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Chemical Process Safety Accident Investigation Best Practices for Government Agencies Chemical Process Safety Accident Investigation Best Practices for Government Agencies 化工安全事故调查的最佳实践化工安全事故调查的最佳实践 David A. Moore, PE, CSP, CPSA President, AcuTech Consulting Group 1919 Gallows Road, Suite 900 Vienna, VA, USA 22101 www.acutech- Allan Su Senior Engineer, AcuTech Consulting Group 210 Central Avenue, Pudong Shanghai, China www.acutech- About AcuTech Consulting GroupAbout AcuTech Consulting Group A Global leader in process safety and security risk management consulting since 1994 成立于1994年，过程安全，安保风险管理的顶尖咨询公司 Offices in US, China, Mideast, India 在美国，中国，中东和印度设有分公司 Thought leadership plus technical excellence in process safety services and investigations 在过程安全服务和技术方面处于国际领先位置。 Wrote CCPS Auditing, Metrics, Inherently Safer, and Culture Guidelines 为CCPS编写了“审核”“指标”“本质安全”“运输”和“过程安全文化”等指导书。 Involved in important incident investigations and cooperation with CSB, OSHA, EPA and other agencies 参与过CSB，OSHA，EPA以及其他政府机关针对重大事故的调查 Connection with CSB because three AcuTech employees have worked for the CSB; 1 – lead investigation team supervisor; 2 – er board members including a er Chairman of the Board 公司内有两位前CSB委员会成员，其中一位为CSB前主席，另外有一位调查组组长在公司就职。 Index 议 题Index 议 题 Introduction to topics of discussion CSB history, purpose, structure, issues CSB的历史，设立的目标，管理结构和权力 CSB investigation approach CSB的调查方法和策略 Recommended investigation s for government authorities 政府机关事故调查的建议 www.csb.gov CSB独特的事故调查技术 调查设备 – 全组行动工具箱 –调查工具 微型磁带录音机 磁带和电池 手电和电池 警戒带 “不准进入” 望远镜 卷尺 放大镜 指南针 录影设备 静态摄影设备 自封塑料袋 镊子 Chain-of-custody s and stickers监管链表格和表格 工具箱 布基胶带 塑料地垫 CSB通常会花更多的调查时间 CSB Mission CSB Mission 愿景愿景 Mission 愿景愿景 The mission of the U.S. Chemical Safety and Hazard Investigation Board CSB is to independently investigate significant chemical incidents and hazards and effectively advocate for the implementation of the resulting recommendations to protect workers, the public, and the environment. 美国化工安全和危害调查委员会（CSB的设立是为了独立的对发生的严重化工 事故和危害进行调查，通过提出有效改进建议并督促执行以有效提高对员工， 公众和环境的有效保护。 Origins of the U.S. Chemical Safety Board CSB 美国化工安全委员会（CSB）的起源 Origins of the U.S. Chemical Safety Board CSB 美国化工安全委员会（CSB）的起源 Concept of CSB was born in the wake of the Bhopal India chemical accident 1984. 设立CSB的最初想法源于1984年印度博帕尔Bhopal严重的化工事故之后。 Passed by U.S. Congress in 1990 under the Clean Air Act Amendments of 1990 Pub. L. No. 101-549. 1990年美国国会通过的清洁空气法案包括了设立CSB的条款，具体条款见 Clean Air Act Amendments of 1990 Pub. L. No. 101-549. Bhopal, India – 3 December 1984Bhopal, India – 3 December 1984 U.S. Regulatory ResponsesU.S. Regulatory Responses 事故后美国通过的相应立法事故后美国通过的相应立法 This history of catastrophic events culminated in the establishment of two significant U.S. federal process safety and risk management regulations 这起灾难空前的事故促成了美国联邦政府通过了两部过程安全和风险 管理的法律和相应的机构 U. S. Occupational Safety its function is investigatory. NTSB本身不具有对交通行业的任何法规执法权，其功能仅为事 故调查 Independent concept is to avoid conflict of interest. 其独立性是为了避免利益冲突 CSB Strategic Goals CSB的目标 CSB Strategic Goals CSB的目标 Strategic Goals目标目标 Goal 1 – Conduct incident investigations and safety studies concerning releases of hazardous chemical substances. 对可能造成有害化学物质泄漏的事故进行调查和安全评估。对可能造成有害化学物质泄漏的事故进行调查和安全评估。 1. Select incidents and hazards for investigation which have high potential to generate recommendations with broad preventive impact. 选取具有代表性，并可能通过调查提出广泛改进意见的事故和危害进行调查。 2. Complete timely, high-quality investigations that examine the technical, management systems, organizational and regulatory causes of chemical incidents. 对事故进行及时且高质量的原因调查，调查对象包括技术，管理体系，组织架构和法规缺陷。 3. Develop recommendations that will help prevent chemical incidents. 为防止以后化工事故提出建议 4. Complete studies with broad safety and environmental preventive impact. 对防治广泛安全和环境影响提供分析 5. Advance the identification and understanding of new and recurring issues in chemical safety and the environment. 对确定和理解化工安全和环境的新风险和问题提供建议 Legislative Authority 法律授权Legislative Authority 法律授权 42 U.S. Code 7412 6 Chemical Safety Board 1990 A Established an independent safety board to be known as the Chemical Safety and Hazard Investigation Board. 建立一个独立的安全委员会命名为“化工安全与危害调查委员会” B The Board shall consist of 5 members, including a Chairperson, who shall be appointed by the President, by and confirmed by the Senate. 该委员会由包括一位主席在内的五位委员组成，委员由总统提名，并由 参议院确认通过。 The terms of office of members of the Board shall be 5 years. 每位委员任期5年。 Duties of the CSB CSB的责任Duties of the CSB CSB的责任 C The Board shall-委员会的责任 i investigate and report to the public in writing the facts, conditions, and circumstances and the cause or probable cause of any accidental release resulting in a fatality, serious injury or substantial property damages; 对所有由于化学泄露造成人员死亡，严重受伤或重大财产损失的事故进 行调查，并向公众公布包括事故事实，发生条件，造成影响，事故原因， 可能原因在内的报告。 ii issue periodic reports to the Congress, Federal, State and local agencies, including the Environmental Protection Agency EPA and the Occupational Safety and Health Administration OSHA 对美国国会，联邦，州和地方政府的OSHA，EPA机构提供周期性报告。 Coordination with Other Agencies and Scope of Investigation Authority 与其他调查机构之间的合作 Coordination with Other Agencies and Scope of Investigation Authority 与其他调查机构之间的合作 The CSB must investigate an accidental release that caused a fatality or serious injury among the general public, or had the potential to cause substantial property damage or a number of deaths or injuries among the general public. CSB必须调查造成厂内死亡，公众重伤或有可能造成严重经济损 失和多人死亡或受伤的化学品相关事故 Research, Evidence, and Recommendations 研究职能 Research, Evidence, and Recommendations 研究职能 F The Board is authorized to conduct research and studies with respect to the potential for accidental releases, whether or not an accidental release has occurred CSB is not limited to regulatory requirements. CSB被授权可以对可能造成化学品相关事故的情形进行研究和调查，即 使该事故并没有发生。（此项规定大大扩充了CSB的调查范围，并且让 CSB调查并不受到法律条文的局限） Research, Evidence, and Recommendations 证据 Research, Evidence, and Recommendations 证据 G The conclusions, findings, or recommendations of the Board relating to any accidental release or the investigation shall not be admitted as evidence or used in any lawsuit. CSB在任何化工事故调查所获取的所有结论，发现和建议不得用 于作为证据或由于法律诉讼。（此条保证了CSB调查的深入性） Recommendations 建议 Recommendations 建议 I Whenever the CSB s a recommendation to the EPA or OSHA, they must respond within 180 days. CSB向OSHA和EPA提出的建议，必须在180内得到答复。 If they don’t implement a recommendation they must explain why not to the CSB. 如果OSHA或EPA决定不执行该建议，必须书面解释原因。 Authority to Hold Hearings, Take Witness Testimony, Enter and Inspect Properties, and Take Samples Authority to Hold Hearings, Take Witness Testimony, Enter and Inspect Properties, and Take Samples L The CSB may hold hearings and require by subpoena or otherwise attendance and testimony of such witnesses CSB有权利举办听证，传票和审讯。 ii CSB has inspection authority, where they can enter any property where an accidental release caused a fatality, serious injury or substantial property damage to conduct the investigation. CSB不得被阻止进入任何发生死亡，公众受伤或严重财产损失的化学品相关 事故的企业进行调查 Funds Since SetupFunds Since Setup Annual Impact Report Annual Impact Report CSB Open Investigations as of end of FY 2015CSB Open Investigations as of end of FY 2015 CSB Outreach and Communications ChannelsCSB Outreach and Communications Channels U.S. Chemical Safety Board Recommendations U.S. Chemical Safety Board Recommendations Investigation Process The investigation process（调查过程） Gather evidence Determine causal factors Determine root causes Make recommendations Address recommendations 证据收集证据收集 确定 关键原因 确定 关键原因 确定根本原因和 管理系统失误 确定根本原因和 管理系统失误 提出改进建议提出改进建议执行改进建议执行改进建议 为事故调查做好准备，做好总结 Pre- Planning Team Training Investigation Root Cause Determination Recommendation Development Report Writing Implementation Follow-Up Critique/ Learnings Finish Start 收集和分析证据 分析原因因素 Causal Factor数据 组织和判断 数据相关性 构建损失 现场场景 生成新数据需求 如何更加有效的收集证据 意识到证据的脆弱性 证据是很容易随着时间被破坏的 证据有可能为假 事实需要交叉证明 证据冲突的地方或许就是需要进一步调查的地方 不带成见的去调查 不提前猜测原因，以证据链为依据 不满足于单一的原因 不局限于法规的要求 不急于对原因定性（区分主要，次要原因） 如果发现原因分析有困难，一定是调查的不够深入 三个常用的追问 为什么要进行这样的操作。 为什么这些防范措施没起作用。 为什么只有这些措施 事故剖析 当所有屏障都失效时，出现事故。 通常在最后一个屏障失效之前很久，其它所有屏障都已失效。 通常多个屏障是由于同一原因而失效。 原因 设计屏障预防性屏障缓和性屏障 偏离 根本原因的追寻到哪里为止 建议需要是可以执行的 一般的追寻会落在管理体系的某一个模块失误上 有时候有必要对失效的模块进行一次全面的审核，以确认根本原 因的认定是正确的。 Wrap Up and Participant DiscussionWrap Up and Participant Discussion Investigations should go beyond finding the persons responsible for the incident. 事故调查可以比找到“责任人”更加深入 Management systems failures are the leading cause of incidents and escalation of incidents and so they must investigation in a systematic manner. 管理体系失效往往是最主要的事故原因，因此必须针对其做出系统性的调查 Wrap Up and Participant DiscussionWrap Up and Participant Discussion A government investigation from an agency that is responsible for a regulation has to determine compliance and legal violations. 针对企业/个人的违法违规行为需要一家政府部门进行有效调查。 A government investigation for improvement of process safety should avoid those limits and be free to openly uate and discuss the root causes. 同时另一种致力于安全改进，不局限于法律法规，并可以对根本原因进行充 分讨论的调查也有必要。 Wrap Up and Participant DiscussionWrap Up and Participant Discussion The results of government sponsored root cause investigations should be widely disseminated for learning and improvement of government regulations. 由此产生的优秀的调查报告，可以被广泛的学习，同时形成对政 府法规的持续改进。 51 ACUTECH CONSULTING GROUP www.acutech- 中国，上海, 浦东新区 艾戈泰安全技术咨询（上海）有限公司 Tel Fax Contact Us AcuTech Consulting DMCC Unit No. 3O-01-1802, Floor No. 1 Bldg. No.3, Plot No. 550-554, JG, DMCC Dubai, United Arab Emirates UAE Tel 971 56 7799 281 Houston – Dubai - Mumbai Global Offices
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