Analyzing Historic Process Data to Identify Near Misses and Warning Signs: Examples from the Buncefield Incident

摘要

Process data is often analyzed during the investigation of industrial fires and explosions. Such analyses sometimes reveal prior near misses or warning signs that foreshadow the eventual causes of a catastrophic event. In some cases the facility may have been unaware of these near misses or not realized their frequency. Proactive analysis of process data prior can be a tool to allow facilities to identify additional near misses and warning signs, and address problems before a catastrophic event occurs. Such techniques are currently being used in a voluntary safety program in the commercial aviation industry. In this paper we examine historical process data from the Buncefield Fuel Terminal. A December 2005 explosion and fire at the facility was caused by the overflow of approximately 300 m3 of premium gasoline from a storage tank. The historical process data from the facility identified multiple reoccurring near misses or warning signs that preceded the December 2005 event. These include sticking of tank level gauges and reliance of operators on alarms. With the benefit of hindsight, it can be argued that, had the facility proactively evaluated their near misses prior to the incident, these warnings signs may have been more fully understood and addressed. In this paper we describe the ways in which this facility could have recognized the significance of the frequent occurrences of equipment failure and operator reliance on alarms in the months prior to the incident and acted upon it.