Analyzing organizational gaps in process accidents with FRAM: The case of the Imperial Sugar refinery explosion (2008)
2023 (English)In: Process safety progress, ISSN 1066-8527, E-ISSN 1547-5913, Vol. 42, no 51, p. S87-S96Article in journal (Refereed) Published
Abstract [en]
This study presents a reanalysis of the Imperial Sugar refinery accident that occurred in February 2008, in Georgia, USA, using functional resonance analysis method (FRAM) and based on technical-scientific materials and the official reports. This explosion was fueled by sugar dust in the packaging building of the refinery, causing 14 fatalities and injuring 38 workers. The purpose of this reanalysis is to seek factors and interactions that could not be well analyzed or evidenced using traditional accident investigation techniques, which are primally designed to analyze linear systems. This reanalysis with FRAM allowed us to perceive the influence of organizational elements, such as culture, in the accidental chain of the event, highlighting the need of a broader approach for accidents involving high-tech process industries. In this sense, FRAM enabled a more comprehensive analysis of the complex functioning of process plants, for both normal operation and in emergency. It was noticed that the greater the complexity of work systems, the greater the interaction and variability between personnel, equipment, and systems, requiring analysis techniques and methodologies capable of recognizing the real complexities that take place in these sociotechnical systems, especially in high-tech process plants, such as the sugar refinery in this case.
Place, publisher, year, edition, pages
John Wiley & Sons, 2023. Vol. 42, no 51, p. S87-S96
Keywords [en]
accident analysis, functional resonance analysis method (FRAM), organizational gaps, process safety
National Category
Production Engineering, Human Work Science and Ergonomics
Research subject
Shipping
Identifiers
URN: urn:nbn:se:lnu:diva-125828DOI: 10.1002/prs.12545ISI: 001091653400001Scopus ID: 2-s2.0-85174636392OAI: oai:DiVA.org:lnu-125828DiVA, id: diva2:1816042
Conference
9th CCPS Latin American Conference on Process Safety October 18, 2022 to October 20, 2022 Rio de Janeiro, Brazil
2023-11-302023-11-302024-04-12Bibliographically approved