Analysis of “2·28” KEEPER Chemical Industries Hazardous Chemical Explosion Accident Based on FTA and HFACS

Abstract

On 28 February 2012, a guanidine nitrate explosion occurred at HEBEI KEEPER Chemical Industries Co., Ltd., China, resulting in 25 deaths, with 4 missing individuals and 46 injured. In order to explore the causal relationship hidden behind this accident, fault tree analysis (FTA) and the Human Factors Analysis and Classification System (HFACS) were used to systematically analyze the incident. Firstly, FTA was used to analyze the causes of the accident in depth, until all the basic causal events causing the guanidine nitrate explosion were identified, and a fault tree diagram of the guanidine nitrate explosion was drawn. Secondly, for the unsafe acts in the basic causal events, the HFACS model was used to analyze the three levels of factors that lead to unsafe acts, including the preconditions for unsafe acts, unsafe supervision, and organizational influences. Finally, based on the analysis results of FTA and HFACS, a complete logic diagram of the causes of the accident was obtained. The FTA and HFACS accident analysis methods allowed for the identification of human factors and the accident evolution process in the explosion accident and provide a reference for accident investigation.