Safety visualisations and their influences on safety concepts are presented. Visualisations like safety posters show a clear message of fear and guilt. This changes after World War II, due to a more tolerant atmosphere. Latent, organisational factors as decisive elements of accident processes appear in visualisations. An example shows a method to follow accident scenarios in real time.

At the OCI Nitrogen ammonia plant, located at the Chemelot site in Geleen, The Netherlands, a project has been initiated to monitor major accident processes at the site. This contribution answers the question whether indicators can be derived from the barrier system status to provide information about the development and likelihood of the major accident processes in the ammonia production process. The accident processes are visualized as scenarios in bowties. This research focuses on the status of the preventive barriers on the so called ‘left-hand side’ of the bowtie, before a hazard becomes uncontrollable. Both the quality – expressed in reliability/availability and effectiveness – and the activation of the barrier system give an indication of the development of the accident scenarios and the likelihood of the central event. This likelihood is calculated as a loss of risk reduction compared to the original design. The calculation gives in an indicator called “preventive barrier indicator”, which should initiate further action. Based on an example, it is demonstrated which actions should be taken and their urgency.

OCI Nitrogen, one of Europe's largest fertilizer producers, is investigating the extent to which it is possible to take targeted measures at an early stage and stop the development of major hazard accident processes. An innovative model has been developed and recently explained and elaborated in a number of publications. This current paper contains a validation of the model by looking at the BP Texas City incident in 2005. The bowtie metaphor is used to visually present the BP Texas City refinery incident, showing the barrier system from different perspectives. Not only is the barrier system looked at from its trustworthiness on the day of the incident but also from the perspective of the control room operator, and from a design to current standards of best practice. The risk reductions of these different views are calculated and compared to their original design. In addition, evidence and findings from the investigations have been categorized as flaws and allocated to nine organizational factors. These flaws may affect the barrier system's quality or trustworthiness, or may act as ‘accident pathogens’ (see also Reason, 1990) creating latent, dangerous conditions. This paper sheds new light on the monitoring of accident processes and the barrier management to control them, and demonstrates that the BP Texas City refinery incident could have been foreseen using preventive barrier indicators and monitoring organizational factors.

Major accidents in Western countries, receiving a lot of media attention in the 1970s, are starting point for research into internal and external domino effects in the chemical and petrochemical sectors and clusters. Initially, these reports are published by government institutions and government-related research centers. With the upcoming quantitative risk analyses in the 1970 and 1980s, the so-called colored books, published in the Netherlands, play a prominent role in quantifying these domino effects. Since the mid-1990s, the second European Seveso Directive encourages scientific research on domino effects, shown in substantial growth of academic publications on the topic. Research in Western countries is dominated by risk assessments, probabilities, and failure mechanisms are calculated for the complex phenomenon of domino effects and its consequences. Previous works are closely related to political, official, and private decision-making.

OCI Nitrogen seeks to gain knowledge of (leading) indicators regarding the process safety performance of their ammonia production process. The current research determines the most dangerous process equipment by calculating their effects resulting from a loss of containment using DNV GL's Phast™ dispersion model. In this paper, flammable and toxic effects from a release from the main equipment of an ammonia plant have been calculated. Such an encompassing approach, which can be carried out for an entire plant, is innovative and has never been conducted before. By using this model, it has been demonstrated that the effects arising from an event of failure are the largest in process equipment containing pressurized synthesis gas and ‘warm’ liquid ammonia, meaning the ammonia buffer tanks, ammonia product pumps, and the ammonia separator. Most importantly, this document substantiates that it is possible to rank the most hazardous process equipment of the ammonia production process based on an adverse impact on humans using the calculated effect distance as a starting point for a chance of death of at least 95%. The results from the effect calculations can be used for risk mapping of an entire chemical plant or be employed and applied in a layer of protection analysis (LOPA) to establish risk mitigation measures.

Professionalization of safety is gaining some interest in international safety literature, including (post)graduate training and education of safety experts. Different from research, there are hardly any publications and discussions on the quality of (post) graduate safety education in the academic safety literature. This article starts with a short historical picture of safety education. After this picture, a description of the ten (post) graduate safety courses involved is presented with a special reference to the assessment of the quality of these courses. It shows that an internal evaluation of quality, like reactions from trainees, and results from examinations, and tests are presently the main quality indicators. Discussions on how quality assessment can be performed has led to an overview of literature on educational objectives and educational models, and possible options for this assessment. The article concludes that the transfer of safety knowledge and skills to companies and organizations is a highly desirable elaboration of the quality concept. But it is also clear that traditional safety indicators can provide no, or only unreliable, information about the degree of this transfer. An overview of possible minor and major accident scenarios of the company or organisation concerned might be a better option, combined with the activities of the trainee to influence and prevent activation of these scenarios.

OCI Nitrogen wants to gain knowledge of (leading) indicators regarding the process safety performance of their ammonia production process. This paper answers the question whether indicators can be derived from the barrier system status to provide information about the development and likelihood of the major accident processes in the ammonia production process. The accident processes are visualized as scenarios in bowties. This research focuses on the status of the preventive barriers on the left-hand side of the bowtie. Both the quality – expressed in reliability/availability and effectiveness – and the activation of the barrier system give an indication of the development of the accident scenarios and the likelihood of the central event. This likelihood is calculated as a loss of risk reduction compared to the original design. The calculation results in an indicator called “preventive barrier indicator”, which should initiate further action. Based on an example, it is demonstrated which actions should be taken and what their urgency is.

OCI Nitrogen seeks to gain knowledge of (leading) indicators regarding the process safety performance of their ammonia production process. The current sub-study raises the question whether major hazard accidents in the ammonia production process can be predicted from organizational factors, also called management delivery systems. This paper links organizational factors to accident processes and their barrier systems, using the bowtie metaphor. It is shown that organizational factors indirectly impact accident processes as they strongly influence the quality or trustworthiness of the barrier systems. By putting the right focus on organizational factors during audits or reviews, major accident processes get the attention they deserve, and the necessary actions are taken at the right management level. Qualitative and quantitative monitoring of organizational factors can provide a picture of their operation and efficiency. Using an example on retrospective data it is demonstrated that information from organizational factors could have stopped the development of the near-accident prematurely. However, organizational factors should first be qualitatively assessed before they are quantitatively monitored. A quantitative assessment has been worked out for one of the management delivery systems so to provide an example of management indicators. Determining these (management) indicators from threshold values is an intricate matter due to the complicated influence of organizational factors on accident processes, and requires more follow-up research.

OCI Nitrogen aims to build up knowledge of (leading, proactive) indicators that provide insight into the process safety performance of the ammonia production process. Three sub-studies have already been published in TtA. The main question of this sub-study is whether major accidents in the ammonia production process can be predicted from organizational factors, also called management delivery systems. A detailed example in retrospect shows that this is possible. Qualitative information can be generated from audits or peer reviews conducted by internal and/ or external experts once every three to four years. In case of no major shortcomings or findings, it makes sense to measure quantitatively. Based on established threshold values, (management) indicators can then be determined. However, determining threshold values is not easy because the influence of organizational factors on the accident processes is difficult to determine. Much (retrospective) investigation into incidents is still needed to be able to standardize this.

Het programma Duurzame Veiligheid 2030 omvat verschillende initiatieven voor een nog veiligere (petro)chemische sector in Nederland. Eén van de onderdelen van dit programma heeft als doel de veiligheid in bestaande (petro)chemische clusters duurzaam en significant te verbeteren. Dit onderzoek is daar onderdeel van, en is een verkennende studie naar parameters die de veiligheid van (petro)chemische clusters en losstaande (petro) chemische bedrijven beïnvloeden. Op basis van inzicht in deze parameters kan er meer gericht ingezet worden (o.a. door overheden en bedrijven) om de veiligheid te verbeteren in zowel clusters als losstaande bedrijven. Het stimuleren van samenwerking en kennisdeling is een belangrijke parameter, zowel binnen clusters als tussen clusters, en bij niet-geclusterde bedrijven. Extra aandacht is nodig wat betreft informatie-uitwisseling over ongevalsscenario’s tussen naburige (petro)chemische bedrijven met en zonder domino-aanwijzing. Een meer proactieve en strategische samenwerking binnen clusters kan veiligheidswinst opleveren. Het inrichten van een overkoepelend clusterorgaan kan hiertoe bijdragen. Verder is het belangrijk dat een clusterbeleid verder gaat dan ruimtelijke ordening en externe veiligheid, en dat ook bijvoorbeeld toezicht en handhaving wordt ingericht vanuit deze clusterbenadering. Er dient aandacht te zijn voor zowel domino-effecten als escalatie-effecten. Ook geïntegreerde fabrieken die onder verschillende bedrijven vallen vragen een aangepaste benadering om de veiligheid te optimaliseren. Tot slot lijkt het nodig om regionale en landelijke initiatieven rond standaardisatie en uniformiteit op vlak van procesveiligheid te bevorderen, en dringt de nood aan blijvende awareness voor fysieke security (met namen anti-terreur) zich op.

Research question: What is the influence of general management trends and research into causes of accidents on safety management? Method: The literature study is limited to English and Dutch books, documents and articles in the scientific, professional, and technical literature from the period 1988–2010. Results and conclusions: Quite some developments occurred in the occupational safety domain. During the period concerned three models are developed, the Dutch Tripod Model, the Swedish Occupational Risk Unit Model (QARU), and the Dutch Occupational Risk Model (QRM), a barrier based model founded on the bowtie metaphor. These models address occupational accidents from different perspectives, and surprisingly similar factors. While terminology differs, these factors are called basic risk factors, situational, or management factors. Self-regulation of companies has been a strong stimulus for research on safety management systems and audits. Traditionally research in management related topics has not been part of safety research, and thus it has to be developed. While the quality of this type of research is rather low, a general structure of safety management systems is related to the Rhineland management concept. Such evidence is found in new management models such as the EFQM/INK and, to a lesser extent, Corporate Social Responsibility (CSR). While organisational learning, its quality and effectiveness on occupational safety is not researched in this period, research interests are focussing on other organisational aspects like safety culture and climate, including a renewed interest in human behaviour.

In The Netherlands, there are six large (petro)chemical clusters. Companies in these clusters are located next or close to each other. The policy of the Dutch government is to invest in these clusters, and to stimulate their growth. However, there is little scientific evidence that a cluster of (petro)chemical companies is safer than stand-alone (petro)chemical companies. This research, with an exploratory design, investigates parameters influencing safety of (petro)chemical clusters and stand-alone (petro)chemical companies. Insight into these parameters can lead to targeted initiatives (e.g. by government and companies) to improve safety in both clusters and stand-alone companies. Stimulating cooperation and sharing of knowledge is an important parameter, both in clusters and between clusters, and with non-clustered companies. Information exchange on accident scenarios between adjacent (petro)chemical companies with and without domino-designation requires extra attention. An overarching cluster body can contribute to a more safe, proactive and strategic cooperation. Furthermore, it is important that cluster policies include more than only spatial planning and external safety. Also after the establishment of clusters, companies should not be treated as individual companies, but as companies being part of a cluster, for instance when inspections are performed. Attention is needed for both domino-A nd escalation-effects, and possible domino-effects with (petro)chemical companies in clusters (just) below the Seveso-threshold. Integrated plants falling under the management of different companies require an adjusted approach to optimise safety.

OCI Nitrogen aims to build up knowledge of (leading) indicators that provide insight in advance into the process safety performance of their ammonia production process. Two sub-studies have already been published in TtA. The first sub-study focused on ranking the most dangerous process units of the ammonia production process. In the second sub-study, the most important static equipment of the ammonia production process was mapped, which are related to mechanical failure mechanisms. This manuscript describes the third part of the research with the question of whether - based on the status of the barrier system – indicators can be derived that provide advance information about the development and likelihood of the major accident processes in the ammonia production process. The accident processes are visualized as scenarios in bowties. This research focuses on the status of the preventive barriers on the left-hand side of the bowtie. Both the quality – expressed in reliability/availability and effectiveness - and the activation of the barrier system give an indication of the development of the accident scenarios and the likelihood of the central event. This likelihood is calculated as a loss of risk reduction compared to the original design. The calculations of this assessment result in indicators called "preventive barrier indicators". They provide an indication of the likelihood of the scenario. This likelihood is not an absolute value, but rather an indication of the change in the status quo which should initiate further action. This manuscript shows what this action must be and what the urgency of the action is. In the presented concept, every technical change of the barrier system is used to determine the current development and likelihood of the scenario. If the quality parameters of the barriers are accommodated in an automated system, the preventive barrier indicator can be calculated and displayed in real time. This is different for non-technical changes: they will have to be entered and processed manually.

In 2016 werd in Nederland het programma Duurzame Veiligheid 2030 opgestart door een gezamenlijke actie van industrie, wetenschap en overheid om de veiligheid in de (petro)chemische industrie te maximaliseren. Om dit te bereiken, worden via vijf roadmaps concrete activiteiten, pilots en onderzoek uitgewerkt. Dit onderzoek maakt daar deel van uit, en is een verkennende studie naar parameters die de veiligheid van (petro)chemische clusters en losstaande (petro)chemische bedrijven beïnvloeden. Door inzicht in deze parameters kan men gerichter inzetten op het verbeteren van de veiligheid in zowel clusters als losstaande bedrijven.

Ever since safety started to be investigated in a consistent manner, around 150 years ago, there has been a tremendous improvement, both in our understanding of accident processes, and in reduction of harm and damage caused by these occupational and major accidents. Major improvements in safety theories, models and metaphors were made after World War II, with the late 1970s till the late 1990s as the ‘golden years’. But still these major accidents occur and they will keep prompting future scientific developments in safety, as they have done in the past. Reducing the frequency of major accidents remains challenging. Improving design and automation, as starting point for safety has its limits due to the complexity of processes and the inability to foresee all safety related conflicts. The modern emphasis to assure the capacity to handle unforeseen events, such as resilience promises to deliver, will become even more important in the future. Inherent safe design on the other hand make a sensible approach when designing production processes for emerging and future technologies, like nano- and biotechnology. Also, it will remain difficult for small and medium sized enterprises to adhere to complicated laws and regulations. In addition, an increased participation of stakeholder groups makes future safety decision-making even more challenging than it already is today. Yet we foresee that there may be grounds for change in which safety rules, laws and regulations are set aside, the bureaucratic approach towards safety is stopped and the focus is on dynamic accident processes detection. Today, methods are developed to automatically assess time-dependant advancement of accident scenarios and barrier degradation. This direction will contribute substantially to a future higher level of safety in different industrial sectors and might alleviate the emphasis on bureaucracy. We end with developments in two countries where safety and safety science is emerging.

A Safety Research project was carried out in an ammonia plant of OCI Nitrogen, located at the Chemelot site in Geleen, The Netherlands. This research focused on the development of a method to monitor accident processes in the chemical industry mainly caused by mechanical integrity of static equipment like vessels, tanks and heat exchangers. A significant part of the mechanical integrity failure scenarios originates from material degradation and corrosion mechanisms which may develop over a relatively long-time period, possibly taking months, years or even longer. Mechanical failure scenarios from two process units have been worked out and visualized using a bowtie. The research project shows that the monitoring of early warnings can provide information about the current development of mechanical failure scenarios. In addition, early warnings can be used to initiate inspections if there is a likelihood that the mechanical failure scenario has been activated. Considering the shift from breakdown maintenance to preventive and predictive maintenance and risk-based inspection (RBI), inspections based on early warnings could also be a new step in the field of maintenance efficiency.

Objective: What is the influence of general management trends and safety research on managing safety? Method: A literature study which is limited to original English and Dutch books, documents, and articles in relevant scientific journals, for the period 1988–2010. Results and conclusions: Safety science does not yet have a unifying theory, which betrays its young age as a scientific discipline. In the period concerned, well-known theories, models and metaphors are established or re-issued, including the High Reliability Theory, the Man-Made Disasters and the corresponding Disaster Incubation Theory, and the Normal Accident Theory. The Swiss cheese metaphor takes its final form, the bowtie metaphor and the Drift into Danger model are published. All these theories, models and metaphors emphasize organisational aspects of major accidents in high-tech-high-hazard sectors. General management trends highlight the importance of external stakeholders, which are only reflected in the Drift into Danger metaphor. These developments must be considered in the context of a dynamic influence of external factors, like a decrease in government influence coinciding with strong market and technology developments, which can conflict with safety requirements for high-tech-high-hazard companies. Organisational/safety culture and risk/safety management systems take off during this period, both in terms of academic research and consultancy activities for companies. Whether these concepts will have a lasting influence on safety levels in companies is yet to be seen, given the unclear relationship with major accident processes. Research findings show that many companies suffer from sloppy management, having only a limited insight into possible disaster scenarios.

Research was carried out in an ammonia plant of OCI Nitrogen, located at the Chemelot site in Geleen, The Netherlands. It focuses on the development of process safety accident processes in which loss of mechanical integrity is one of the root causes. A significant share of the mechanical integrity scenarios originate from corrosion mechanisms which develop over a relatively long time period, possibly taking months, years or even longer before turning into an event. Based on an example, a failure mechanism is worked out and visualized using a bow tie. Bow-ties have shown a good visual representation of the 'early warnings' and the barriers in place. The monitoring of the 'early warnings' and barriers can provide information about the current probability of the scenario in order to intervene prematurely.

Majeure ongevallen in de chemische en petrochemische sector in het Westen, die veel media aandacht hebben gekregen in de jaren zeventig, zijn het startpunt geweest van onderzoek naar interne en externe domino-effecten in dezesectoren.Aanvankelijkzijnditrapportagesgeweestvan analyses van deze ongevallen vanuit overheidsinstellingen en aan overheden gelieerde onderzoekscentra. Ook zijn studies naar potentiele ongevallen in deze en de nucleaire sector gestart. Met de opkomst van de kwantitatieve risico-analyse hebben de, in Nederland gepubliceerde, gekleurde boekenreeks internationaal een prominente rol gespeeld in de kwantificering van domino-effecten. Vanaf begin jaren tachtig hebben de Europese Seveso richtlijnen wetenschappelijk onderzoek gestimuleerd. Dit is zichtbaar in het aantal publicaties over domino-effecten in wetenschappelijke tijdschriften. Een kwantitatieve benadering domineert het onderzoek in Westerse landen. Met verschillende analysetechnieken zijn waar- schijnlijkheden en faalmechanismes berekend van het zeer complexe fenomeen van domino-effecten en haar consequenties. Een transitie naar risicomanagement staat nog in haar kinderschoenen. Een toekomstige transitie is nodig om initiele scenario's, de start van domino-effecten, te begrijpen. In India heeft een grote ramp in een chemisch bedrijf een vergelijkbare invloed gehad als in het Westen, alleen 20 jaar later. Chinese publicaties over domino-effecten in de wetenschappelijke pers verschijnen later dan in India. Door de snelle industrialisatie in dit land zijn de aantallen overweldigend, zowel in het aantal chemische bedrijven, als in de majeure ongevallen in deze sector.

In order to control occupational accidents, it is crucial to have a clear view on the potential accident scenarios that are present in a company. The bow-tie method is a way to capture and visualise these accident processes in an integrative way. Included in the bow-tie are safety barriers (both technical as organisational and human) and management delivery systems that can intervene in these accident processes. Once bow-ties are composed, they are an excellent point of departure to assign indicators to the safety barriers and management delivery systems in order to control (i.e. prevent or mitigate) the accident scenarios. Two types of indicators can be distinguished. Firstly, there are general indicators that are linked to management delivery systems interrupting multiple accident scenarios, and which can yield a higher safety gain (as they intervene in multiple accident scenarios). Secondly, there are scenario-specific indicators targeting one specific accident scenario, and which can be valuable as they target a specific safety problem in the company. Some crucial aspects have to be taken into account when using indicators, such as sequentiality in follow-up and prioritization of indicators, and the focus on quality rather than quantity.