CAST UYGULAMASI: CAPECO ÇOKLU TANK PATLAMASI ÖRNEK ÇALIŞMA

Year 2022, Volume: 10 Issue: 1, 74 - 83, 23.03.2022

Müge Ensari Özay

https://doi.org/10.21923/jesd.936013

Abstract

Petrol ürünleri gibi tehlikeli kimyasalların neden olduğu büyük endüstriyel kazalar kimya ve petrol işleme endüstrilerinde nadir görülmesine rağmen, önemli mali kayıplara, ölümlere ve ciddi çevresel etkilere neden olmaktadırlar. Geleneksel kaza inceleme yöntemleri doğrusal sistemler için iyi çalışsa da, sistemler teorisine dayanan bir kaza analizi yöntemi, büyük endüstriyel kazaların analiz edilmesinde daha etkili olmaktadır. Bu çalışma, Karayip petrol tankı terminal patlamasını Sistemler teorisi yöntemine dayalı nedensel analiz (CAST) yöntemini kullanarak analiz etmektedir. Karayip petrol tankı terminal patlaması, son 50 yıldaki en büyük tank olaylarından biridir. CAST analizi sırasında CAPECO kazasıyla ilgili doğrudan ve dolaylı nedensel faktörler ortaya çıkarılmıştır. Yönetim standardizasyonu ve operasyonel sistemlerin eksikliği, kazanın önde gelen doğrudan nedenleri olarak belirlenmiştir. Diğer ana nedenler, bağımsız bir otomatik taşma önleme sisteminin olmaması, en kötü durum senaryosunun dikkate alınmaması, güvenilmez kritik ekipman ve terminal alanına yayılan büyük bir taşan buhar bulutunun tespit edilememesi olarak belirlendi. Çalışma, CAST'ın bir sistemin farklı hiyerarşik seviyelerinde birçok nedensel faktörü ortaya çıkarabileceğini göstermektedir.

Keywords

Kaza Analizi, Patlama, Güvenlik Yönetimi, İş Güvenliği, Büyük Endüstriyel Kaza

CAST APPLICATION: A CASE STUDY OF CAPECO MULTIPLE TANK EXPLOSION

Abstract

Although major industrial accidents caused by hazardous chemicals such as petroleum products are rare in the chemical and petroleum processing industries, they cause significant financial losses, deaths and serious environmental impacts. Even though traditional accident investigation methods work well for linear systems, an accident analysis method built on systems theory helps to analyze major industrial accidents. This study analyzes the Caribbean petroleum tank terminal explosion using Causal Analysis based on Systems Theory (CAST) method. The main purpose of this research is to examine the causes of the accident with a risk assessment based on systems theory apart from traditional methods. The Caribbean petroleum tank terminal explosion was chosen for the study because it was one of the largest tank accidents in the last 50 years. In order to prevent future accidents, it is of great importance to analyze past accidents by analyzing them with new methods. For this purpose, various data and documents related to CAPECO accidents were examined in detail within the framework of CAST methodology. The CAST analysis revealed direct and indirect causal factors related to the CAPECO accident. The lack of management standardization and operational systems were the leading direct causes for the accident. Other main reasons were identified as the absence of an independent automatic overfill prevention system, a lack of considerations on the worst-case scenario, unreliable critical equipment, and inability to detect a large overflowing vapor cloud spreading into the terminal area. The study indicates that CAST methodology can reveal many causal factors at different hierarchical levels of a system.

Keywords

Accident Analysis, Explosion, Safety Management, Occupational Safety, Major Industrial Accident

References

• Accou, B., Reniers, G., 2019. Developing a method to improve safety management systems based on accident investigations: The SAfety FRactal Analysis. Safety Science, 115, 285–293.
• Altabbakh, H., AlKazimi, M.A., Murray, S., Grantham, K., 2014. STAMP - Holistic system safety approach or just another risk model?. Journal of Loss Prevention in the Process Industries, 32, 109–119,
• Atkinson, G., Cowpe, E., Halliday, J., Painter, D. 2017. A review of very large vapour cloud explosions: Cloud formation and explosion severity. Journal of Loss Prevention in the Process Industries, 48, 367–375.
• Casal, J., 2018. Evaluation of the effects and consequences of major accidents in industrial plants. Cambridge, MA: Elsevier.
• CSB. 2010. Caribbean Petroleum Tank Terminal Explosion and Multiple Tank Fires. Investigation Report, No. 2010.02.I.PR, US Chemical Safety and Hazard Investigation Board, Washington, DC.
• Doğan, B., Scarabella, H.A., Akman, A., 2020. Proses Güvenliği Kazalardan Çıkarılan Dersler. ÇASGEM, Ankara, Turkey.
• Düzgün H. S., Leveson, N., 2018. Analysis of soma mine disaster using causal analysis based on systems theory (CAST). Safety Science, 110, 37–57.
• Gür, B., Yavuz, Ş., Çakır, A, D., Köse, D, A., 2021. Determination of Hazards and Risks in a Solar Power Plant Using the Matrix Risk Analysis. European Journal of Science and Technology, 23, 497-511.
• Hou, J., Gai, W., Cheng, W., Deng, Y., 2021. Hazardous chemical leakage accidents and emergency evacuation response from 2009 to 2018 in China: A review. Safety Science, 135, 105101,
• Johnson, D.M., 2010. The potential for vapor cloud explosions - Lessons from the Buncefield accident. Journal of Loss Prevention in the Process Industries, 23, 921–927.
• Jung, S., Woo, J., Kang, C., 2020. Analysis of severe industrial accidents caused by hazardous chemicals in South Korea from January 2008 to June 2018. Safety Science, 124, 104580.
• Kaya, G., Ovalı, H. ve Özturk, F., 2019. Using the functional resonance analysis method on the drug administration process to assess performance variability. Safety Science, 118, 835-840.
• Kim, T.E., Nazir, S., Øvergård, K. I., 2016. A STAMP-based causal analysis of the Korean Sewol ferry accident. Safety Science, 83, 93–101.
• Leveson, N.G., 2011. Applying systems thinking to analyze and learn from events. Safety Science, 49 (1), 55–64.
• Leveson, N.G., 2012. Engineering a Safer World: Systems Thinking Applied to Safety. The MIT Press, Cambridge, England.
• Leveson, N.G., 2019. CAST HANDBOOK : How to Learn More from Incidents and Accidents.
• Li, F., Wang, W., Xu, J., Dubljevic, S., Khan, F., Yi, J., 2020. A CAST-based causal analysis of the catastrophic underground pipeline gas explosion in Taiwan. Engineering Failure Analysis, 108, 104343.
• Marsh Report. 2018. The 100 Largest Losses 1978-2017 Large Property Damage Losses in the Hydrocarbon Industry. 25th Edition, Marsh Ltd.
• Mogles, N., Padget, J., Bosse, T., 2018. Systemic approaches to incident analysis in aviation: Comparison of STAMP, agent-based modelling and institutions. Safety Science, 108, 59–71.
• Ni, Y., Sattari, F., Lefsrud, L., Tufail, M., 2020. A rising tide raises all boats: Regional promotion of process safety through joint government/industry management. Journal of Loss Prevention in the Process Industries, 68, 104331.
• Saleh, J. H., Marais, K. B., Bakolas, E., Cowlagi, R.V., 2010. Highlights from the literature on accident causation and system safety: Review of major ideas, recent contributions, and challenges. Reliability Engineering & System Safety, 95, 1105–1116.
• Underwood P., Waterson, P., 2013. Systemic accident analysis: Examining the gap between research and practice. Accident Analysis and Prevention, 55, 154–164.
• Zhang, Q., Zhou, G., Hu, Y., Wang, S., Sun, B., Yin, W., Guo, F., 2019. Risk evaluation and analysis of a gas tank explosion based on a vapor cloud explosion model: A case study. Engineering Failure Analysis, 101, 22–35.