Institutional Support of Learning from Accidents: Some Obstacles to Getting a Useful Community-wide Database in the EU

1. Institutional Support of Learning from Accidents: Some Obstacles to Getting a Useful Community-wide Database in the EU SRA 2006 - Annual Conference of the Society for Risk Analysis, Sep 2006, Ljubljana. Authors: Frank Huess Hedlund, COWI A/S, Parallelvej 2, DK-2800 Lyngby, Denmark. fhhe@cowi.dk, and, Technical University of Denmark, Building 321, DK-2800 Lyngby, Denmark. fhh@imm.dtu.dk Henning B. Andersen, Risø National Laboratory DK-4000 Roskilde, Denmark; hba@risoe.dk Some Obstacles to Getting a Useful Community-wide Database in the EU

2. Key points • In this paper we examine man's perhaps oldest accident prevention strategy: learning from past mistakes. • The benefit of such learning is obvious. What is not so obvious, however, is how to provide institutional support and to set up systems that facilitate such learning. • We are going to suggest that the well-known database operated by the European Union, the Major Accident Reporting System (MARS) may not fully live up to the noble intentions behind its creation. We provide examples of insufficient information contained in the MARS database and we offer some suggestions for improvement. Some Obstacles to Getting a Useful Community-wide Database in the EU

3. Case example - bulk storage of methanol Case: Existing gasoline tank converted to methanol service Vapours Liquid Some Obstacles to Getting a Useful Community-wide Database in the EU

4. Some Obstacles to Getting a Useful Community-wide Database in the EU

6. Two records are relevant for bulk storage of methanol

7. #113 – despite rudimentary description, this turned out to be an eye-opener

8. #233 – despite rich text description, the record is not useful

9. #5 – no causes, no lessons learned, indicates possible scope problems

10. #6 – similar, if not identical, accident recur at same site one year later, suggesting that no lessons have been learned. Causes still not identified. Record does not meet the most basic criteria for accident investigation.

11. Insight - Differences between properties of motor gasoline and methanol Some Obstacles to Getting a Useful Community-wide Database in the EU

12. Inherent explosion hazards of methanol storage • For all practical matters, the vapour space in a methanol tank is rarely lean or rich. Most of the time it is ignitable, only waiting for an ignition source for it to explode violently. This was the major finding in 1994 case story, and it was a direct consequence of insights gained from the MARS data. • Experience has shown that it is extremely difficult to eliminate all sources of ignition. • This hazard is not present in gasoline storage tanks • Local experience and knowledge therefore supported an uncomplicated and straightforward fire prevention case – it was simply a change of one flammable liquid for another. The only perceived significant change was that methanol, unlike gasoline, is classified as toxic. Seveso legislation supported this interpretation. The methanol storage tanks were subject to Seveso legislation, not because of methanol’s flammability classification, but because of its toxicity classification. Some Obstacles to Getting a Useful Community-wide Database in the EU

13. Actual methanol tank explosions Some Obstacles to Getting a Useful Community-wide Database in the EU

14. Tank lift-off due to internal explosion Some Obstacles to Getting a Useful Community-wide Database in the EU

15. Another tank explosion Some Obstacles to Getting a Useful Community-wide Database in the EU

16. Methanol tank explosions are beyond doubt a ”major accident” • Yet, in 1994 the methanol storage tank was subject to Seveso legislation (upper-tier), not because of methanol’s flammability classification, but because of its toxicity classification. • In 2005, according to Seveso II legislation, a 2,000 m3 methanol tank is not subject to upper-tier requirements (Column 3 limit is 5,000 tons) – safety report is not required • An identical hazard analysis can be performed for ethanol bulk storage (biofuels). Many existing gasoline tanks are converted into ethanol service. Yet, column 3 limit for ethanol is 50,000 tons effectively excluding most ethanol tanks from Seveso II legislation. • Our case is simple. These types of installations exist in all member states. Would have been of great practical value if the EU database had contained information on the inherent explosion risks of methanol (and ethanol). • Q: To which degree does MARS live up to its stated objective of preventing accidents through information sharing ? (scope/model) Some Obstacles to Getting a Useful Community-wide Database in the EU

17. Institution of Chemical Engineers IChemE (UK) - The Accident Database (TAD) Short comparative study with IChemE’s TAD Some Obstacles to Getting a Useful Community-wide Database in the EU

18. Comparative analysis MARS-TAD Some Obstacles to Getting a Useful Community-wide Database in the EU

19. Findings 1 – value of info on past accidents • Our case example with bulk methanol storage has shown that some of the data in some of the Short Reports in MARS have a number of serious shortcomings. Causes are not identified and lessons learned are left blank. The value of this information in the efforts to prevent future methanol accidents is limited - but not nil. • Our case also demonstrates that even the most rudimentary data on past accidents can be of value in accident prevention. Ironically, it was the Short Report in MARS with the most meagre data that gave inspiration to an accident causation hypothesis which eventually proved useful. Also, the mere knowledge of past accidents undermined the Company’s assertion that it had no knowledge of any prior accidents involving the bulk storage of methanol. Some Obstacles to Getting a Useful Community-wide Database in the EU

20. Findings 2 – less than 30 records per year enter MARS for the entire EU • Over the course of 22 years the EU database has only accumulated about 600 Short Reports for all its member states. We consider it highly unlikely that this number represents all “major accidents” according to a common sense definition of this concept for such a large territory. From the data in our glyoxylic acid case we hypothesise that scope limitations imposed by strict legal interpretation of the Seveso legislation may be counter productive and self-defeating for the Seveso legislation’s stated objective of accident prevention through information sharing. • We have identified 114 academic citations that mention the MARS major accident reporting system. The ratio of citations to accident records is 1:6, a very large ratio. Some Obstacles to Getting a Useful Community-wide Database in the EU

21. Findings 3 – public funding appears to be crucial to sheer survivability • We have undertaken a comparative analysis of accident records in MARS and in TAD. TAD suffers from many of the fundamental shortcomings as do MARS. On all parameters, however, the TAD seems to be superior to MARS. It is noteworthy, and unsettling, that despite much targeted advertising there has been very limited consumer interest in TAD. TAD has failed to be commercially viable and is now in a dormant state. • It is beyond the scope of this paper to examine or speculate about the reasons for this. Echoing the title of Kletz’ 2003 publication, ”Still going wrong”, we acknowledge that there are many barriers to evolutionary learning. We conclude by emphasising, however, that the value of accident reporting schemes is not only determined by the quality of the data they contain but that public funding appears to be crucial to sheer survivability. In this respect, the MARS database may come out on top of the TAD Some Obstacles to Getting a Useful Community-wide Database in the EU

22. Some Obstacles to Getting a Useful Community-wide Database in the EU

23. Some Obstacles to Getting a Useful Community-wide Database in the EU