Macroergonomic Case Analysis: Fire Control Response After the Tianjin Explosion

The Tianjin explosion is a recent chemical explosion that happened in China just a few years ago. The explosion was caused by a combination of poorly handling chemicals and violation, and weather. During the rescue phase, a failure to maintain situational awareness (SA) and environmental setup made before the explosion resulted in delayed fire control; along with improper storage of hazardous chemicals, the warehouse soon had two explosions, equivalent to 430 tons of TNT with mushroom clouds, which led to many deaths, missings, destroyed properties, and the environmental damages. By analyzing this disaster using a system approach, flaws of the existing organizational culture and infrastructure can be examined and corrected to enhance further the rescue processes of fire and explosion in the future.

Event

The Tianjin explosion occurred on August 12, 2015, at 22:51 in the city of Tianjin, located in Northern China (Fu et al., 2016). The event's trigger started with a combustible and explosive canister of nitrocellulose on fire due to a combination of rough handling of the packaging and hot weather. As gas was generated, temperature and pressure increased. Spontaneous combustion led to the initial fire. The fire was reported in less than a minute. The firefighters arrived within five minutes of the initial fire. Evacuation began fifteen minutes after firefighters arrived. Due to previous human and organization non-compliance, which will be discussed in detail, the fire was not distinguished efficiently and adequately. Twenty minutes after the beginning of evacuation marked the first explosion as the fire reached nearby combustible chemicals. Thirty seconds later, the second, stronger explosion occurred 20 m away from the first explosion. The fire was finally distinguished almost two days later, on August 14, 2015, at 16:40.

The explosion and shock wave resulted in 165 deaths, eight missings, nearly 800 injuries, around 300 destroyed buildings within the perimeter of 150 meters of the explosion, and approximately 7500 destroyed containers (Zhao, 2016; Zhou et al., 2018). Because the Tianjin explosion is considered a hazardous chemical accident (HCA) where a significant amount of toxic and explosive chemicals are released, the explosion resulted in exceeded amounts of environmental pollution, including air, water, and soil contamination (Zhou et al., 2018). The effects of pollution and contamination are still actively monitored as the event is considered recent (Zhao, 2016); therefore no adverse effects of chemical release on human health and the environment have been confirmed.

The Tianjin explosion involved one warehouse near the Tianjin Port called the Ruihai International Logistics Co., Ltd., a hazardous goods warehouse storing 111 chemicals (Aitao & Lingpeng, 2017; Fu et al., 2016). Geographical and temporal factors are two crucial boundaries that measure the success of the response and rescue processes. As mentioned, the warehouse is located by a port, which is close to the ocean. Without a timely response, the chemicals will breach into the ocean water, posing environmental impacts, and potentially affecting human health. Organizational and economic boundaries also present as determinants of the success of the response process. From the warehouse to the fire department to the government supervisor, components (organizations) require smooth and interconnected communication for the response to be successful. Components involved include the company, and multiple layers of government safety departments including fire brigade of public security bureau (PSB), PSB, district fire control bureau, city fire control bureau, and ministry of public security. Each government organization has their duties and supervisory roles. They act to reinforce the laws, ensuring organizations like the warehouse are following the rules, such as not exceeding maximum storage of a certain hazardous chemical and ensuring warehouse fire standards are followed. 

Analysis

Both human and organizational errors made before the Tianjin explosion, organization safety culture, and a lack of SA resulted in delayed rescue responses, in other words, the lack of constant supervision as required by the law represents unsafe supervision, which then setup for preconditions for unsafe acts (Zhou et al., 2018). According to Chen et al. (2019), the company had a history of operating without abiding by the law of chemical handling. The warehouse ran the business without obtaining proper licenses, permits, or approval.

The company stored almost 1323 tons of potassium nitrate, a hazardous chemical, when the maximum amount can be stored, according to the law, is 25 tons (Fu et al., 2016). The extra canisters lead to stacking and mixing the containers due to inadequate space, resulting in undefined combustion and obstructed fire engine access, leading to human errors (Fu et al., 2019). The consequences included delayed and inefficient fire control and exacerbation of fire. A few officials believed that when the first batch of firefighters arrived, they exacerbated the fire by using water because calcium carbide, one type of chemicals stored, produces flammable gas when in contact with water (Global Resilience Institute, 2020). Because the company did not update the firefighters regarding the storage, they lacked SA to put out the fire properly.

The administrative error presented the greatest weakness in the Tianjin explosion response, as unsafe supervision persisted. Based on the Human Factors Analysis and Classification System for hazardous chemicals (HFACS-HC), the organizations involved in this disaster exhibited all the actions, including inadequate supervision, planned inappropriate operations, failure to correct problems, and supervisory violation (Zhou et al., 2018). In the Tianjin explosion, organization commands did not directly affect the response process. The current laws exhibited some inadequacy in providing safety measures (Zhang et al., 2020). The weakness of this disaster response is still mainly attributed to human errors. However, the human errors made by the fire department mentioned above are a direct result of inadequate organizational safety supervision and reinforcement of the laws by both the government and the company before the explosion. 

For example, the fire brigade was not aware of the itemized storage content at the warehouse. This is due to poor fire control supervision, inspection, and training of the public security bureau, which directly oversees the fire brigade within the area. The fire brigade, knowing there is a warehouse containing hazardous goods within its area, failed to organize special training and assignments regularly. When an emergency does come, and firefighters are not familiar with their roles, their performance lowers. When the organization does not follow the law, which is thoroughly thought through and accounting for emergencies in advance, the emergency becomes more chaotic and diverging from the expected path. 

Recommendation

SA is intertwined in human and organizational errors. SAis crucial in the success of any emergency response because the information received determines how the firefighters will act. When SA is not maintained, whether through regular inspection or company honesty in abiding by the laws, team performance is reduced. Performance, in this case, refers to the success and timely response to fire. Information exchange is linked with high levels of SA, which is then linked with high levels of performance in teams (Sorensen & Stanton, 2013). The lack of knowledge on the types of the chemicals present, the storage location of the chemicals, and the amounts of chemicals made the fire control challenging, especially when some chemicals are toxic and combustible, further introducing uncertainty and posing a danger.

To maintain SA, the Ministry of Public Security first needs to establish clear laws. These laws act as boundaries to control actions and make the system more predictable, hence, easier to respond when a single chain within the system is out of control. The subsequent lower-level organizations also need to reinforce the laws. Lastly, both warehouse employees and firefighters need to receive training specific to hazardous materials handling and proper response (Zhou, 20176). When Coskun and Ozcelyan (2011) proposed the Complexity in Emergency Management and Disaster Response Systems (EMDRIS), they emphasized that the system is real-time. This is also due to the importance of maintaining SA during the response phase of a disaster, which then adapts to uncertainty and changes in a complex and dynamic system, especially during a disastrous event, more tolerable.

Conclusion

The Tianjin Explosion is a preventable disaster. The most tremendous damages are caused by the later explosions rather than the initial fire. Suppose SA is maintained throughout the entire system, from the government to the fire department, to the company. In that case, fire control should have been easy, considering how timely the fire was reported and the fire department arrived on scene. However, due to a lack of awareness of the types of chemicals inside, the fire brigade could not correctly and efficiently control the fire. A failure to execute supervisory tasks also led to more challenging fire response missions. The company and the government failed to foresee possible emergencies. If they were to take a socio-technical system approach to establish a rescue plan when in an emergency, the components would value their interconnectedness and attempt to maintain SA, making firefighters’ response actions more appropriate and productive, resulting in less damage and casualties.

References

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Chen, Q., Wood, M., & Zhao, J. (2019). Case study of the Tianjin accident: Application of barrier and systems analysis to understand challenges to industry loss prevention in emerging economies. Process Safety and Environmental Protection, 131, 178-188. https://doi.org/10.1016/j.psep.2019.08.028

Coskun, E., & Ozceylan, D. (2011). Complexity in emergency management and disaster response information systems (EMDRIS). 8th International ISCRAM Conference, 1–5. http://idl.iscram.org/files/coskun/2011/415_Coskun+Ozceylan2011.pdf

Fu, G., Wang, J., & Yan, M. (2016). Anatomy of Tianjin port fire and explosion: Process and causes. Process Safety Progress, 35(3), 216-220. https://doi.org/10.1002/prs.11837

Global Resilience Institute. (2020, March 12). Tianjin Explosion. Global Resilience Institute at Northeastern University. https://globalresilience.northeastern.edu/tianjin-explosion

Sorensen, L. J., & Stanton, N. A. (2013). Y is best: How distributed situational awareness is mediated by organisational structure and correlated with task success.Safety Science, 56, 72-79. https://doi.org/10.1016/j.ssci.2012.05.026

Zhang, Y., Sun, C., Shan, W., Junqing, C., Jing, L., & Shao, W. (2020). Systems approach for the safety and security of hazardous chemicals. Maritime Policy and Management, 47(4), 500-522. https://doi.org/10.1080/03088839.2019.1710612

Zhao, B. (2016). Facts and lessons related to the explosion accident in Tianjin port, china. Natural Hazards (Dordrecht), 84(1), 707-713. https://doi.org/10.1007/s11069-016-2403-0

Zhou, L., Fu, G., & Xue, Y. (2018). Human and organizational factors in chinese hazardous chemical accidents: A case study of the '8.12' Tianjin port fire and explosion using the HFACS-HC. International Journal of Occupational Safety and Ergonomics, 24(3), 329-340. https://doi.org/10.1080/10803548.2017.1372943