Journal of Loss Prevention in the Process Industries 16 (2003) 551560 www.elsevier.

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Predicting the frequency of accidents in port areas by developing event trees from historical analysis
A. Ronza, S. Felez, R.M. Darbra, S. Carol, J.A. Vlchez, J. Casal
` ` Centre dEstudis del Risc Tecnologic (CERTEC), Department of Chemical Engineering, E.T.S.E.I.B., Universitat Politecnica de Catalunya Institut dEstudis Catalans, Diagonal 647, 08028 Barcelona, Catalonia, Spain

Abstract The historical analysis of 828 accidents in port areas, which have been selected from a database, has been used to identify the sequences of the accidents. Processing these data has allowed the event trees and the probability of the various accident scenarios to be determined. By using these event trees and gures detailing the frequency of the events that initiated the accidents, as taken from various authors, the frequency of the accidents has been determined. 2003 Elsevier Ltd. All rights reserved.
Keywords: Ports; Accidents; Historical analysis; Risk analysis; Event trees; Environmental assessment

1. Introduction Of the 5000 million tonnes of seaborne cargo, 1590 million tonnes are crude oil, 430 are other oil products and a signicant part of the rest are other hazardous sub stances (Zamora Terres & Leon Arias, 2000). A trade such as this entails the risk of serious accidents, to which shores and especially port areas and their vicinities are highly exposed. The most signicant port area accidents in terms of the quantity of hazardous substances involved are compiled in Table 1. Accidents as signicant as those of the Urquiola (1976, A Coruna), the Haven (1991, Genoa), the Aegean Sea (1992, A Coruna) and the recent Pres tige (2002, A Coruna) highlight the nancial and social repercussions of these events. Their consequences, beyond direct material losses, include the costs of emergency action; of cleaning up the affected areas; of spilled product recovery (Darbra, Carol, & Casal, 2002); irreversible damages to the environment (protected species, destroyed habitats, etc.); losses as a result of bringing various activities, such as shing and tourism, to a standstill; and the evident risks to the life of the people

Corresponding author. Tel.: +34-93-401-6675; fax: +34-93-4017150. E-mail address: joaquim.casal@upc.es (J. Casal).

living next to or working in these ports. Table 2 includes the most signicant accidents that have occurred after 1970 in terms of the number of casualties. Although the Seveso II Directive (1996) regulates risk analysis and control for major accidents in xed installations, it does not affect transportation of hazardous substances, whether airborne, seaborne, by road, rail, or inland waterway. Moreover, the risk associated with the presence of hazardous substances on ships and/or in port areas is difcult to evaluate, due to the particular nature of these systems. A port area is characterized by a wide range of activities: whereas some of these activities are common to the majority of industrial areas (e.g. big oil terminals, presence of rail and road trafc, chemical and petrochemical plants, general manufacturing and industry), there are several activities that are to be encountered exclusively in a harbour setting. The latter involve all aspects of navigation and ships: loading and unloading of goods, oil jetties, shipyards, the presence of shing eets, marinas, dredging, the building of port infrastructures, etc. Several of these aspects have been analysed by Rmer, Brockhoff, Haastrup, and Styhr Petersen (1993), Rmer, Haastrup, and Styhr Petersen (1995), Rao and Raghavan (1996), Christou (1999), Thevik, Srgard, and Fowler (2001), and Rigas and Sklavounos (2002). The need to evaluate the risk associated with these activities requires the use of quantitative risk-analysis

0950-4230/$ - see front matter 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.jlp.2003.08.010

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Table 1 List of the most signicant port area accidents in terms of the quantity of hazardous substances involved Description Operation Quantity (tonnes) 100,000 95,000 89,999 70,000 58,999 50,001 34,000 32,000 28,299 25,000 Crude oil Crude oil Crude oil Crude oil Crude oil LNG Oil Crude oil Kerosene Crude oil Substance

AN

Year

Location

316 1132 2787 4575 1515 171 871 6698 1196 4132

1976 1979 1975 1989 1981 1976 1979 1993 1980 1990

Spain; A Coruna Turkey; Istanbul Portugal; Leixoes Morocco; Khark 5 Italy; Genoa Ecuador; Guayaquil Germany; Duisburg Indonesia; Sumatra Turkey; Istanbul; Karadeniz Bogazi Portugal; Madeira

Tanker Urquiola; release of crude oil into sea Massive fire + explosions at port after collision between ships; killed 52 people Accident caused by Danish tanker Jacob Maersk Release of crude oil Tanker Hakuyoh Maru struck by lightning Explosion on jetty after a short circuit on unloading tanker ignited LNG vapours Explosion affecting 17 port tanks + release into water Collision between tankers Sanko Honour and Maersk Navigator Collision of Greek ship Stawanda with British Nordic Faith Crude oil spilled from tanker reached coast of Madeira and Porto Santo

Approach Manoeuvre Manoeuvre Manoeuvre Loading/unloading Loading/unloading Storage Manoeuvre Approach Approach

AN = MHIDAS accident no.

Table 2 List of the most signicant accidents that have occurred after 1970 in terms of the number of casualties Description Huge re spread during unloading of a ship Operation Loading/unloading Manoeuvre Killed 56 52 Injured 20 3 35 Substances

AN

Year

Location

8721

1997

1132

1979

India; Andhra Pradesh, Visakhapatnam Turkey; Istanbul

Crude oil; kerosene; LPG; petroleum products Crude oil

A. Ronza et al. / Journal of Loss Prevention in the Process Industries 16 (2003) 551560

1851 5882 2851 6946 5618 2783

1975 1992 1987 1994 1992 1987

USA; Pennsylvania; Marcus Hook Malaysia; Strait of Malacca Philippines; Manila Iran; Bandar Khomeini Malaysia; Port Kelang Italy; Porto San Vitale

Manoeuvre Manoeuvre Loading/unloading Storage Loading/unloading Maintenance Loading/unloading Manoeuvre

26 22 15 13 13 13 13 12

26

Crude oil Crude oil Methyl methacrylate Wheat Toluene; xylene LPG 8 Crude oil Butane

2677

1974

USA; Pennsylvania; Fort Mifn

893

1979

USA; Louisiana; Good Hope

Massive fire + explosions at port after collision between ships: killed 52 people Collision between tankers Collision between tanker and container vessel Fire spread from a tanker unloading into two barges Explosion + fire at wheat silo in port Explosion + huge fire on chemical tanker at depot Explosion/re during maintenance work on LPG carrier Elisabetta Montanari Tanker Elias wrecked by series of explosions while berthed Collision of cargo vessel with loading butane barge; reball lasting 1 min

AN = MHIDAS accident no.

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techniques, which involves the following steps: (1) to identify the hazards; (2) to determine the frequency of occurrence (e.g. with fault trees); (3) to analyse the accident sequences by working out event trees; (4) to evaluate the effects and consequences on the population of each accident scenario that has been identied; and (5) to determine whether such a risk is acceptable or not (Vilchez, Carol, Espejo, & Perez, 2002). The development of event trees for port areas is normally carried out from a theoretical point of view (Det Norske Veritas, 2002). However, it is also possible to obtain the event trees directly from a historical analysis of the accidents that have occurred in these areas. This methodology has already been used to analyse accidents involving ammable substances in xed installations (Carol, Vilchez, & Casal, 2001). In this paper, event trees are presented for accidents involving hazardous substances that have occurred in port areas, and which are included in a list of 828 accidents extracted from the MHIDAS database (MHIDAS, 2003).

2. Accident selection methodology The MHIDAS database, which has been used to carry out the present study, is developed and managed by the safety and reliability directorate (SRD) that belongs to the UK health and safety executive (HSE); it includes accidents that have occurred in 95 countries since the beginning of the 20th century. The rst version appeared in 1980, although the present study refers to the January 2003 version, which contains 13,018 records on 11,353 accidents. There are other databases that could be used in this kind of study, such as the one developed by Lloyds of London. Nevertheless, MHIDAS has been chosen because the elds of each record are categorized, which facilitates the automatic processing of information. In order to identify the records specically related to accidents in port areas, the search criteria shown in Fig. 1 have been used and implemented in a computer code. Obviously, this selection procedure has some limitations, as it is based solely on lexical criteria and, above all, it only includes the ABSTRACT and LOCATION elds in MHIDAS. Nevertheless, there are no other possibilities, because it is only the ABSTRACT eld that allows one to gauge whether an accident is port-related or not. As a result, there are some relevant omissions in the list (e.g. the Exxon Valdez accident and the accidents that occurred in Texas City in 1947, causing 552 deaths and 3000 injuries, and at Bantry Bay, Eire in 1979, causing 50 deaths; for the latter two see Lees, 1996). Additionally, several incidents that did not occur in port areas are automatically included in the selection and, as a consequence, a record-by-record revision has been necessary to eliminate errors. At the end of this process,

824 accidents were left, to which four more, which recently took place at the Port of Barcelona, have been added (for the Vento di Scirocco accident, see Vilchez, et al., 1998). The MHIDAS elds used in this study are shown in Table 3. Moreover, for each accident, more information has been drawn up and organized in additional elds that were not originally present in MHIDAS; these are shown in Table 4. Given the databases lack of precision, the information concerning the amount of hazardous substance involved or spilled (in the QR eld) and the possibility of water being reached by the spillage (in the water (Y/N) eld) has not provided signicant results. The operation eld includes seven different categories, according to the activity that was being carried out when the accident occurred: (1) approach (a ship approaching or leaving the port); (2) manoeuvre (ships moving in port waters or mooring); (3) loading/unloading (of ships); (4) maintenance (of ships at docks); (5) storage (of goods in land terminals and warehouses); (6) process (in industrial plants located in the port area); and (7) transport (of goods by train, lorry or pipeline through the port area). Table 5 shows how these accidents are distributed within these categories. Approximately a third of them occurred during loading/unloading operations. Loading and unloading must be considered highly dangerous, not only because of the large amounts of hazardous substances that are manipulated, but also because of the decisive inuence of the human factor (i.e. the possibility of human error) during these operations. One should remember that approximately 8% of all accidents that occur in xed installations and during the transportation of hazardous materials occur during loading/unloading operations (Vilchez, Sevilla, Montiel, & Casal, 1995). Similarly, Table 5 shows that manoeuvring operations very often lead to accidents (27%), as a consequence of the difculties of ships movement in port waters, the possibility of anomalous trafc conditions in such reduced areas and, again, of the possibility of human error. As far as the location of the accidents is concerned, 40% occurred in the sea (approach + manoeuvre), whilst only 21% did so on land (storage + process + transport). It is worth noting that the remaining 39% occurred at a sealand interface (loading / unloading + maintenance), which is a particular characteristic of ports as industrial areas. Wherever possible, the element that caused the unexpected event has been identied; this information has been made available in 276 cases. The gures obtained can be seen in Table 6. Ship-related elements are not included, as MHIDAS has proved to be too generic in this regard. Concerning the type of substances involved in the accidents, the study shows that most of them (62%) are

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Fig. 1.

Search criteria applied in order to extract port area accidents from MHIDAS. Table 4 Additional elds used in the study that were not originally present in MHIDAS Name of the additional eld Operation Sequence Element Water (Y/N) Observations Description

Table 3 Fields of MHIDAS used in the present study Name of Description MHIDAS eld AN IY LO AB OG IT SC QR KR IR ER MN MHIDAS accident number Year of the accident Location Abstract (a short explanation of how the accident occurred) Origin (general and specic, describing the area and circumstances of the accident) Incident type (whether it was a release, gas cloud, explosion or re, or a combination of these) Specic cause Quantity (of hazardous substance involved in the accident, in tonnes) Number of deaths Number of injured persons Number of evacuated persons Material name (name of the material/substance involved in the accident)

The activity being carried out when the accident occurred Determined on the basis of elds AB and IT The element or device that caused the accident, if known Indicates whether a spillage reached the water or not, if known Any relevant comments on the accident

crude oil or other oil products. Table 7 summarizes the substances most frequently involved in the accidents: those substances ranked in the rst four, and eight of those ranked in the rst 10, are hydrocarbons, with a signicant prevalence of crude oil. The quantity involved in the accident has also been analysed, and a quantity-probability plot obtained. Nevertheless, given that an accident involving a small

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Table 5 Classication of the accidents in terms of the type of operation Operation Loading/unloading Manoeuvre Approach Storage Transport Maintenance Process Total Number of accidents 280 224 108 101 56 40 19 828 % 34 27 13 12 7 5 2 100

Table 6 Elements that caused the accident Element Warehouse Pipeworks Hose Valve Drum Lorry Rail tanker Crane Number of accidents 100 77 38 20 20 12 7 2 (%) 12.1 9.3 4.6 2.4 2.4 1.4 0.8 0.2

2.

Table 7 Ranking of the substances most frequently involved Substance Crude oil Fuel oil Oil Gasoline Chemicals Ammonia Gas oil Diesel fuel Petrol LPG Number of accidents 148 59 47 45 25 22 21 21 20 19 (%) 17.9 7.1 5.7 5.4 3.0 2.7 2.5 2.5 2.4 2.3

3.

4. amount of substance is not normally assigned a value for the quantity, the analysis clearly showed that such accidents are underrepresented. As a result, these data have undergone no further research.

3. Accident classication criteria With the aim of obtaining event trees that are sufciently representative, the following agreements and hypotheses have been adopted: 1. MHIDAS eld IT (incident type) classies each accident under four basic categories: re, release,

5.

explosion and gas cloud. Each accident may belong to one or more of such types. Moreover, each basic IT may include more detailed information (if the accident involved a re, MHIDAS may indicate whether it was a pool re, a jet re, etc.); in any case, in the present study, such additional information is irrelevant as it is often incomplete or even absent. It has therefore been ignored, and only the four basic types have been applied to the sequence eld. Furthermore, if we take into account the fact the MHIDAS normally reports accidents according to their actual evolution, an evident shift or change in the event sequence has been corrected when detected. For example, an accident involving a release followed by (or including) a pool release, is classied in the release category, according to the present criteria; in the same way, an event described as an unconned explosion by MHIDAS, is classed simply as explosion. MHIDAS appears to be quite incoherent when it lists the res that are directly caused by an explosion. Whilst an explosion is generally the cause of a re, albeit just a sudden blaze, such an event is usually cited only if it is very destructive and/or long-lasting; in any case, MHIDAS does not show any clear criteria in this regard. Therefore, the decision has been taken to categorize an explosion followed by a re simply as an explosion. In some cases, MHIDAS lists res followed by gas clouds, due to the production of smoke. In the few cases where this happens, it is always because the smoke, which was particularly toxic, caused damage to peoples health, whereas if this did not occur, the gas cloud was not reported. Taking into account that the great majority of res do produce toxic smoke that might be classied as gas clouds (although, strictly speaking, the term gas cloud usually refers to a somewhat different phenomenon), the regas cloud sequence has simply been assimilated into the re category. The few accidents that did prove to be res or explosions followed by a release are to be considered episodic events; in these cases, the re or explosion is not the direct cause of the release (e.g. ships on re, losing control and colliding with a jetty, thus provoking a spillage). Hence, in such cases, the release event has been ignored and the accident sequence has been categorized simply as a re or explosion. MHIDAS does not always report the spillage that can cause gas clouds, while it is evident that gas clouds are a direct consequence of an unwanted gas emission; therefore, all the gas clouds have been considered to be preceded by a release.

MHIDAS does not provide IT information for 153 of the 828 accidents investigated. Of these 153, 24 are com-

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pletely lacking usable information, even in the AB (abstract) eld, and thus had to be excluded from the collection of data as far as any statistical considerations regarding the event trees was concerned. The remaining 129 could be classied as collisions without consequences and in principle could be included in the selection of accidents under a new incident type. Nevertheless, careful consideration advises against this decision. Indeed, this type of accident would account for about 16% of the usable accidents, a gure far lower than a realistic estimate. For example, Lees (1996), when summarizing the results of the Canvey Reports (Health and Safety Institute, 1978, 1981), states that the probability of a spillage occurring is 20% in the case of ship-toship collisions and groundings, and 10% in the case of berthing contacts, indicating that 8090% of ship collisions have no consequences (considering that the rst tangible outcome of a ship crash in terms of hazards may just be a release, possibly followed by a re or an explosion). Therefore, the conclusion that must be drawn is that there is a patent underrepresentation of those ship collisions that do not turn out to have negative consequences; this is due to the absence of negative effects, which often results in an accident being overlooked in a database. The information regarding these 129 accidents has not been considered further and the selection has nally been restricted to 675 (828 24 129 = 675 ) accidents, all of which resulted in some consequence in terms of release, re, explosion or gas cloud. 4. Results Taking into account the above hypotheses, the general event tree shown in Fig. 2 has been obtained. The gures in square brackets represent the probability of occurrence referred to the level immediately above (i.e. obtained from the ratio of the number of accidents to the number of accidents at the previous level). The gures at the end of every branch show the overall probability of occurrence of each specic accident sequence, with reference to the whole set of events. By an identical procedure, which was applied on reduced (and, at the same time, more homogeneous and representative) subsets of data, it has been possible to obtain event trees for the operations of approach/manoeuvre, loading/unloading and for land operations (process, storage, transport). Maintenance has not been taken into account at this stage, because only 37 accidents occurred during this operation, and developing a tree for such a small number of cases has been shown to be unrepresentative. Thus, the probability of each accident sequence occurring is shown in Table 8, where these gures are classed according to the type of operation. The following observations can be made with reference to the results shown in Table 8:

The percentage of release cases without further consequences is always the highest and, except in the case of operation approach + manoeuvre (76%), it assumes values of 50%. In general, releasere sequences account for 4.4% of cases, while releasereexplosion sequences accounts for a further 0.9%; that is to say, one out of every 13.0 releases gives way to a re. This rate is approximately the same for every operation analysed (14.3%, 12.3% and 13.3% for approach + manoeuvre, loading/unloading and land operations, respectively). The probability of a releasereexplosion sequence is close to 1% for the general event tree. Nevertheless, it is worth noting that, whilst in general one out of every 6.0 releasere events produces an explosion, such a rate is 1:4.0 for approach/manoeuvre and 1:2.3 for land operations. 5% of the accidents that happened during the loading/unloading of ships and during land operations have a releasegas cloud sequence; this rate is reduced to 1% for approach + manoeuvre. The releasegas cloudexplosion sequence, which is equivalent to a delayed explosion, is produced once every 14 times a releasegas cloud sequence occurs. Immediate explosions after a release are produced in 2.1% of cases. Fires (all types and sequences), which are not very frequent in manoeuvre and approach operations (14.6%), are more common (32.4%) during land operations (process, storage, land transport). These gures are obtained by summing up all the accidents involving a re, regardless of the stage at which the re occurs. In the general set of accidents, only one out of every 4.0 res leads to an explosion; during loading operations, this rate is one explosion for every 3.5 res; and for land operations, one for every 5.2 res. The limitations of the MHIDAS database do not allow complete knowledge of the circumstances in which the accident was produced (whether a ship is single or double hulled, collision angle, weather conditions, location of the striking point, etc.). Therefore, it is not possible to show these details in the event trees. However, several previous studies (Four Elements Limited, 1993; BTC, 2002; Det Norske Veritas, 2002) have provided semi-theoretical event trees in which probability values describing the above characteristics were given, although these are at the very least dubious. For example, Four Elements Limited (1993), when providing theoretical event trees on the consequences of the collision of fuel oil tankers against jetties, estimates that the probability of ignition of leaks on the water is 0.5. However, when looking at Table 8, such an assessment appears to be too conservative: assuming that a release

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Fig. 2.

General event tree.

Table 8 Ranking of accidental sequences, classed according to the operations that were being carried out when the accident occurred Sequence Approach+manoeuvre No. Release Releasere Releasereexplosion Releasegas cloud Releasegas cloudexplosion Releaseexplosion Fire Fireexplosion Explosion Total 152 9 3 2 0 5 12 5 11 199 Probability 0.764 0.045 0.015 0.010 0.000 0.025 0.060 0.025 0.056 1.000 Loading/unloading No. 149 15 0 13 1 7 22 15 41 263 Probability 0.566 0.057 0.000 0.049 0.004 0.027 0.084 0.057 0.156 1.000 Land operations No. 74 4 3 9 1 2 42 8 33 176 Probability 0.420 0.023 0.017 0.051 0.006 0.011 0.239 0.045 0.188 1.000

Note: this table does not include accidents that occurred during maintenance operations, as there are too few of them for reliable statistical analysis.

occurs during an approach and manoeuvre operation, the probability of ignition is 0.143 (see above).

5. Applying the chosen methodology With the event trees obtained by the method described above, it is possible to determine the probability of an accident evolving towards a certain accident sequence, according to the operation being carried out when the accident occurs (it should be noted that the probability gure shown in Fig. 2 and Table 8 does not consider accidents without consequences in terms of re, release, explosion or gas cloud). Therefore, if one could ascribe a frequency value to an accident, using the data in Table

8, it would be possible to estimate the probable frequency of occurrence of every sub-branch of the tree. Scientic literature provides several gures on frequency, which are shown in Table 9. For example, supposing one wants to estimate the frequency of occurrence of various accident sequences deriving from a single hulled ship-to-ship collision. The rst datum of Table 9 should be used, which reads 1 10 5 events per harbour movement. This must be multiplied by the gures in Table 8 under the column approach+manoeuvre, because this is the kind of operation that is usually being carried out when a ship-toship collision occurs. Thus, the event tree in Fig. 3 is obtained; it should be noted that in this gure it is not only the nal but also the intervening events that are

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Table 9 Several references describing the frequency of port accidents Type Ship-to-ship collision in port waters+release Collision of two fuel oil tankers, one of which moored+release Collision of two LPG carriers, one of which moored+release Ship-to-ship collision in approach to port (estuary) with release Berthing contact with release Impact with jetty while loading, fuel oil tanker Impact with jetty while loading, LPG carrier Grounding with release Structural failure of crude oil tanker during approach and manoeuvre Fire on-board Fire-explosion in cargo area Release from loading arms Release from ship-loading pipeline Cargo transfer failure+release, fuel oil tankers Cargo transfer failure+release, LPG carrier
a

Frequency 1.010 5a 4.810 4 1.4810 7 1.4810 8 4.610 6a 1.510 5a 2.810 4 8.1610 5 8.1610 6 610 6a 3.010 4 510 5 3.410 4 1.9410 4 2.6710 4 1.910 4 7.610 5

Units Harbour movement 1 Ship 1year 1 Harbour movement 1 Harbour movement 1 Harbour movement 1 Harbour movement 1 Ship 1year 1 Harbour movement 1 Harbour movement 1 Harbour movement 1 Ship 1year 1 Harbour movement 1 Ship 1year 1 Loading operation 1 km 1year 1 Transfer 1 Transfer 1

Source Lees (1996) BTC (2002) Four Element Four Element Lees (1996) Lees (1996) BTC (2002) Four Element Four Element Lees (1996) BTC (2002) Lees (1996) BTC (2002) BTC (2002) BTC (2002) Four Element Four Element

Limited (1993) Limted (1993)

Limited (1993) Limited (1993)

Limited (1993) (1993)

Single hulled ship.

Fig. 3.

Calculation of the frequency of occurrence of various accident sequences deriving from a single hulled ship-to-ship collision.

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Fig. 4.

Calculation of the frequency of occurrence of various accident sequences deriving from a release from a ship-loading pipeline.

assigned a frequency (e.g. the frequency of the release re sequence is the sum of the frequency of the release reexplosion and releasereno further consequence sequences). Similarly, if one is concerned about the frequency of accident sequences originating from a release from a ship-loading pipeline, the initial frequency of 2.67 10 4 km 1 year 1 (Table 9) should be used, together with the data under the Loading/unloading column in Table 8, thus obtaining the event tree in Fig. 4.

6. Conclusions In spite of the evident lack of information in the MHIDAS database, it has been possible to analyse the accident sequences of more than 800 accidents occurring in port areas. Furthermore, it has been possible to ascertain the probability of different scenarios occurring by considering, on one hand, the accidents as a whole and, on the other, the operations that were being carried out

when the events took place (approach, loading/unloading, etc.). By using this new methodology, once the frequency of the initial event has been ascertained (such as shipto-ship collision, berthing contact, etc.), it is possible to ascribe a frequency value to the sequence scenarios, by multiplying the probability of occurrence by the frequency of the root event. The reliability of this procedure is proved by a wide range of historically documented accidents. Lastly, a signicant amendment of scientic literature containing probability data and based on expert opinion can be achieved by carefully considering the results obtained. This often leads to the conclusion that probability data in scientic literature, when not supported by historical analysis, tend to be too conservative. References
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