Systematic Cause Analysis of an Explosion Accident During the Packaging of Dangerous Goods

Abstract

Chemical plants inherently handle and operate with a wide range of hazardous materials, making them more prone to accidents compared to other industrial sectors. Consequently, safety management in chemical plants tends to be systematically organized based on elements of process safety management (PSM) systems. In June 2023, South Korea’s Ministry of Employment and Labor released the Serious Injury and Fatality (SIF) report, which summarized 4432 major accident cases that occurred over six years (2016–2021), including 1834 cases in manufacturing and related industries and 2574 cases in construction. The report provided an overview of these accidents, their causes, and measures to prevent their recurrence, with a focus on fatalities and severe injuries associated with critical losses across different industries. This study examined 16 accident cases that occurred at PSM-regulated facilities, which are managed on the basis of a systematic safety framework established by regulatory requirements. Among these, particular attention was paid to an explosion accident in the organic catalyst packaging process at a facility with no prior accident history and exhibiting unique accident characteristics. A systemic root cause analysis was conducted using the barrier-based systemic cause analysis technique (BSCAT) and the system theoretic accident model and process (STAMP-CAST) methodologies. The systemic analysis highlighted the critical importance of clearly identifying materials or factors that may inadvertently mix during the process design or mass production phases and evaluating whether such interactions could lead to accidents during the hazard assessment stage. Beyond incorporating the risk mitigation measures identified in the process design and procedural development phases without omissions, it is essential to periodically conduct “worker-centered risk assessments”. These assessments help evaluate the potential for accidents resulting from human errors, such as workers’ non-compliance with established procedures, which is a key aspect of preventing chemical accidents. Although this study did not include an evaluation of the impacts of high pressures or high temperatures on workers near chemical accident sites—hence, no specific recommendations regarding safe working distances are made—the findings are expected to contribute to the development of preventive measures for chemical accidents in smaller-scale plants where workers directly manage and operate processes.