Organisational and human factors – La référence du retour d'expérience sur accidents technologiques

Early analysis of technical or organisational changes

02/06/2017
Fact sheet

An early analysis of technical or organisational changes often proves to be insufficient, or overlooked altogether, resulting in numerous accidents. In many cases, it is simpler and less costly to use existing installations in order to develop or advance a particular process. Such a step however does require an in-depth analysis of the modifications, combined with an accurate identification of the risks tied to anticipated changes. This fact sheet presents a few examples of accidents before revealing the tools available to enable the successful [...]

47277

17/10/2015
Accident report
FRANCE

The summary of this accident has not yet been translated. In the meantime, please refer to the French summary :

Compresseur n°1 accidenté : compresseur à double étage comprimant l'éthylène de 3 à 33 bar. Il fonctionne en alternance avec le compresseur principal. Le jour de l'accident, il totalisait 43 jours de fonctionnement depuis sa dernière maintenance 5 mois avant. Il jouxtait 2 autres compresseurs (n°2 et 3). Ces derniers étaient arrêtés et isolés automatiquement sur déclenchement des détecteurs gaz, ce qui n'était pas le cas [...]

Explosions within a warehouse containing hazardous substances

12/08/2015
Accident report
CHINE

> 173 fatalities

> Destruction of civil infrastructure within a 1-km radius

> Cyanide pollution

> Site rehabilitation

Fire broke out at 10:50 pm at the site of a logistics company, operating since 2011 in the Tianjin port sector with a floor area covering 46,000 m². At the time of the accident, the company had been storing on-site several types of hazardous substances: calcium carbide, toluene diisocyanate, ammonium nitrates, potassium and sodium, as well as 700 tonnes of sodium cyanide.

As fire-fighters were attacking the blaze with water, 2 expl [...]

Explosion of a tank of alcohol in a vinegar factory under development

11/08/2015
Accident report
FRANCE

In a 3,000 m² vinegar factory, a 150 m³ tank containing 40 m³ of alcohol vinegar exploded at around 9:40 a.m. while undergoing welding work. The tank, measuring 13 m in height and 4 m in diameter, was projected like a missile. It flew through the roof and landed 80 m from the building, on the Nîmes-Grau du Roi railway line. The emergency rescue services took 2 injured employees to the hospital, one of whom had been badly burned. Rail traffic was interrupted. The spilt alcohol was collected in the holding tank. The building adjoining the [...]

Pyrotechnics : why did the technician fail to follow the procedure ?

05/06/2015
Fact sheet

In the pyrotechnics sector, 12% of accidents are related to inappropriate human intervention: mainly non-compliance with procedures (since the creation of the ARIA database, 132 accidents are in this case out of a total of 1076). Based on real examples, the purpose of this fact sheet is to present the typical configurations in which operators are knowingly bypassing procedures and investigating the root causes associated, in the different contexts described.

Chronic leakage of toxic effluents in a chemical plant

12/05/2015
Accident report
ALLEMAGNE

In a chemical plant, a leak of effluents containing acetonitrile (a harmful and flammable solvent) from the process wastewater system lead to groundwater contamination. As the network was used only sporadically, the duration of the leak could not be accurately determined. A maximal estimate gave 557 days. The potential loss is estimated to be 61 t of acetonitrile.

Wells were established to try to recover the pollutant through pumping and to sample the groundwater. Three tonnes of acetonitrile were recovered by pumping operations over a period [...]

Lessons learnt from accidents in the fireworks sector

18/03/2015
Slideshow

This document presents the conclusions of an analysis conducted on 322 accidents (104 in France, 218 in other countries) extracted from the ARIA database. For each stage of the fireworks process (manufacturing, storage, use, transport and disposal) major causes and circumstances involved in the accidents have been studied. Recommendations are presented, among those: Need for an exhaustive risk analysis Rigorous management of quantities of hazardous products present Special attention to works/maintenance phases (10% of accidents) [...]

46180

21/01/2015
Accident report
FRANCE

The summary of this accident has not yet been translated. In the meantime, please refer to the French summary :

Vers 5h20, une explosion se produit dans une fonderie. Le bilan est de 8 blessés légers dont 5 soignés sur place et 3 à l'hôpital. Les 76 employés présents évacuent les lieux. L'explosion entraîne un dépôt au sol des poussières qui se trouvaient sur les structures du bâtiment, en hauteur. Des plaques de fibrociment du toit sont endommagées sur 200 m². Le souffle provoque le déplacement et la destruction partielle de ces [...]

Video ”Toxic alarm in the control room”

28/11/2014
Movie

This video, produced by the BARPI, presents an actual accident that occurred inside a French chemical plant in 2012. This media offers a better pedagogical approach for understanding the accident context and its causes than paper documents.

Rupture of a crude oil pipeline

26/05/2014
Accident report
FRANCE

The summary of this accident has not yet been translated. In the meantime, please refer to the French summary :

Une rupture longitudinale se produit vers 6 h sur un pipeline de pétrole brut (DN 500, prof. d'enfouissement : 1 m en sol argileux, année de mise en service : 1965, pression : 69 bar) à 1,5 km d'une réserve naturelle. Aucune perturbation ni à-coup de pression dans le pompage en régime établi ne sont observés avant l'accident. Le pipeline est arrêté et isolé lors du déclenchement des alarmes en salle de contrôle. Les sols et [...]