Analysing Organizational Gaps in Process Accidents with Fram: The Case of the Imperial Sugar Refinery Explosion (2008)

This study presents a reanalysis of Imperial Sugar refinery accident, occurred in February 2008, in the northwest of Georgia, US, using the FRAM (Functional Resonance Analysis Method) methodology, and based on technical-scientific materials such as books, articles, the official report from the company and the CSB (U.S. Chemical Safety Board) report. This explosion was fuelled by massive accumulations of combustible sugar dust throughout the packaging building of the refinery, causing 14 fatalities and injuring 38 workers. The purpose of this reanalysis is to seek elements, factors, characteristics and interactions that could not be well analysed or evidenced using traditional risk assessment and accident investigation techniques, primally designed to analyse simple and linear systems. This reanalysis with FRAM allowed to perceive the influence of organizational elements, such as culture, in the entire accidental chain of the event and failures in decision making, highlighting the need of a broader approach for accidents involving high-tech process industries. In this sense, the FRAM enabled a more comprehensive and coherent analysis of the complexities of the functioning of a process plants, for both normal operation and emergency. Comparisons between the traditional analysis methodologies, with the results obtained with the application of the FRAM, showed that there are elements contributing to the accidents that need to be considered, but that techniques limited to linear and simple systems still cannot cover this recognition. It was noticed that the greater the complexity of work systems, the greater the interaction and variability between personnel, equipment and systems, requiring analysis techniques and methodologies capable of recognizing the real complexities that take place in these sociotechnical systems, especially in high-tech process plants, such as the sugar refinery of this accident.