Systems thinking in a gas explosion accident - lessons learned from Taiwan

摘要

On July 31, 2014, at around 23:57, several huge explosions occurred that lasted for 2 h in Kaohsiung City, Taiwan. As a result of a gas leak from a ruptured underground pipeline, the catastrophic incident destroyed more than 6 km of roads, killed 32 people, injured 321 people, and damaged 3259 buildings. Pipeline explosions have been reported as a repeatedly occurring problem, indicating that (1) complex systems are difficult to manage and control, and (2) humans are unable to effectively learn from experiences of accidents. Initial analyses results reveal that root causes of this incident were a combination of a series of complex chain reactions, which eventually led to propylene leakage and explosion. This is a systematic problem, which can hardly be investigated or analyzed by traditional research approaches. Based on the investigation reports and "systems thinking" method, this study develops causal loop diagrams for the Kaohsiung gas explosion to explore the root causes of the disaster. The research results indicate that (1) this pipeline explosion incident was the result of the chain reactions and was the output of a complex system; (2) the mental model of "production first" and "experience gap" were the root causes of the disaster, and (3) to achieve a higher safety standard, continuous education to improve the mental model of "safety first and safety over production" are essential. The findings of this study may contribute toward the improvement of the standard operating procedure for disaster management and preventing similar incidents in the future.