Journal of Failure Analysis and Prevention

, Volume 18, Issue 6, pp 1386–1400 | Cite as

Systems-Based Analysis of China-Tianjin Port Fire and Explosion: A Comparison of HFACS, AcciMap, and STAMP

  • Yingyu ZhangEmail author
  • Linlin Jing
  • Chang Sun
Technical Article---Peer-Reviewed


China-Tianjin Port fire and explosion on August 12, 2015, was a major accident that involved hazardous chemicals and resulted in 165 fatalities and 798 injuries. Three-system-based accident models, human factor analysis and classification system (HFACS), AcciMap, and system theoretic accident modeling and process (STAMP), were applied to identify contributory factors and relationships in the accident. The analysis outputs and usage of the three techniques were compared. The three-system accident models show several differences in terms of the emphasis on the models, system structure, classification of contributory factors, and interactions between system components. An important advantage of HFACS is the taxonomic nature, which can be easily applied in practical application. AcciMap provides a clear graphic representation of the causal flow of accidents, which is suitable for academic research. STAMP is suitable for both academic research and practical applications.


Systems-based analysis Human factor analysis and classification system (HFACS) System theoretic accident modeling and process (STAMP) AcciMap China-Tianjin Port fire and explosion 



This work was supported by the National Social Science Foundation of China (Project ID: 16BGL176).


  1. 1.
    Accident Investigation Team of the State Council (AITSC) (2016) Investigation Report of Special Major Fire and Explosion Accident in Hazardous Goods Warehouse of Ruihai Company in Tianjin Port.
  2. 2.
    E. Akyuz, A hybrid accident analysis method to assess potential navigational contingencies: the case of ship grounding. Saf. Sci. 79(11), 268–276 (2015)CrossRefGoogle Scholar
  3. 3.
    M. Celik, S. Cebi, Analytical HFACS for investigating human errors in shipping accidents. Accid. Anal. Prev. 41(1), 66–75 (2009)CrossRefGoogle Scholar
  4. 4.
    Center for Chemical Process Safety (CCPS), Inherent Safer Chemical Process: A Life Cycle Approach, 2nd edn. (Wiley, Hoboken, 2009)Google Scholar
  5. 5.
    C. Chauvin, S. Lardjane, G. Morel, J.P. Clostermann, B. Langard, Human and organisational factors in maritime accidents: analysis of collisions at sea using the HFACS. Accid. Anal. Prev. 59(5), 26–37 (2013)CrossRefGoogle Scholar
  6. 6.
    S.T. Chen, A. Wall, P. Davies, Z. Yang, J. Wang, Y.-H. Chou, A human and organisational factors (HOFs) analysis method for marine casualties using HFACS-maritime accidents (HFACS-MA). Saf. Sci. 60(12), 105–114 (2013)CrossRefGoogle Scholar
  7. 7.
    M. Christou, Analysis and control of major accidents from the intermediate temporary storage of dangerous substances in marshalling yards and port areas. J. Loss Prev. Process Ind. 12(1), 109–119 (1999)CrossRefGoogle Scholar
  8. 8.
    A.Y. Daramola, An investigation of air accidents in Nigeria using the human factors analysis and classification system (HFACS) framework. J. Air Trans. Manag. 35(4), 39–50 (2014)CrossRefGoogle Scholar
  9. 9.
    R.M. Darbra, J. Casal, Historical analysis of accidents in seaports. Saf. Sci. 42(2), 85–98 (2004)CrossRefGoogle Scholar
  10. 10.
    J. Debrincat, C. Bil, G. Clark, Assessing organisational factors in aircraft accidents using a hybrid reason and AcciMap model. Eng. Fail. Anal. 27(1), 52–60 (2013)CrossRefGoogle Scholar
  11. 11.
    S.W.A. Dekker, Reconstructing human contributions to accidents: the new view on error and performance. J. Saf. Res. 33(3), 371–385 (2002)CrossRefGoogle Scholar
  12. 12.
    S.W.A. Dekker, The Field Guide to Understanding Human Error (Ashgate Publishing Limited, Aldershot, 2006)Google Scholar
  13. 13.
    Y. Dien, N. Dechy, E. Guillaume, Accident investigation: from searching direct causes to finding in-depth causes-problem of analysis or/and analyst? Saf. Sci. 50(6), 1398–1407 (2012)CrossRefGoogle Scholar
  14. 14.
    S. Dirk, H.R. Sebastian, W. Jan, S. Eckehard, Integration of Petri Nets into STAMP/CAST on the example of Wenzhou 7.23 accident, inControl and Automation Theory for Transportation Applications September 16–17, 2013. Istanbul, Turkey, pp. 65–70Google Scholar
  15. 15.
    G. Drogaris, Learning from major accidents involving dangerous substances. Saf. Sci. 16(2), 89–113 (1993)CrossRefGoogle Scholar
  16. 16.
    R. Elvik, Laws of accident causation. Accid. Anal. Prev. 38(4), 742–747 (2006)CrossRefGoogle Scholar
  17. 17.
    W.H. Heinrich (ed.), Industrial Accident Prevention (McGraw-Hill, New York, 1941)Google Scholar
  18. 18.
    E. Hollnagel, Cognitive Reliability and Error Analysis Method—CREAM (Elsevier, Amsterdam, 1998)Google Scholar
  19. 19.
    E. Hollnagel, FRAM-The Functional Resonance Analysis Method (Ashgate, Farnham, 2012)Google Scholar
  20. 20.
    N. Jang, J. Koo, D. Shin et al., Development of chemical accident database: considerations, accident trend analysis and suggestions. Korean J. Chem. Eng. 29(1), 36–41 (2012)CrossRefGoogle Scholar
  21. 21.
    C.W. Johnson, I.M.D. Almeida, An investigation into the loss of the Brazilian space programme’s launch vehicle VLS-1 V03. Saf. Sci. 46(1), 38–53 (2008)CrossRefGoogle Scholar
  22. 22.
    P. Katsakiori, G. Sakellaropoulos, E. Manatakis, Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models. Saf. Sci. 47(7), 1007–1016 (2009)CrossRefGoogle Scholar
  23. 23.
    K. Kazaras, K. Kirytopoulos, A. Rentizelas, Introducing the STAMP method in road tunnel safety assessment. Saf. Sci. 50(9), 1806–1817 (2012)CrossRefGoogle Scholar
  24. 24.
    D. Kee, G.T. Jun, P. Waterson, R. Haslam, A systemic analysis of South Korea Sewol ferry accident-Striking a balance between learning and accountability. Appl. Ergon. 59 Part B, 504–516 (2016)CrossRefGoogle Scholar
  25. 25.
    F.I. Khan, S.A. Abbasi, Assessment of risks posed by chemical industries–application of a new computer automated tool MAXCRED-III. J. Loss Prev. Process Ind. 12(6), 455–469 (1999)CrossRefGoogle Scholar
  26. 26.
    F.I. Khan, S.A. Abbasi, Major accidents in process industries and an analysis of causes and consequences. J. Loss Prev. Process Ind. 12(5), 361–378 (1999)CrossRefGoogle Scholar
  27. 27.
    K. Kidam, M. Hurme, Method for identifying contributors to chemical process accidents. Process Saf. Environ. Prot. 91(5), 367–377 (2013)CrossRefGoogle Scholar
  28. 28.
    T. Kim et al., A STAMP-based causal analysis of the Korean Sewol ferry accident. Saf. Sci. 83, 93–101 (2016)CrossRefGoogle Scholar
  29. 29.
    S. Lee, Y.B. Moh, M. Tabibzadeh, N. Meshkati, Applying the AcciMap methodology to investigate the tragic Sewol Ferry accident in South Korea. Appl. Ergon. 59 Part B, 517–525 (2016)Google Scholar
  30. 30.
    M.G. Lenné, P.M. Salmon, C.C. Liu, M. Trotter, A systems approach to accident causation in mining: an application of the HFACS method. Accid. Anal. Prev. 48(3), 111–117 (2012)CrossRefGoogle Scholar
  31. 31.
    N. Leveson, System Safety Engineering: Back to the Future (Aeronautics and Astronautics Department, Massachusetts Institute of Technology, Cambridge, 2002)Google Scholar
  32. 32.
    N. Leveson, A new accident model for engineering safer systems. Saf. Sci. 42(4), 237–270 (2004)CrossRefGoogle Scholar
  33. 33.
    N. Leveson, Engineering a Safer World: Systems Thinking Applied to Safety (The MIT Press, Cambridge, 2012)Google Scholar
  34. 34.
    N. Leveson, A. Samost, S. Dekker et al., A systems approach to analyzing and preventing hospital adverse events. J. Patient Saf. (2016). CrossRefGoogle Scholar
  35. 35.
    S. Newnam, N. Goode, Do not blame the driver: a systems analysis of the causes of road freight crashes. Accid. Anal. Prev. 76, 141–151 (2015)CrossRefGoogle Scholar
  36. 36.
    M. Ouyang, L. Hong, M.-H. Yu, Q. Fei, STAMP-based analysis on the railway accident and accident spreading: taking the China-Jiaoji railway accident for example. Saf. Sci. 48(5), 544–555 (2010)CrossRefGoogle Scholar
  37. 37.
    J.M. Patterson, S.A. Shappell, Operator error and system deficiencies: analysis of 508 mining incidents and accidents from Queensland, Australia using HFACS. Accid. Anal. Prev. 42(4), 1379–1385 (2010)CrossRefGoogle Scholar
  38. 38.
    T. Pawlicki, A. Samost, D.W. Brown et al., Application of systems and control theory-based hazard analysis to radiation oncology. Med. Phys. 43(3), 1514–1530 (2016)CrossRefGoogle Scholar
  39. 39.
    H.S.J. Rashid, C.S. Place, G.R. Braithwaite, Helicopter maintenance error analysis: beyond the third order of the HFACS-ME. Int. J. Ind. Ergon. 40(6), 636–647 (2010)CrossRefGoogle Scholar
  40. 40.
    J. Rasmussen, Risk management in a dynamic society: a modelling problem. Saf. Sci. 27(2–3), 183–213 (1997)CrossRefGoogle Scholar
  41. 41.
    J. Rasmussen, I. Svedung, Proactive Risk Management in a Dynamic Society (Swedish Rescue Services Agency, Karlstad, 2000)Google Scholar
  42. 42.
    J.T. Reason, Human Error (Cambridge University Press, Cambridge, 1990)CrossRefGoogle Scholar
  43. 43.
    J.T. Reason, Managing the Risks of Organizational Accidents (Ashgate, Aldershot, 1997)Google Scholar
  44. 44.
    S. Reinach, A. Viale, Application of human error framework to conduct train accident/incident investigations. Accid. Anal. Prev. 38(2), 396–406 (2006)CrossRefGoogle Scholar
  45. 45.
    F. Rigas, S. Sklavounos, Risk and consequence analysis of hazardous chemicals in marshalling yards and warehouses at Ikonio/Piraeus harbour, Greece. J. Loss Prev. Process Ind. 15(6), 531–544 (2002)CrossRefGoogle Scholar
  46. 46.
    P.M. Salmon, N. Goodea, F. Archerb, C. Spencerb, D. McArdleb, R.J. McClureb, A systems approach to examining disaster response: using Accimap to describe the factors influencing bushfire response. Saf. Sci. 70, 114–122 (2014)CrossRefGoogle Scholar
  47. 47.
    P.M. Salmon, M. Cornelissen, M.J. Trotter, Systems-based accident analysis methods: a comparison of Accimap, HFACS, and STAMP. Saf. Sci. 50(4), 1158–1170 (2012)CrossRefGoogle Scholar
  48. 48.
    P.M. Salmon, G.J.M. Read, N.J. Stevens, Who is in control of road safety? A STAMP control structure analysis of the road transport system in Queensland, Australia. Accid. Anal. Prev. 96, 140–151 (2016)CrossRefGoogle Scholar
  49. 49.
    L. Shaw, H.S. Sichel, Accident Proneness. Research in the Occurrence, Causation and Prevention of Road Accidents (Pergamon Press, Oxford, 1971)Google Scholar
  50. 50.
    S.A. Shappell, D.A. Wiegmann, Applying reason: the human factors analysis and classification system (HFACS). Gastroenterol. Res. 1(5), 207–212 (2001)Google Scholar
  51. 51.
    O. Soner, U. Asan, M. Celik, Use of HFACS-FCM in fire prevention modelling on board ships. Saf. Sci. 77, 25–41 (2015)CrossRefGoogle Scholar
  52. 52.
    I. Svedung, J. Rasmussen, Graphic representation of accident scenarios: mapping system structure and the causation of accident. Saf. Sci. 40(5), 397–417 (2002)CrossRefGoogle Scholar
  53. 53.
    K. Tsunekawa, B.L. Liu, J.M. Gao et al., The initial researches on management of chemical work safety at home and abroad as the cooperation project between China and Japan. J. Saf. Sci. Technol. 3(5), 87–91 (2007)Google Scholar
  54. 54.
    P. Underwood, P. Waterson, Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. Accid. Anal. Prev. 68(1), 75–94 (2014)CrossRefGoogle Scholar
  55. 55.
    G. Vierendeels, G.L.L. Reniers, B.J.M. Ale, Modeling the major accident prevention legislation change process within Europe. Saf. Sci. 49(3), 513–521 (2011)CrossRefGoogle Scholar
  56. 56.
    Waterson, P. and Jenkins, D.P. (2010), Methodological considerations in using Accimaps and the risk management framework to analyse large-scale systemic failures. in Paper presented at the 5th IET International System Safety Conference, Manchester, UK, pp.1-6Google Scholar
  57. 57.
    D.A. Wiegmann, S.A. Shappell, A Human Error Approach to Aviation Accident Analysis: The human Factors Analysis and Classification System (Ashgate Publishing Ltd, Burlington, 2003)Google Scholar
  58. 58.
    Y. Zhang, L. Jing, Q. Bai, T. Liu, Y. Feng, A systems approach to extraordinarily major coal mine accidents in China from 1997 to 2011: an application of the HFACS approach. Int. J. Occup. Saf. Ergon. (2017). CrossRefGoogle Scholar
  59. 59.
    Y. Zhang, W. Shao, M. Zhang, H. Li, S. Yin, Y. Xu, Analysis 320 coal mine accidents using structural equation modelling with unsafe conditions of the rules and regulations as exogenous variables. Accid. Anal. Prev. 92, 189–201 (2016)CrossRefGoogle Scholar
  60. 60.
    Y. Zhang, T. Liu, Q. Bai, W. Shao, Q. Wang, New systems-based method to conduct analysis of road traffic accidents. Transp. Res. Part F: Traffic Psychol. Behav. 54, 96–109 (2018)CrossRefGoogle Scholar
  61. 61.
    M.Q. Zheng, X.H. Zhuang, A tentative idea for setting-up port emergency response counterplan on dangerous chemical accident. Traffic Environment Protection 24(3), 22–25 (2003)Google Scholar

Copyright information

© ASM International 2018

Authors and Affiliations

  1. 1.School of ManagementQufu Normal UniversityRizhaoChina

Personalised recommendations