Hazardous Spray Release from a Pipeline under Maintenance: Causes and Lessons Learned by a Combined Accident Analysis Perspective

As widely acknowledged, learning from accidents represents one of the main source of knowledge for future loss prevention. An effective investigation may help enhancing the process of continuous improvement of the safety management system. Recently, during a pipeline batching operation between two storage facilities of the same corporation, a LOC from the flange caused a spary release of atomised diesel, impacting on the adjacent national road. Two complementary approaches for accident investigation are here considered, i.e., customized root cause analysis workflow and Causal Analysis using System Theory approach. The best approach lies in the systemic nature of the selected methods applied to the whole socio-technical hierarchy of the concerned process trying to improve on one hand existing hazard analysis and on the other hand accident analysis. The paper outlines the fact-finding process from the technical viewpoint, as well as preconditions and latent failures.