A CAST-based causal analysis of the catastrophic underground pipeline gas explosion in Taiwan

Abstract A deep and thorough analysis of typical accidents beyond immediate failures from a systematic perspective is necessary for safety decision-making in an area. The Systems-Theoretic Accident Model and Processes (STAMP) is one of the most widely used accident models based on systems and control theory, which derives a powerful accident analysis tool defined as Causal Analysis based on Systems Theory (CAST). This study adopts a CAST analysis of the catastrophic underground pipeline gas explosion in Taiwan, which is one of the largest petroleum catastrophes in Chinese history. The safety control structure to enforce the safety constraints required by the system hazards is developed and analyzed hierarchically. The analysis has systematically demonstrated the inadequate control and violated safety constraints and uncovered the in-depth rationale behind the decisions that were made leading up to this tragedy. The necessary changes in the overall system safety structure are also recommended based on control flaws identified for each hierarchical level, accordingly. The CAST model is demonstrated to be feasible for continuous improvements in accident analysis and in turn establishing a robust safety system of pipeline gas transportation in Taiwan.

[1]  Wei Wu,et al.  Dynamic safety assessment of oil and gas pipeline containing internal corrosion defect using probability theory and possibility theory , 2019, Engineering Failure Analysis.

[2]  Faisal Khan,et al.  SHIPP methodology: Predictive accident modeling approach. Part I: Methodology and model description , 2011 .

[3]  Tibor Bosse,et al.  Systemic approaches to incident analysis in aviation: Comparison of STAMP, agent-based modelling and institutions , 2018, Safety Science.

[4]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .

[5]  Paul M. Salmon,et al.  Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP , 2012 .

[6]  Jiang Xu,et al.  Comparative study on vulnerability assessment for urban buried gas pipeline network based on SVM and ANN methods , 2019, Process Safety and Environmental Protection.

[7]  Her-Yung Wang,et al.  Case analysis of catastrophic underground pipeline gas explosion in Taiwan , 2016 .

[8]  Hongyong Liu,et al.  Risk propagation mechanism: Qingdao Crude Oil Leaking and Explosion case study , 2015 .

[9]  Wei Liang,et al.  A comprehensive risk evaluation method for natural gas pipelines by combining a risk matrix with a bow-tie model , 2015 .

[10]  Kjell Ivar Øvergård,et al.  A STAMP-Based Causal Analysis of the Korean Sewol Ferry Accident , 2016 .

[11]  Nancy G. Leveson,et al.  Applying systems thinking to analyze and learn from events , 2010 .

[12]  Mehdi Davoudi,et al.  Quantitative risk assessment of sour gas transmission pipelines using CFD , 2016 .

[13]  Qingsheng Wang,et al.  A mathematical model of crevice corrosion for buried pipeline with disbonded coatings under cathodic protection , 2016 .

[14]  Faisal Khan,et al.  Failure probability analysis of the urban buried gas pipelines using Bayesian networks , 2017 .

[15]  Her-Yung Wang,et al.  Investigation on the Key Response Factors of Action Plan in Underground Pipeline Emergency Scenario , 2016 .

[16]  Z Y Han,et al.  Comparison study on qualitative and quantitative risk assessment methods for urban natural gas pipeline network. , 2011, Journal of hazardous materials.

[17]  Guy H. Walker,et al.  Broken components versus broken systems: why it is systems not people that lose situation awareness , 2015, Cognition, Technology & Work.

[18]  Susan L. Murray,et al.  STAMP – Holistic system safety approach or just another risk model? , 2014 .

[19]  Mingda Song,et al.  Failure analysis of a natural gas pipeline , 2016 .

[20]  Jiang Xu,et al.  Analysis on accident-causing factors of urban buried gas pipeline network by combining DEMATEL, ISM and BN methods , 2019, Journal of Loss Prevention in the Process Industries.

[21]  Bo Yu,et al.  Fast method for the hydraulic simulation of natural gas pipeline networks based on the divide-and-conquer approach , 2018 .

[22]  Patrick Waterson,et al.  Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. , 2014, Accident; analysis and prevention.

[23]  Nancy G. Leveson,et al.  Engineering a Safer World: Systems Thinking Applied to Safety , 2012 .

[24]  Nancy G. Leveson,et al.  Analysis of soma mine disaster using causal analysis based on systems theory (CAST) , 2018, Safety Science.