Anatomy of a domino accident: Roots, triggers and lessons learnt

作者：Abdolhamidzadeh Bahman^*; Hassan Che Rosmani Che; Hamid Mahar Diana; FarrokhMehr Sajjad; Badri Naser; Rashtchian Davood

来源：Process Safety and Environmental Protection, 2012, 90(5): 424-429.

DOI：10.1016/j.psep.2012.04.003

• Lessons learnt
• Domino accident
• Fish Bone Analysis
• Event Sequence Diagram

On July 24th, 2010, several explosions and fires devastated a hydrocarbon processing plant in Kharg Island, Iran. Four workers were killed and many others were severely injured. The plant became out of service for 80 days. The way the accident happened and its sequence was representing as a domino accident. In this paper, events leading up to the disaster have been analyzed in details. Graphic presentation techniques such as Fish Bone Analysis and Event Sequence Diagram (ESD) have been utilized to enhance the understanding of the accident mechanism. Finally major lessons learnt from this domino accident have been addressed.

• 出版日期2012-9