authors have addressed this problem and held that the problem could be solved by decentralization of authority structures. But still others point out that organizational drift is natural, but not unavoidable. It could be reversed but the organization and the people holding responsible positions need to be constantly aware of the propensity and design the structure appropriately.
... In addition, the API 581 and RIMAP standards are extremely complicated, very comprehensive, and very time and financially demanding to implement (Jovanovic, 2004;Kauer et al., 2004;Khan & Abbasi, 1998), so they pose a challenge in the case of smaller process plants and factories. The analysis of the history of accidents also shows that the mechanical integrity of the equipment is a significant indicator and in that sense, the risk analysis of such a system focuses on a given direction (Baker et al., 2007;Golubović et al., 2021;Hopkins, 2000;Nivolianitou et al., 2006). However, a more detailed analysis makes it clear that in most cases there would be no equipment failure or the consequences would be significantly less if there were no omissions in the organization (Pate-Cornell & Murphy, 1996;Skogdalen & Vinnem, 2011;Smith et al., 2013). ...
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Full-text available
In recent decades, process safety control and process safety risk assessment have become very attractive topics. The way control is carried out, using tools such as HAZOP, FMEA, FTA, and similar is not sufficient to adequately prevent or control accidents with serious consequences in the process industry. The need to analyze the causes of the causes themselves, with special emphasis on the impact of organizational factors has arisen. This research results in the development of an original, reliable, and valid measuring instrument for assessing organizational factors important for risk assessment methodologies in working with pressure equipment. The initial instrument was designed based on the previous research and then checked by statistical analysis, using the Kaiser-Meyerto-Olkin test, exploratory factor, and reliability analysis. The proposed instrument has reduced 71 to 48 dimensions, describing 10 organizational factors important for risk management of pressure equipment. Providing a valid and reliable measurement instrument is essential for a proactive approach, which enables managers employed in the organization to mitigate the risks of pressure equipment operation, and prevent accidents. The proposal of further research is the application of confirmatory factor analysis or/and structural equation modeling on data collected.
... Companies use several methods and indicators to make a diagnostic of the safety level and to manage safety. The assumption made is that companies fear high potential accidents but express their goals using largely irrelevant low consequence counting ( Hopkins, 2000;Dekker, 2015). The safety professional has an important role to play but there is still an on-going debate in the safety literature concerning how to measure safety. ...
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Provan et al (2017) conducted a systematic literature review in Safety Science that included more than 100 publications of the last 30 years published on the role of the safety professional. This comprehensive review identified 25 factors that shape and influence the role of the safety professional. These factors are organized in three categories: institutional, relational, and individual. The review highlighted a dearth of empirical research into the practice and role of the safety professionals. This article presents the results of a project combining two objectives: (1) conduct empirical research into the practice and role of the safety professionals; (2) support the reflection by safety students about their future role in organizations and the factors that will influence that role. The main contribution of this paper consists in delivering empirical data from a research setup that helped students to understand more clearly their role as (future) safety professionals. This is achieved through getting the students themselves engage with Provan's work and do interviews with practicing safety professionals using Provan's categories as inspiration for interview questions and discussion topics. The blending of Provan’s categories of factors with a role theory was used as a general analysis frame. This work presents several findings: (1) the factors identified by Provan et al. (2017) can be associated to a theoretical model of factors involved in the taking of organizational roles by the safety professionals. (2) We can also identify those 25 factors in real professional contexts, these factors are pertinent and relevant for safety professionals. (3) The 25 factors are not independent, some of them are reciprocal related and some of them have dependencies. Those relationships can give light on how roles of safety professionals are socially constructed. Reflection on those factors is very useful for future safety professionals (the students), this appeared to be an effective pedagogic process that enhance the processes of professional socialization of future safety professionals (Foussard et al., 2021). However, this last point will not be discussed in this paper.
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Continuing professional development recognises that changes in the contemporary world demand that engineering professionals continuously learn. Today’s professional landscape requires the provision for ongoing learning relevant to evolving workplace requirements. This is particularly the case for engineers working in hazardous industries who make decisions every day with significant consequences. Despite this, the safety literature has paid little attention to best practice in professional learning. There is a large literature regarding lessons to be learned from accidents. Other published studies focus on training methods such as simulation. Educator-focused approaches such as these separate learning from real day-to-day workplace contexts and the learning needs of professionals. It is increasingly recognised that professionals learn, in a way that shapes their practice, from a diverse range of activities. Learning must therefore be active, social, and situated within the sphere of professional responsibilities, contexts, and groups. This paper presents a learner-centred framework that can be used to develop professional learning for safety that is grounded in day-to-day work practices and professional context needs. The framework aims to move away from the limitations that have been found with the current professional development approaches to enhance learner-centred professional learning. The framework was developed and used in the context of engineering practices regarding safety, but, because the framework encourages learning to be designed based on workplace contexts, it is applicable across a range of training needs and professions.
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Objectives. The analysis of previous research shows that indicators of human factors have not been sufficiently integrated into the models for risk assessment of pressure equipment to date. Therefore, the goal of this article is the creation of a universal measurement scale to assess the current condition of the impacts of human factors on the risk of pressure equipment exploitation in factories and plants. Methods. A research instrument with nine constructs and 61 dimensions was designed and tested on a sample size of 268 companies, by reliability, exploratory and confirmatory factor analysis. Results. The final model contains exact quantification of nine constructs described by 27 influencing human factors on risk associated with pressure equipment exploitation. Conclusions. The most influencing construct is 'communication', whereas the construct 'organizational change management' is the least influencing. Also, applying Pareto analysis shows that the most important constructs identified are 'communication', 'safety and health at work', 'potentially hazardous materials and equipment', 'maintenance/inspection', 'human error' and 'trainings and competences of employees for crisis situations'. It is a recommendation for the process industry enterprises, where pressure equipment is in operation, to include the obtained model in the risk assessment processes they are using.
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The IFMIF-DONES (International Fusion Material Irradiation Facility-DEMO Oriented NEutron Source) facility is being designed with the general objective of providing irradiation of representative samples of power fusion machine materials under prototypical conditions. A linear accelerator will deliver deuterons at high intensity to circulating lithium in a loop, which will produce neutrons capable of obtaining the required damage conditions. As a result of this process, radionuclides will be produced as a by-product, which is characterized by several degrees of mobility. Shielding and radiation protection measures will be required in the facility. IFMIF-DONES will be classified as a first class radioactive facility according to national regulations, with Spain being the European candidate to site the facility. Several aspects of the main safety instructions affecting the facility’s design are explained and discussed in this paper.
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[v.1]. Safeguarding the worker : job hazards and the role of the law / by Neil Gunningham (1984)--[v.2]. Smart regulation : designing environmental policy / Neil Gunningham, Peter Grabosky, with Darren Sinclair (1998)--[v.3]. Regulating workplace safety : system and sanctions / Neil Gunningham and Richard Johnstone (1999)
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