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.@en

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.@en

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.@en

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.@en

A Belgian manufacturing company uses pallet movers for internal transport. Despite the company's efforts to improve occupational safety, accidents with pallet movers remain noteworthy. In order to control occupational accidents, it is crucial to have a clear view of the potential accident scenarios that are present in a company. The bow-tie method is a way to capture and visualize these accident processes in an integrative way. Included in the bow-tie are safety barriers (both technical as organizational 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) accident scenarios. Two types of indicators can be distinguished. Firstly, there are general indicators that are assigned to management delivery systems interrupting multiple accident scenarios, 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, which can be valuable as they target a specific problem in the company. For the development of the bow-ties, a multi-method design with the inclusion of different data sources was used, leading to a comprehensive overview. This makes the bow-tie analysis of internal transport with pallet movers transferable to other settings where pallet movers are used for internal transport.@en

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.@en

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.@en

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.@en

Procesveiligheidsindicatoren geven informatie over ongevalsscenario’s en over de effectiviteit van veiligheidsbarrières. Dat is de bedoeling. Het is de vraag of dat lukt. In de vakliteratuur wordt een onderscheid gemaakt tussen leidende (leading) en volgende (lagging) indicatoren. Dit lijkt overtuigend. Behalve bedrijven gebruikt ook de overheid deze indeling. Indicatoren worden vaak gekwantificeerd. Wat betekent dat getal? Veiligheidsindicatoren zijn ook binnen arbeidsveiligheid een onderwerp. Deze bijdrage beperkt zich voornamelijk tot indicatoren in procesveiligheid en in high-tech-high-hazard-sectoren. Het onderwerp veiligheidsindicatoren zal nog lang in de belangstelling blijven staan.@en

Het programma Duurzame Veiligheid 2030 omvat verschillende initiatieven om tot een nog veiligere (petro)chemische sector in Nederland te komen. Eén van de onderdelen (roadmaps) van dit programma heeft als doel de veiligheid in bestaande (petro)chemische clusters duurzaam en significant te verbeteren. Dit onderzoek kadert binnen deze roadmap, en is een verkennende studie om in kaart te brengen welke parameters een invloed hebben op de veiligheid van (petro)chemische clusters, en in welke mate zijn deze parameters aanwezig bij losstaande (petro)chemische bedrijven. (Petro)chemische clusters kunnen immers opportuniteiten met zich meebrengen op het vlak van veiligheid, maar kunnen evengoed zorgen voor beperkingen of nadelen op het vlak van veiligheid. Op basis van een duidelijk zicht op de verschillen tussen beïnvloedende veiligheidsparameters bij (petro)chemische clusters en losstaande (petro)chemische bedrijven kan er meer gericht ingezet worden (o.a. door overheden en bedrijven) om de veiligheid te verbeteren in zowel clusters als losstaande bedrijven. Een (petro)chemische cluster wordt gedefinieerd als een geografisch gebied waarbinnen verschillende BRZO-bedrijven gevestigd zijn, al dan niet omgeven door niet-BRZO-bedrijven. De geografische afbakening impliceert de mogelijkheid van directe effecten tussen de verschillende bedrijven ten gevolge van een procesgerelateerd incident (brand, explosie, toxische wolk). De samenwerking tussen de bedrijven kan variëren van niet of zeer licht georganiseerd tot intensief georganiseerd. Uitgaande van deze definitie zijn er in Nederland zes (petro)chemische clusters: Amsterdam, Delfzijl-Eemshaven, Moerdijk, Rotterdam-Rijnmond (met als sub-clusters Pernis, Botlek, Europoort, Maasvlakte), Sittard- Geleen (Chemelot) en Zeeland (Terneuzen). @en

Een Belgisch bedrijf uit de maakindustrie gebruikt palletwagens voor intern transport. Ondanks de veiligheidsinspanningen komen ongevallen met palletwagens frequent voor. Om arbeidsongevallen te beheersen is het belangrijk om een goed zicht te hebben op de potentiële ongevalsscenario’s in het bedrijf. De BowTie- of het vlinderdasmodel is een manier om deze ongevalsscenario’s visueel in kaart te brengen op een integrale manier.@en

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.@en

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.@en

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.@en

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.@en

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.@en

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.@en

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.@en