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    Fifteen years of incident analysis : Causes, consequences, and other characteristics of incidents with hazardous substances at major hazard companies in the period 2004-2018

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    Authors
    Kooi, ES
    Manuel, HJ
    Mud, M
    Bellamy, LJ
    Series/Report no.
    RIVM report 2020-0115
    Type
    Report
    Language
    en
    
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    Title
    Fifteen years of incident analysis : Causes, consequences, and other characteristics of incidents with hazardous substances at major hazard companies in the period 2004-2018
    Translated Title
    Vijftien jaar incidentanalyse : Oorzaken, gevolgen en andere kenmerken van incidenten met gevaarlijke stoffen in de periode 2004-2018
    Publiekssamenvatting
    Het RIVM heeft 326 incidenten met gevaarlijke stoffen geanalyseerd die tussen 2004 en 2018 plaatsvonden bij grote chemische bedrijven. Bij deze incidenten was de veiligheid van werknemers in het geding. In totaal vielen er 215 slachtoffers, onder wie vijf doden. De aard, omvang en oorzaken van de incidenten zijn in de onderzochte periode gelijk gebleven. Het jaarlijkse aantal incidenten met relatief ernstige gevolgen is in de periode ook niet wezenlijk veranderd. Bij 90 procent van de incidenten kwamen gevaarlijke stoffen vrij. Bij 28 procent ontstond een brand of explosie. Drie keer (1 procent) gingen werknemers een besloten ruimte met gevaarlijke stoffen binnen. Incidenten ontstonden vooral tijdens de normale werkzaamheden (60 procent) of tijdens het onderhoud (20 procent). Slachtoffers ademden giftige of schadelijke stoffen in of kregen brandwonden door chemische reacties of hitte. Bij de incidenten tijdens het onderhoud vielen verhoudingsgewijs meer slachtoffers. Chemische bedrijven zijn ervoor verantwoordelijk dat installaties op orde zijn en de productieprocessen en -werkzaamheden veilig worden uitgevoerd. De incidenten ontstonden doordat in de reguliere procesvoering dingen mis gingen. De afwijkingen die daar het gevolg van waren, zijn niet op tijd opgemerkt. De veiligheid kan onder meer worden verbeterd door geschikte maatregelen in te voeren om deze afwijkingen op tijd in beeld te krijgen en te herstellen. Dit verkleint onder andere de kans dat incidenten ontstaan door ongewenste menselijke handelingen of door materiaalverzwakking. Voor deze analyse zijn incidentonderzoeken van de Inspectie SZW gebruikt. In opdracht van het ministerie van SZW gaat het RIVM na wat de overeenkomsten en verschillen tussen de onderzochte incidenten zijn. Inspectiediensten kunnen de analyse gebruiken voor hun inspectie- en handhavingsstrategieën. Bedrijven kunnen de inzichten gebruiken om de veiligheid te verbeteren.
    RIVM has analysed 326 incidents involving hazardous substances that took place at chemical companies between 2004 and 2018. These incidents posed a threat to the safety of workers. A total of 215 persons were injured, including five fatalities. The nature, scale and causes of the incidents remained the same during the period analysed. The number of incidents per year with relatively serious consequences also did not change significantly during the same period. Hazardous substances were released in 90% of the incidents. A fire or explosion occurred in 28%. In three incidents (1%), workers entered a confined space that contained hazardous substances. Most of the incidents took place during normal work activities (60%) or during maintenance (20%). Victims inhaled toxic or hazardous substances or suffered burn wounds caused by chemical reactions or heat. The incidents that took place during maintenance resulted in a relatively larger number of victims. Chemical companies are responsible for ensuring that their installations are in order and that their production processes and activities are carried out safely. The incidents took place because things went wrong during the regular operational processes. The resulting deviations were not noticed in time. One of the ways to improve safety is to implement suitable measures to identify and correct these deviations in time before incidents occur. This would, for example, reduce the risk of incidents occurring as a result of unwanted human actions or material degradation. Incident investigations carried out by the SZW (Ministry of Social Affairs and Employment) Inspectorate were used for the analysis at hand. RIVM is commissioned by the Ministry of Social Affairs and Employment to analyse the similarities and differences between the investigated incidents. Inspection services can use this analysis for their inspection and enforcement strategies. Companies can use the insights gained to improve safety.
    Publisher
    Rijksinstituut voor Volksgezondheid en Milieu (RIVM)
    Sponsors
    Ministerie van SWZ
    DOI
    10.21945/RIVM-2020-0115
    URI
    http://hdl.handle.net/10029/624357
    ae974a485f413a2113503eed53cd6c53
    10.21945/RIVM-2020-0115
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