Diapositiva 1

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4th Meeting TWG1 Ispra, 31Jan-2Feb 2007
REPORTING AND ANALYSIS OF INDUSTRIAL ACCIDENTS
IN ITALY
Fausta DELLI QUADRI APAT National Agency for
the Protection of Environment Risk Industrial
Service Loretta De Giorgi CNR/ MATTM Ministry
of Environment/National Research Centre
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REPORTING AND ANALYSIS OF A MAJOR INDUSTRIAL
ACCIDENT
COUNCIL DIRECTIVE 96/82/EC of 9 December 1996 on
the control of major-accident hazards involving
dangerous substances
ARTICLE 14
ARTICLE 15
Implementation in Italy Legislative Decree n.
334, 17th August 1999
ARTICLE 24
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REPORTING AND ANALYSIS OF A MAJOR INDUSTRIAL
ACCIDENT
Following a major accident
ARTICLE
24 of the Legislative Decree n. 334, 17th August
1999
IEP
Prefect
EEP
Operator
MINISTRY OF ENVIRONMENT

• Ministry of Interior
• Civil protection
• Prefects of near districts

• Mayor
• Fire Brigade
• Region President
• District President

Accident meets the criteria of Annex VI
Commission for the accident investigation
FIRE BRIGATE APAT ISPESL
EUROPEAN COMMISSION
MARS Forms
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REPORTING AND ANALYSIS OF A MAJOR INDUSTRIAL
ACCIDENT
IN CASE OF MAJOR INDUSTRIAL ACCIDENT
The justice Authority carries out an accident
investigation by expertise
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REPORTING AND ANALYSIS OF MAJOR INDUSTRIAL
ACCIDENTS
MOREOVER the regulatory requirements, it is
possible
Data gathered during MARS investigation
Fire Brigade Italian Environmental Agencies
System ISPESL
Data processing aimed to specific analysis and
researches
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ACCIDENT INVESTIGATION/RECORDING
TOOLS AVAILABLE
aimed to point out the SMS faults connected to
the accident itself or anyhow shown related to
the accident. Reference is made to the check list
of the SMS elements
FORMAT for accident analysis (Annex II to
Italian Guidelines for SMS Inspections)
TEMPLATE for recording accident data (recording
territorial network implemented by APAT/ARPA/FIRE
BRIGADE)
aimed to collecting quickly preliminary and
reliable data at a national level. Information
system and exchanges among technical institutions
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ACCIDENT INVESTIGATION
FORMAT for accident analysis

• used during SGS inspections procedure in Seveso
  establishments
• compiled by the operator and then discussed
  together with the inspectors
• the analysis covers all the chemical accidents
  (accident, near-misses or operational faults)
  occurred in the last 10 years in the
  establishment or in similar ones
• requires the analysis of each case to identify,
  among the root causes of the event, the
  management factors (SMS elements)

It has been modified in the last years, to
simplify and optimise the framework in order to
underline the management features (with reference
to the check list of the SMS elements and to the
main SMS articulation given by the Seveso II
Directive)
its importance ? overstep the direct causes,
normally quickly recognized by the company, and
identify the management deficiencies hidden
behind the direct causes
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ACCIDENT INVESTIGATION
FORMAT for accident analysis old version
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ACCIDENT INVESTIGATION
FORMAT for accident analysis change
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ACCIDENT INVESTIGATION
FORMAT for accident analysis new version
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ACCIDENT INVESTIGATION
FORMAT for accident analysis example
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ACCIDENT INVESTIGATION
FORMAT for accident analysis other usefulness

• the recorded frequency of remark for each SMS
  element gives an indication of the criticality of
  that element
• the format is also useful to the inspection team
  to better orientate the inspection providing a
  sort of priority list of SMS elements to be
  controlled

point out SMS faults

• the events, accident, near-accidents and
  operating difficulties experienced by the
  establishment, are collected according to the
  format, in order to

• identify possible improvements
• specific terms as punctual reaction/action to the
  event
• general terms as adjustment of funtional parts of
  the SMS of the establishment (lines of
  communication, document management, )

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ACCIDENT RECORDING
TEMPLATE for recording accident data

• Collaboration Agreement APAT Fire Brigade
  stipulated in 2001 on the control of major
  accident hazards
• a specific TWG APAT/ARPA Fire Brigade has been
  created in 2003 to develop a territorial network
  shared for the accident data collecting/reporting
• using a reporting tool (simple template) to
  collect data in a quick way, thanks to the local
  Agencies and Fire Brigades involvement
• network built on central points (APAT and
  Ministry of Interior/Fire Brigades) and local
  points (ARPA/APPA and local Fire Brigades)

• its importance
• improvement of qualitative and quantitative data
  features ? improvement of accident analysis
  reliability
• improvement of risk assessment training and
  creation of a common didactical base
• more exhaustive and systematic view of the
  territorial accidental situation, to be used by
  central and local administration involved in the
  inspections

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ACCIDENT RECORDING
TEMPLATE for recording accident data framework
FORM 1 (compiled within the 24 hours from the
accident) preliminary info
TEMPLATE
FORM 2 (compiled within 1 month from the
accident) more detailed info
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ACCIDENT RECORDING
TEMPLATE for recording accident data form 1

• form made by 5 parts containing the following
  accident data
• identification data (date, site, society, etc.)
• technical data (typology, scenario, substances,
  equipment, etc.)
• describing data (event sequence, causes, effects,
  etc.)
• emergency data (fire means and interventions)
• identification data of the reporter
• form compiled by the local officer that makes
  the post-accident inspection immediately
• sent to the correspondent central institution
  within the 24hours from the accident, to have a
  quick recording and sharing of data

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ACCIDENT INVESTIGATION
F O R M A T 1
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ACCIDENT RECORDING
TEMPLATE for recording accident data form 2

• follows the 5 parts of the form1, providing a
  more extensive space for each one to contain the
  next deeper accidental info
• more detailed info especially on the accident
  key-data causes, root-causes, internal and
  external effects (also economical and
  ecological), emergency operations, next actions
  taken and planned, authorities involved
• compiled by the local authorities after
  collecting deeper info coming from the society
  and the local CTR meeting
• sent to the correspondent central institution
  within 30 days from the accident
• . central specific TWG APAT/ARPA Fire Brigade
  provide with the analysis and recording of all
  the accident data
• . APAT provides with update the accident database
  BIRD

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ACCIDENT INVESTIGATION
F O R M A T 2
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ACCIDENT RECORDING
TEMPLATE for recording accident data accidents
selection criteria

• accident must to involve at least a chemical
  dangerous substance
• major accidents, accident or near-misses occurred
  in Seveso establishments
• major accidents, accident or near-misses occurred
  in other establishments/activities (not Seveso),
  which dynamics is particularly interesting

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ACCIDENT RECORDING
TEMPLATE for recording accident data
preliminary results

• significant results, in terms of local
  institutions involvement
• improvement in qualitative and quantitative
  aspects of data collected
• not completely exhaustive result, because of the
  different kinds and heterogeneity of sources

• need to optimise the communication and diffusion
  of data
• need to provide an electronic management of the
  template
• need to award an effective national dimension to
  the network-plan

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ACCIDENT RECORDING
TEMPLATE for recording accident data further
development

• Ministry of Environment required the creation of
  a national database, according with the triennial
  convention MATT-APAT stipulated in 2003
• Collaboration Agreement APATFire Brigade
  stipulated in 2001 on the control of major
  accident hazards goes on, the specific TWG
  APAT/ARPA Fire Brigades work goes on
• need to develop a national accidents database,
  starting from BIRD (APAT database) experience,
  shared by the CA and the technical institutions
  involved, using the territorial network for the
  accident data collecting/ reporting created

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ACCIDENT RECORDING
TEMPLATE for recording accident data further
development

• national accidents database framework congruent
  with the template (base-format)
• amplification of the base-format by inserting
  detailed info, where needed possibility to
  insert additional important info
• ? high flexibility of the database, still using a
  fixed data format

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ACCIDENT RECORDING
TEMPLATE for recording accident data

• collaboration and exchange experience among
  local and central AC (MATTM, APAT-ARPA, Fire
  Brigades), during last years, in analysis and
  reporting accident data, has shown the
  feasibility and usefulness of the national
  reporting network
• in this sense, the national accident database
  project appears important, and requests specific
  criteria to be defined (for framework and
  contents)
• in this prospect, APAT is now reviewing the
  BIRD, also in order to provide accidental info
  available at a national level, according with
  MATTM requests

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ACCIDENT INVESTIGATION
Other activities

• technical report n33/2005 accident
  investigation in Seveso activities edited by
  APAT
• contents
• a general view of the main investigation
  techniques available, most of all MCSOII and CTM
• description of the whole investigation process
• planning and organization
• evidences collecting
• multi-causes defining
• recommendations and corrective actions
• communication e reporting
• wide diffusion of the report a national level
• training activities made by APAT on the report

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ACCIDENT INVESTIGATION
Other general activities

• Fire Investigation Centre a Fire Pole managed
  by Ministry of Interior
• tasks
• study, research and analysis to evaluate the
  fire-accidents causes support for the competent
  judicial police institutes to conduct
  investigation activities connected to the
  fire-accidents
• in particular (tasks)
• urgent investigation and technical relieves after
  a fire, to identify the causes request of useful
  info to the persons involved in the accident
  coordination of technical tests to be done in
  laboratory simulation of fires through
  calculation models and its validation
  communication of investigation results to the CA
  cooperation with national and international
  institutions engaged in technical-scientific
  investigation training of the centre personnel
  and the local references
• relationship with judicial Authority,
  universities and research institutes