Case study of the Tianjin accident: Application of barrier and systems analysis to understand challenges to industry loss prevention in emerging economies

摘要

Accident analysis methods are widely used in industry to understand how companies with seemingly strong safety management systems failed to prevent a serious incident. These methods can equally be used to help governments, particularly in emerging economies, to analyse industrial incidents to understand how their institutions may be failing to control risk, providing insight into potential improvements while also extracting lessons for other emerging economies with similar risk profiles. The fire and explosion accident of the Ruihai hazardous goods warehouse at Tianjin Port, China, that occurred on 12 August 2015 is a prime example of a common emerging economy dilemma. Emerging economies typically struggle for years, sometimes decades, to build the capacity sufficient to address the challenges of sustainability that accompany rapid and wide-spread economic development. These economies experience particularly high rates of serious and catastrophic industrial disasters, with significantly higher rates of injury, death and environmental impacts in comparison to more mature developed economies. Yet, in many of these incidents, the country may already have some, or even substantial, legal frameworks in place to address industrial risk. In the case of Tianjin, China has strengthened industrial law substantially since the early 2000s to establish more rigorous control over chemical hazard sources. In this circumstance, understanding the sequence of events, and missed opportunities by various actors to prevent the accident and mitigate its impacts could provide support to targeted improvements to risk governance in China, and also other countries who are striving to impose a higher standard of industrial risk management. This paper describes a study in which accident analysis methods based on bow tie barrier analysis and safety systems theory were used to analyse the institutional failures that contributed to the occurrence and severity of the Tianjin disaster. The resulting analysis shows that the application of accident analysis methods to industrial disasters can highlight weaknesses in the evolving governance systems of emerging economies that may also offer lessons to other countries who are also on a similar path. (C) 2019 Institution of Chemical Engineers. Published by Elsevier B.V. All rights reserved.