CSB發(fā)布杜邦La Porte工廠4死1傷甲硫醇泄漏最終調(diào)查報(bào)告
2014年美國(guó)當(dāng)?shù)貢r(shí)間11月15日凌晨，世界第二大化工公司、美國(guó)杜邦公司位于休斯敦東南拉波特地區(qū)的工廠，因儲(chǔ)存甲硫醇的存儲(chǔ)罐閥門失效，造成甲硫醇大量泄漏，由于現(xiàn)場(chǎng)有5名工人直接暴露于有害氣體甲硫醇中，最終導(dǎo)致造成4人死亡。
事故最終調(diào)查結(jié)果
CSB的調(diào)查發(fā)現(xiàn)，杜邦LaPorte工廠的安全管理體系存在大量缺陷，未能形成強(qiáng)有力的工藝安全文化。在2016年4月份杜邦宣布將關(guān)閉這家殺蟲劑工廠），該事件為化學(xué)工業(yè)提供了重要的教訓(xùn):The CSB determined that the cause of the highly toxic methyl mercaptan release was the flawed engineering design and the lack of adequate safeguards.e Contributing to the severity of the incident were numerous safety management system deficiencies, including deficiencies in formal process safety culture assessments, auditing and corrective actions, troubleshooting operations, management of change, safe work practices, shift communications, building ventilation design, toxic gas detection, and emergency response. Weaknesses in the DuPont La Porte safety management systems resulted from a culture at the facility that did not effectively support strong process safety performance.
01.應(yīng)急響應(yīng)Emergency Response
杜邦La Porte工廠在有毒化學(xué)品泄漏期間，應(yīng)急響應(yīng)混亂，導(dǎo)致操作人員、應(yīng)急響應(yīng)人員和公眾置于危險(xiǎn)之中。事件發(fā)生當(dāng)晚，工廠內(nèi)操請(qǐng)求緊急反應(yīng)小組(ERT)趕到現(xiàn)場(chǎng)，執(zhí)行緊急響應(yīng)行動(dòng)。從最初的ERT援助請(qǐng)求到最后的應(yīng)急響應(yīng)行動(dòng)，整個(gè)響應(yīng)過(guò)程凸顯出溝通失誤、組織混亂和態(tài)勢(shì)感知缺乏等。• Emergency Response. The emergency response efforts at the DuPont La Porte facility during the toxic chemical release were disorganized and placed at risk operators, emergency responders, and potentially the public. Chemical plants need arobust emergency response program to mitigate emergencies and to protect thehealth of workers, emergency responders, and the public
02.杜邦的工藝安全管理體系 DuPont’s ProcessSafety Management System
杜邦公司創(chuàng)建了自己的企業(yè)工藝安全管理體系，將其內(nèi)部安全要求與美國(guó)化學(xué)理事會(huì)（ACC）的Responsible Care®項(xiàng)目、EPA RMP規(guī)則以及OSHA PSM標(biāo)準(zhǔn)規(guī)定的要求相結(jié)合。DuPont created its own corporate process safetymanagement system that integrated its internal safety requirements with thoseof the American Chemistry Council’s Responsible Care® programbandthose required by regulations under theEPARMP rule and the OSHA PSM standard. Over the course of five years, despiteimplementing its corporate process safety management system, DuPont experiencedthree major process safety incidents
除了建立了一套完整的工藝安全管理體系外，杜邦公司還制定了實(shí)施該體系的計(jì)劃。杜邦公司表示，工藝安全管理體系的實(shí)施可以分為兩部分:In addition to developing an integrated processsafety management system, DuPont established a program to implement it.According to DuPont, the implementation of the process safety management systemcan be broken down into two parts:
(1)建立安全文化
雖然杜邦 La Porte工廠應(yīng)用一項(xiàng)專有的安全認(rèn)知調(diào)查，該調(diào)查聚焦于個(gè)人或職業(yè)安全，但沒(méi)有對(duì)工藝安全文化進(jìn)行評(píng)價(jià)或評(píng)估。由于安全認(rèn)知調(diào)查未能對(duì)安全文化的所有方面進(jìn)行合理評(píng)估，因此無(wú)法確定 La Porte工廠的重大工藝安全缺陷，使得該場(chǎng)所容易發(fā)生潛在的過(guò)程安全事故。雖然衡量工人對(duì)個(gè)人安全的認(rèn)知很重要，但安全文化評(píng)估計(jì)劃中也應(yīng)提供對(duì)過(guò)程安全的有效衡量。
(2)實(shí)施工藝安全管理和風(fēng)險(xiǎn)模型。
第二個(gè)杜邦公司用來(lái)實(shí)現(xiàn)其過(guò)程安全管理體系的工具是工藝安全管理和風(fēng)險(xiǎn)模型。公司利用可視化的表現(xiàn)形式來(lái)呈現(xiàn)一個(gè)有效的過(guò)程安全管理體系,包括管理層領(lǐng)導(dǎo)力和承諾的實(shí)施、全面的過(guò)程安全管理計(jì)劃和操作規(guī)程。
但調(diào)查發(fā)現(xiàn)，杜邦La Porte 工廠在2014年11月事件發(fā)生前并未有效實(shí)施該體系，也沒(méi)有正式評(píng)估其工藝安全文化。
03.杜邦La Porte工廠的工藝安全管理缺陷DuPont La Porte’sProcess Safety Management Deficiencies
CSB指出，杜邦La Porte工廠存在嚴(yán)重的工藝安全缺陷是導(dǎo)致事故的原因之一。這些缺陷包括過(guò)程危險(xiǎn)分析(PHA)、審核、變更管理(MOC)、操作程序和安全工作實(shí)踐等。
盡管杜邦公司和杜邦La Port工廠制定了很多的書面政策，但這些書面政策并未轉(zhuǎn)化或聚焦于生產(chǎn)現(xiàn)場(chǎng)關(guān)于過(guò)程安全管理體系的有效實(shí)施。
CSB認(rèn)為，公司本身的安全管理制度，對(duì)防止重大事故的發(fā)生至為重要。公司應(yīng)確保其過(guò)程安全管理體系中的各個(gè)要素是有效的、充分實(shí)施的，并按預(yù)期發(fā)揮作用。而杜邦公司制定的過(guò)程安全管理體系中的要素未能使La Porte工廠及時(shí)發(fā)現(xiàn)、預(yù)防或減少重大過(guò)程安全缺陷。
企業(yè)必須有效地實(shí)施工藝安全管理體系及其相應(yīng)的計(jì)劃，才能獲得相應(yīng)的工藝安全效益。
The CSB identified significant process safetydeficiencies at the DuPont La Porte site that contributed to the incident.DuPont’s corporate process safety management system did not identify, prevent,or mitigate these deficiencies. A company must effectively implement a processsafety management system and its corresponding programs to reap theaccompanying process safetybenefits.
04.杜邦La Porte工廠的員工缺少激勵(lì)計(jì)劃DuPont La Porte’sEmployee Incentive Program
因?yàn)槎虐頛a Porte工廠的獎(jiǎng)金結(jié)構(gòu)缺乏激勵(lì)性，員工缺乏報(bào)告事故和未遂事故的積極性。
確保員工能夠按照規(guī)定報(bào)告事故、傷害和未遂事故，而不用擔(dān)心受到歧視、報(bào)復(fù)或其他不利后果，這是保護(hù)工人安全和健康以及幫助預(yù)防事故的核心。
The DuPont La Porte bonus structure may havedisincentivized workers from reporting injuries, incidents, and “near misses.”Ensuring that employees can report injuries or incidents in accordance with theOccupational Safety and Health (OSH)Act and OSHA regulations, without fear ofdiscrimination, retaliation, or other adverse consequence is central toprotecting worker safety and health, and aiding accidentprevention
庫(kù)利諾夫斯基博士表示:“工藝安全管理是任何企業(yè)工廠安全高效運(yùn)行的關(guān)鍵工具。而此次事故就是一個(gè)教科書般的例子，當(dāng)工藝安全管理沒(méi)有得到充分實(shí)施和監(jiān)管時(shí)，就會(huì)產(chǎn)生災(zāi)難性的后果。”