Bir Sıcak İş Kazasının Olaylar ve Nedensel Faktörler Analizi İle Araştırılması ve Balık Kılçığı Diyagramı ile Kök Sebeplerinin Bulunması: Dupont Tedlar Üretim Tesisi Örneği

Year 2022, Volume: 37 Issue: 4, 863 - 874, 30.12.2022

Onur Şahin Nuri Bingöl Uğur Sur

https://doi.org/10.21605/cukurovaumfd.1230782

Abstract

Proses endüstrisindeki çoğu kaza tesislerin proses emniyeti sisteminde gerçekleşen ihlallerden kaynaklanmaktadır. 9 Kasım 2010’da Dupont şirketine ait New York’ta ki bir kimyasal tesiste sıcak iş çalışması sırasında vinil florür depolanan tankta meydana gelen patlama da bu kazalardan biridir. Kaza bir ölüm ve bir yaralanma ile sonuçlanmıştır. Bu makale ile endüstriyel tesislerde sıcak iş çalışmalarından kaynaklanan kazaların ve yaralanmaların yaşanmaması için kazanın kök sebeplerini ortaya koyarak endüstrinin faydalanabileceği ve proses emniyeti yönetim sistemlerine entegre edebileceği bir çalışma olması amaçlanmıştır. Olaylar ve nedensel faktörler (events and causal factors) yöntemi ile kazanın oluşmasındaki etkenler belirlenmiş, elde edilen faktörlere göre balık kılçığı diyagramı ile kazanın 5M (Management-Machine-Man-Material-Method) başlıkları altındaki kök sebeplerine ulaşılmıştır. Kazanın ana nedenleri bakım onarım ve alt işveren yönetimindeki kusurlar, emniyete alma sistemindeki belirsizlikler, iş izin yönetim sürecindeki eksiklikler ve tank-borulama sistemindeki tasarım eksiklikleri olarak tespit edilmiştir. Tehlikeli kimyasalların bulunduğu alanlarda yapılan çalışmalarda proses emniyeti gerekliliklerinin eksiksiz olarak yerine getirilmesi ve sürdürülebilirliğinin sağlanması bu tür kazaların önlenmesindeki başlıca unsurdur.

Keywords

Sıcak işler, Patlama, Bakım yönetimi, Olaylar ve nedensel faktörler analizi, Balık kılçığı yöntemi

Investigation of a Hot Work Accident by Events and Causal Factors Analysis and Finding Root Causes with Fishbone Diagram: The Example of Dupont Tedlar Production Plant

Abstract

Most accidents in the process industry result from violations of the plant’s process safety system. One of these accidents is the explosion of a vinyl fluoride storage tank on November 9, 2010, during hot work at a Dupont company’s chemical plant in New York. The accident resulted in one death and one injury. With this article, it is aimed to be a study that the industry can benefit from and integrate it into process safety management systems by revealing the root causes of the accident in order to prevent accidents and injuries caused by hot works in industrial facilities. The factors in the occurrence of the accident were determined by the events and causal factors method and the root causes of the accident under the 5M (Management-Machine-Man-Material-Method) headings were reached with the fishbone diagram according to the factors obtained. The main causes of the accident were identified as defects in maintenance and subcontractor management, uncertainties in the safety system, deficiencies in the work permit management process and design deficiencies in the tank-piping system. Fulfilling the process safety requirements and ensuring its sustainability in the works carried out in the areas where hazardous chemicals are present are the main factors in the prevention of such accidents.

Keywords

Hot works, Explosion, Maintenance management, Events and causal factors analysis, Fishbone method

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