Definitions

Accident: a specific unplanned event or sequence of events that has a specific undesirable consequence consequence. Consequences: the results of an accident event sequence. It is originally considered to be the fire, explosion, and release of toxic material that results from the accident, but not the health effects, economic loss, etc., which is the ultimate result.
Battelle, Guidelines for Hazard Evaluation Procedures, AIChE, New York (1985).

EXAMPLES
Feyzin, France, 1966 Fixborough, England, 1974 Bhopal, India, 1984

TABLE 1-1. ELEMENTS OF ACCIDENTS

Hazards Initiating Event/Upsets Intermediate Events (System or Operator Responses to Upsets) Propagating Ameliorative Process Parameter Deviations a) Pressure b) Temperature c) Flow Rate d) Concentration e) Phase/State Change Safety System Responses a) Relief Valves b) Back-up Utilities Fires c) Back-up Components d) Back-up Systems Explosions Impacts Accident Consequences

Significant Inventories of a) Flammable Materials b) Combustible Materials c) Unstable Materials d) Toxic Materials e) Extremely Hot or Cold Materials f) Inerting Gases (Methane, Carbon Monoxide) Highly Reactive a) Reagents b) Products c) Intermediate Products d) By-products

Machinery and Equipment Malfunctions a) Pumps, Valves b) Instruments, Sensors

Containment Failures a) Pipes b) Vessels c) Storage Tanks d) Gaskets

Containment Failures a) Pipes b) Vessels c) Storage Tanks d) Gaskets, Bellows, etc. e) Input/output or venting

Mitigation System Responses a) Vents b) Dikes c) Flares d) Sprinklers

Dispersion of Toxic Materials Dispersion of Highly Reactive Materials

Hazards

Initiating Event/Upsets

Intermediate Events (System or Operator Responses to Upsets) Propagating Ameliorative Material Releases a) Combustibles b) Explosive Materials c) Toxic Materials d) Reactive Materials Ignition/Explosion Operator Errors Control Responses Operator Responses a) Planned b) Ad Hoc

Accident Consequences

Reaction Rates Especially Sensitive to a) Impurities b) Process Parameters

Human Errors a) Operations b) Maintenance c) Testing

Loss of Utilities a) Electricity b) Water c) Air d) Steam

Contingency Operations

a) Alarms b) Emergency Procedures a) Omission c) Personnel Safety b) Commission d) Evacuations c) Diagnosis/Decision-Making e) Security External Events a) Delayed Warning b) Unwarned External Events a) Early Detection b) Early Warning

External Events a) Floods b) Earthquakes c) Electrical Storms d) High Winds e) High Velocity Impacts f) Vandalism Method/Information Errors a) As Designed b) As Communicated

Method/Information Failure a) Amount b) Usefulness c) Timeliness

Information Flow a) Routing b) Methods c) Timing

DEFINITIONS
Incident
The loss of containment of material or energy (e. g., a leak of 10 1b/sec of ammonia from a connecting pipeline to the ammonia tank, producing a toxic vapor cloud).

Incident Outcome
The physical manifestation of the incident; for toxic materials, the incident outcome is a toxic release, while for flammable materials, the incident outcome could be a BLEVE (Boiling Liquid Expanding Vapor Explosion), flash fire, unconfined vapor could explosion, etc. (e. g., for a 10 1b/sec leak of ammonia, the incident outcome is a toxic release).

Incident Outcome Case

The quantitative definition of a single result of an incident outcome through specification of sufficient parameters to allow distinction of this case from all others for the same incident outcome [e. g., a concentration of 3333 ppm (v) of ammonia 2000 ft downwind from a 10 1b/sec ammonia leak is estimated assuming a 1.4 mph wind, and Stability Class D].

Consequence
A measure of the expected effects of an incident outcome case (e. g., an ammonia cloud from a 10 1b/sec leak under Stability Class D weather condition, and 1.4 mph wind traveling in a northerly direction will injure 50 people).
*CCPS, Guidelines for Chemical Process Quantitative Risk Analysis, AIChE, New York (1989)

INCIDENTS

INCIDENT OUTCOMES
Toxic Vapor Atmospheric Dispersion

INCIDENT OUTCOME CASES

5 mph Wind, Stability Class A 10 mph Wind, Stability Class D 15 mph Wind, Stability Class E o o o etc.

100 1b/min Release of HCN from a Tank Vent

Jet Fire

BLEVE of HCN Tank

Tank Full Tank 50% Full o o o etc. After 15 min. Release After 30 min. Release After 60 min. Release o o o etc.

Unconfined Vapor Cloud Explosion

The relationship between incidents, incident outcomes, and incident outcome cases for a hydrogen cyanide (HCN) release.

Definitions
Hazard
a physical situation with a potential for human injury, damage to property, damage to environment or some combination of these. (IChem E) a characteristic of the system/plant/process that represents a potential for an accident. (AIChE)

Risk
the likelihood of a specified undesirable event occurring within a specified period or in specified circumstances. (IChem E) a measure of potential economic loss or human injury in terms of the probability of the loss or injury occurring and the magnitude of the loss or injury if it occurs. (AIChE)

TYPICAL HAZARDS
Significant inventories of: Extreme physical conditions Flammable materials Combustible materials Unstable materials Corrosive materials Asphyxiants Shock sensitive materials Highly reactive materials Toxic materials Inerting gases Combustible dusts Pyrophoric materials High temperatures Cryogenic temperatures High pressures Vacuum Pressure cycling Temperature cycling Vibration/liquid hammering

TASKS OF HAZARD ASSESSMENT

1. 2. 3. 4. Identification of undesired events. Analysis of the mechanisms by which undesired events could occur. Consideration of the extent of any harmful effects. Consideration of the likelihood of the undesired events and the likelihood of specific detrimental outcomes. Likelihood may be expressed as probability or frequency. Judgements about the significance of the identified hazards and estimated risks. Making and implementing decisions or courses of action, including ways of reducing the likelihood or consequences of undesired events.

5. 6.

Risk Assessment Procedure

System Description

Hazard Identification

Accident Probabilities Estimation Risk Determination

Risk Acceptance

Accident Consequences Estimation

No

Modify System

Yes
Operate System

hazard, risk, safety + analysis, assessmentevalution = ?

Hazard identification = (1) + (2) Hazard Analysis = (1) + (2) + (3) + (4)
qualitative

Risk Analysis = (1) + (2) + (3) + (4)

quantitative

(Hazard Assessment) or (Hazard Evaluation) = (1) + (2) + (3) + (4) + (5) + (6)
qualitative

Risk Assessment = (1) + (2) + (3) + (4) + (5) + (6)

quantitative

Hazard Identification and Assessment

Hazard Identification
the techniques for finding out what hazards are present in a plant or process.

Hazard Assessment
the techniques for deciding how far we ought to go in removing the hazards or protecting people from them.

Results of Hazard Identification and Assessment

Identification and description of hazards which could lead to undesirable consequences. Identification and description of the mechanisms leading to the hazardous event, i. e. accident event sequence. A qualitative estimate of the likelihood and/or consequence of each accident event sequence. A quantitative estimate of risk, which can be compared with acceptable risk to determine whether or not expenditure on particular safety measure is justified. A relative ranking of the risk of each hazard and accident event sequence. Some suggested approaches to risk reduction.

Possible Actions to Reduce Risk

A change in the physical design and control system. A change in the operating procedure. A change in process configuration or conditions. A change in the process material. A change in the testing, inspection/calibration and maintenance procedure of key safety items.

Classification of Risk Reduction Measures

1. Those actions which eliminate hazard (substitution) 2. Those actions which reduce the likelihood of its occurrence to an acceptable level. (attenuation) 3. Those actions which eliminate or reduce its consequence. (second chance)

[Example] Consider a reaction vessel where, in a

HAZOP session, it was discovered that if a certain impurity were introduced with one of the raw materials, there would be a sudden evolution of gas and an increase in pressure.

Solution
Eliminating the possibility of gas evolution by changing the raw material responsible for the problem.

(substitution)
Lowering the possibility of gas evolution by altering one of the process condition. (attenuation) Fitting an appropriate pressure relief valve and vent system to protect the plant. (second chance)

Hazard Evaluation procedures Steps in Hazard Evaluation Process Process/ System Checklists Safety Review Relative Ranking Dow & Mond Preliminary Hazard Analysis What If Method

Identify Deviations From Good Practice Identify Hazards Estimate Worst Case Consequences Identify Opportunities to Reduce Consequences Identify Accident Initiating Events Estimate Probabilities of Initiating Events

Primary Purpose Primary Purpose*

Primary Purpose Primary Purpose*

Primary Purpose Primary Purpose* Primary Purpose Primary Purpose Secondary Purpose Primary Purpose Primary Purpose Primary Purpose

Primary Purpose

MATRIX RELATING HAZARD EVALUATION PROCEDURES TO HAZARD EVALUATION PROCESS STEPS (upper left)

Hazard Evaluation procedures Steps in Hazard Evaluation Process Identify Opportunities to Reduce Probabilities of Initiating Events Identify Accident Event Sequences and Consequences Estimate Probabilities of Event Sequences Estimate Magnitude of Consequences of Event Sequences Identify Opportunities to Redure Probabilities and/or Consequences of Event Sequences Quantitative Hazard Evaluation Primary Purpose Process/ System Checklists Safety Review Relative Ranking Dow & Mond Preliminary Hazard Analysis What If Method

MATRIX RELATING HAZARD EVALUATION PROCEDURES TO HAZARD EVALUATION PROCESS STEPS (lower left)

Steps in Hazard Evaluation Process

Hazard Evaluation procedures Failure Modes Hazard and Effects and Fault Event Cause Human Operability Criticality Tree Tree Consequence Error Study Analysis Analysis Analysis Analysis Analysis

Identify Deviations From Good Practice Identify Hazards Estimate Worst Case Consequences Identify Opportunities to Reduce Consequences Identify Accident Initiating Events Estimate Probabilities of Initiating Events Primary Purpose Provides Context Only Provides Context Only Primary Purpose Provides Context Only Primary Purpose Primary Purpose Provides Context Only Primary Purpose Provides Context Only Primary Purpose Primary Purpose Provides Context Only

Primary Purpose

Primary Purpose

Primary Purpose

MATRIX RELATING HAZARD EVALUATION PROCEDURES TO HAZARD EVALUATION PROCESS STEPS (upper right)

Steps in Hazard Evaluation Process Identify Opportunities to Reduce Probabilities of Initiating Events Identify Accident Event Sequences and Consequences Estimate Probabilities of Event Sequences Estimate Magnitude of Consequences of Event Sequences Identify Opportunities to Reduce Probabilities and/or Consequences of Event Sequences Quantitative Hazard Evaluation

Hazard Evaluaton procedures Failure Modes Hazard and Effects and Fault Event Cause Human Operability Criticality Tree Tree Consequence Error Study Analysis Analysis Analysis Analysis Analysis Primary Purpose Primary Purpose Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose Provides Context Only

Primary Purpose Provides Context Only

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

Primary Purpose

MATRIX RELATING HAZARD EVALUATION PROCEDURES TO HAZARD EVALUATION PROCESS STEPS (lower right)

What is acceptable risk?

Acceptable Risk
Most treatment of acceptable risk deal primarily with the risk of death. This may appear somewhat arbitrary. But there is justification for this approach:
Data on fatalities are most possibly recorded and are relatively straightforward. (number of fatalities) (number of other injuries) measures which reduce death from a particular hazard tend to reduce injuries as well.

Computation of Risk
1 r N 1 N

x f
i 1 i n i i

N P f
i 1

where, fi = the rate at which the event occurs (event/year) xi = number of fatalities per event i (death/event) Ni = number of peoples exposed to event i (number of exposed peoples/event) Pi = the probability of fatalities among the exposed people (death/exposed people) N = total number of peoples at risk

Fatal Accident Frequency Rate (FAFR)

fatalities FAFR 8 10 (men ) ( exposed hours)
Total number of deaths due to accidents 108 Total number of workers Average total working hours in a specified period
* Based on the total working hours of 1000 employees (2000 hr/year and 50 year/person).

Table 9.2 Fatal Accident Rates in different industries and jobs in the U.K.
Fatal Accident Rate (FAR) (deaths/108 exposed hours) Clothing and footwear industry Vehicle industry Chemical industry British industry Steel industry Agricultural work Fishing Coal mining Railway shunting Construction work Air crew Professional boxers Jockeys (flat racing) 0.15 1.3 3.5(a) 4 8 10 35 40(b) 45 67 250 7000 50000

(a). This value of the FAR for the chemical industry predates Flixborough. If the Flixborough fatalities are averaged over 10 years the value becomes 5. (b). This value is now appreciably less. Sources: Sowby (1964), Pochin (1975), Kletz (1971,1976d)

Table 9.3 Fatal Accident Rates for the chemical industry in different contries Fatal Accident Rate (FAR) (deaths/108 exposed hours) France West Germany United Kingdom (before Flixborough) 8.5 5 4

(including Flixborough)
United States
Sources: Sowby (1964), Pochin (1975), Kletz (1971,1976d)

5
5

Table 9.4 Fatal Accident Rates for some non-industrial activities

Fatal Accident Rate (FAR) (deaths/108 exposed hours) Staying at home Travelling: by bus by train by car by bicycle by air by moped by motor scooter by motor cycle Canoeing Rock climbing
Sources: Sowby (1964), Pochin (1975), Kletz (1971,1976d)

3 3 5 57 96 240 260 310 660 1000 4000

Maximum Risk to Employees

FAFR m ax 3.5 ~ 4.0

(Kletz, 1986)

FAFRmax 5.0

(U.S.)

Fatality Rate per Person per Year

Annual death toll due to a common cause (unrelated to working hour) Total number of individuals in a population

Table 9.5 Death rates for some voluntary and involuntary risks (after Kletz, 1976d)
Fatality rate (deaths per person per year) Voluntary risk Taking contraceptive pill Playing football Rock climbing Car driving Smoking (20 cigarettes/day) 2 10-5 4 10-5 4 10-5 17 10-5 500 10-5 6 10-11 0.2 10-7 0.2 10-7 0.5 10-7 1 10-7 1 10-7 Reference

Gibson (1976c) Pochin (1975) Pochin (1975) Roach (1970) Pochin (1975) Wall (1976) Gibson (1976c) Wall (1976) Bulloch (1974) Turkenburg (1974)

Involuntary risk Meteorite Transport of petrol and chemicals (U.K.) Aircraft crash (U.K.) Explosion of pressure vessel (U.S.A.) Lightning (U.K.) Flooding of dikes (Netherlands) Release from nuclear power station (at 1 km) (U.K.) Fire (U.K.) Run over by road vehicle Leukemia

1 10-7 150 10-7 600 10-7 800 10-7

Melinek (BRE 1974 CP 88/74) Gibson (1976c)

Acceptable Risk to Public

Voluntary:
10-5/person/year

Involuntarily:
Natural Disaster
10-5/person/year Man-made 10-7/person/year

Maximum Risk to Public (Kletz)

Averaged over the whole population (average risk)
10-7/person/year

For anyone in public (individual risk)

10-5 to 10-6/person/year

OSHA Incidence Rate

OSHA Incidence Rate (injury or sickness)
= (total number of injuries/sicknesses ) (total working hours of all employees) 200,000

OSHA Incidence Rate (loss of work days)

= (total number of lost work days) (total working hours of all employees) 200,000

Based on the total working hours of 100 employees in 1 year (2000 hr/year).