International Journal of Occupational Safety and

Ergonomics

ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: https://www.tandfonline.com/loi/tose20

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

Lin Zhou, Gui Fu & Yujingyang Xue

To cite this article: Lin Zhou, Gui Fu & Yujingyang Xue (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,
DOI: 10.1080/10803548.2017.1372943

To link to this article: https://doi.org/10.1080/10803548.2017.1372943

Published online: 07 Nov 2017.

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International Journal of Occupational Safety and Ergonomics (JOSE), 2018
Vol. 24, No. 3, 329–340, https://doi.org/10.1080/10803548.2017.1372943

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
∗
Lin Zhou , Gui Fu and Yujingyang Xue
College of Resources and Safety Engineering, China University of Mining and Technology (Beijing), China

Human and organizational factors have been proven to be the prime causes of Chinese hazardous chemical accidents
(HCAs). A modified version of the Human Factors Analysis and Classification System (HFACS), namely the HFACS-
Hazardous Chemicals (HC), was developed to identify the human factors involved in Chinese HCAs. The ‘8.12’ Tianjin Port
fire and explosion, the costliest HCA in recent years, was reanalyzed using this framework, and the results were compared
with the official accident inquiry report to determine their differences related to the identification of human and organizational
factors. The study revealed that interacting human factors from different levels in Ruihai Company led to this catastrophe,
and the inquiry report had limitations in the identification of human factors and the guidance for similar accident prevention.
This study showed the applicability of the HFACS-HC in HCA analyses as well as the necessity to recommend this approach
for future HCA investigations.
Keywords: human and organizational factors; Human Factors Analysis and Classification System-Hazardous Chemicals;
‘8.12’ Tianjin Port fire and explosion; accident analysis

1. Introduction Several studies analyzed the characteristics of Chi-

Hazardous chemical accidents (HCAs) occur when a sig-
nificant amount of toxic, explosive or flammable chemicals
are released unintentionally during production, operation,
storage, transportation, usage or disposal; these types of
accidents can result in casualties, property damage and
environmental pollution (excluding toxic gas poisoning
and explosions during mine exploitation) [1]. As China is
a major chemical producer and user, severe HCAs occur
frequently. Official figures state that in 2015 there were 97
HCAs in China, resulting in 157 fatalities (based on the
Chinese accidents statistical method, HCAs during trans-
port are excluded) [2]. Learning from previous accidents
is important in the prevention of future ones [3], therefore,
it is necessary to comprehensively analyze the causes of
HCAs to ensure the safety of the chemical industry, prevent
fatalities and reduce economic losses.
Human and organizational factors play significant roles
for the occurrences of Chinese HCAs. Zhang and Zheng
[4] analyzed the statistical characteristics of 1632 Chi-
nese HCAs between 2006 and 2010.The statistical find-
ings showed that human errors, as the immediate cause,
accounted for the majority of HCAs; however, root causes
could be traced back to internal corporate management
problems. Therefore, there is a need to fully identify and
control the human and organizational factors to prevent
such accidents.
nese HCAs based on statistical investigations. Hou and
Zhang [5] established a designed database to collect the
information of 80 major pollution accidents from 2002 to
2006 in China, showing that flawed workers’ competence,
inadequate emergency systems and operating procedures
were the contributory factors to accidents. By analyzing
1632 HCAs, Zhang and Zheng [4] concluded that con-
scious rule-breaking behaviors of workers accounted for
more than 90% of cases as immediate causes, while defi-
ciencies in maintenance, procedures, training and limited
physical or mental capacity of employees could be traced
to management-driven issues which were viewed as the
main root causes. Seventeen chemical accidents occurring
in small and medium enterprises in China were analyzed,
showing that flaws in process hazard analysis (PHA), train-
ing (TNG) and emergency response (ER) in the Chinese
process safety management (PSM) standard [6] repeatedly
contributed to the occurrences of accidents [7]. The afore-
mentioned studies indicate that the importance of human
and organizational factors in Chinese HCAs has received
attention from scholars; however, since a limited num-
ber of factors are considered, an incomplete understanding
of human errors and organizational failures involved in
HCAs is achieved. According to the ‘what-you-look-for-
is-what-you-find’ principle, the model or method applied
in accident analysis determines the results which can be

*Corresponding author. Email: zhoulin8826@126.com

© 2017 Central Institute for Labour Protection – National Research Institute (CIOP-PIB)
330 L. Zhou et al.
obtained [8]; therefore, an analysis tool which thoroughly
highlights human and organizational factors is needed in
similar studies.
The Human Factors Analysis and Classification System
(HFACS) [9,10], which was proposed based on Reason’s
Swiss cheese model (SCM) [11,12], is a framework avail-
able for identifying and classifying the human factors
associated with accidents. According to the mechanism of
accident demonstrated by the SCM, the HFACS describes
the human and organizational factors related to an accident
at four levels – (a) unsafe acts of front-line operators; (b)
preconditions for unsafe acts; (c) unsafe supervision; (d)
organizational influences – and has specific failure mode
taxonomies for each level [9,10]. As the HFACS identi-
fies failures from front-line operators to latent conditions
in the organization, researchers are able to perform system-
atic and thorough accident analyses by using it [13]. The
original HFACS was designed to identify the specific fail-
ures associated with aviation accidents [9,10]. Later on, the
framework was successfully adapted to analyze accidents
and accident data across a wider range of domains such as
train accidents [13], mining accidents [14], collisions at sea
[15] and an outdoor activity accident [16].
There is little information about the application of the
HFACS to Chinese HCAs. Gong and Fan [17] applied
the HFACS to analyze an explosion at the Bi-benzene
Plant in Jilin Province, China, to prove the feasibility of
the framework in the petro-chemical industry. However,
there are two limitations. Firstly, the original framework
was used, therefore, its applicability to the chemical indus-
try was not optimized; secondly, the recommendation to
include the HFACS in future accident investigations in
petro-chemical industry was proposed, but limitations in
current investigations related to the identification of human
and organizational factors were not discussed.
In this study, firstly, an enriched causal taxonomy,
namely the HFACS-Hazardous Chemicals (HC), was pro-
posed. Three modifications were made to optimize the
compatibility of this framework with the hazardous chem-
ical industry. Secondly, as a case study, the fire and
explosion which occurred in Tianjin Port on August
8, 2016 was reanalyzed by the HFACS-HC to verify
the applicability of the framework for Chinese HCAs.
Thirdly, the results of the HFACS-HC and official acci-
dent inquiry report were compared to determine whether
human and organizational factors were identified in the
official accident investigation and to discuss the neces-
sity to adopt the HFACS-HC in future Chinese HCA
investigations.
2. Adapted HFACS-HC framework
When the HFACS is used in domains other than aviation,
modifications were usually made in order to optimize its
relevance to the industry domains [14,15,18]. Therefore,
three modifications were incorporated into the original
HFACS framework and a new HFACS-HC was developed
for the hazardous chemical industry.
Firstly, at the second level, the category ‘crew resource
management’ was changed to ‘communication and coordi-
nation.’ Crew resource management (CRM) is a term used
in the aviation domain [19,20], and this causal category in
the original HFACS is used to identify the influences that
improper communication and coordination within aircrew
bring to unsafe acts [9]. In the HFACS-HC, CRM was sim-
ply renamed ‘communication and coordination’ to avoid
the confusion brought to users. ‘Communication’ refers to
any kind of failures related to the content, type, timing or
medium of communication in the workplace; while ‘coor-
dination’ refers to the unsuccessful interaction among two
or more people when they complete a job [21].
Secondly, the conformity of requirements in PSM
should be included at the fourth level ‘organizational influ-
ences.’ As a specific safety management system, PSM
needs to be implemented in organizations to prevent fires,
explosions and toxic emissions caused by unexpected
release of hazardous chemicals during their usage, stor-
age, manufacturing, handling or on-site movement [22].
PSM comprises interrelated elements to help the organi-
zation understand the chemical hazards and risks involved
in its activities, and prevent HCAs by the management
of facilities, technology and personnel [23,24]. Safety
management is carried out via a safety program [25];
therefore, poor implementation of the requirements of
PSM reflects the fallible decisions of upper-level decision-
makers related to the prevention of unexpected hazardous
chemical releases, which should be classified as deficien-
cies in ‘organizational influences.’ State Administration
of Work Safety (SAWS) of China released Standard No.
AQ/T 3034–2010 [6] in 2010, which contains 12 man-
agerial elements to help an organization implement and
maintain an effective PSM program. The 12 managerial
elements are: process safety information (PSI), process
hazard analysis (PHA), operating procedure (OP), train-
ing (TNG), contractors (CONT), pre-startup safety review
(PSSR), mechanical integrity (MI), work permits (WP),
management of change (MOC), emergency response (ER),
accident management (AM) and compliance audit (CA).
These elements were used as criteria and integrated into
the fourth level ‘organizational influences’ in the original
framework to identify safety management-related issues
contributing to HCAs. In the original HFACS, the sub-
category ‘resource management’ at the fourth level refers
to the upper-level decision-making regarding to manage-
ment of organizational assets such as human resources and
equipment/facility resources [9], which overlaps with the
requirements of TNG and MI in PSM; therefore, the acci-
dent causes related to TNG and MI can be incorporated
into ‘resource management.’ ‘Organizational process’ at
the fourth level refers to flaws in corporate decisions
 International Journal of Occupational Safety and Ergonomics (JOSE) 331

and rules which govern the everyday activities within an 3. Case study
organization [9]; therefore, deficiencies related to other 3.1. Accident description
managerial elements in PSM can be integrated into this
On August 12, 2015 at 22:51 (local time), a fire occurred
sub-category.
in a hazardous chemicals warehouse at Ruihai International
Thirdly, the fifth level named ‘outside factors’ was
Logistics Co., Ltd (hereafter, Ruihai Company) located at
added to the HFACS-HC and grouped into two sub-
Tianjin Port, which was engaged in the business of ware-
categories: ‘government supervision’ and ‘other factors.’
housing hazardous chemicals. The fire spread and ignited
In China, as relevant government authorities play an
nearby containers filled with various kinds of chemicals.
important role in supervising organizational compliance
At 22:52, the Command Centre of Tianjin Public Security
with laws, regulations and industrial standards, the neg-
Bureau received an emergency call from Ruihai Company,
ligence of government supervision remains an outside
and 4 min later firefighters from the Tianjin Port Public
contributory factor to HCAs [4] and has contributed to
Security Bureau arrived at the accident scene. As the fire
several catastrophic disasters, such as the explosion and
escape in Ruihai Company was blocked by containers, the
leakage at the Bi-benzene Plant in Jilin Province [17]
firemen were unable to access the fire scene and, there-
and the fire and explosion at Tianjin Port [26]. Therefore,
fore, were only able to control the fire from a distance,
‘government supervision’ was included as a sub-category.
using equipment such as a fire hose. At 23:08, reinforce-
‘Other factors’ encompasses influences from society, the
ments reached the scene, established the water supply lines
environment, policies and the economy which lead to
and covered the burning containers with retardant foam.
HCAs.
Five minutes later, more reinforcements arrived and began
The structure of the HFACS-HC is shown in Figure 1
to evacuate nearby people. The first explosion occurred at
and a brief description of each causal category is presented
23:34:06, followed by a more severe explosion 31 s later.
in Table 1.

Figure 1. The Human Factors Analysis and Classification System-Hazardous Chemicals framework.
332 L. Zhou et al.

Table 1. Description of the HFACS-HC causal categories.

Category Description

Outside factors
Government supervision
Other factors
Organizational influences
Resource management
Organizational process
Organizational climate
Unsafe supervision
Inadequate supervision
Planned inappropriate operations
Failure to correct problem
Supervisory violations
Preconditions for unsafe acts
Condition of operators
Adverse physiological states
Adverse mental states
Physical/mental limitations
Personnel factors
Communication and coordination Deficiencies related to communication and coordination between workers in the workplace
Personal readiness
Environmental factors
Physical environment
Technological environment
Unsafe acts
Errors
Skill-based errors
Decision errors
Perceptual errors
Violations
Routine violations
Exceptional violations
Government authorities fail to supervise the organizations whose business activities involve
usage, manufacturing, storage or on-site movement of hazardous chemicals
Influences that society, environment, policy, economy, etc. bring on the safety of organizations
in the chemical industry
Inappropriate or inadequate allocation and management of various resources, including
human resources, monetary assets and process equipment/facilities resources, including the
inadequate implementation of TNG and MI in PSM
Failures in managerial decisions and rules that govern the daily activities within the organization,
including the issues in operations and the nonconformity of requirements of PSM
Deficiencies in the prevailing work atmosphere within the organization, presenting as failures in
the organizational structure, culture and policy
Supervisors fail to provide adequate and appropriate oversight, incentives, guidance, training or
leadership to the operator to ensure that the job is performed safely and efficiently
Improper or inappropriate management and assignment of work by supervisors
Supervisors already know the deficiencies in individuals, facilities, management or other safety
issues but fail to correct them
Supervisors willfully disregard the existing rules, regulations, instructions and operating
procedures during the course of supervision
The operator’s adverse physiological states which affect performance
The operator’s adverse mental states which affect performance
The job requirements exceed the physical or mental capabilities of the operator. The physical
and mental capabilities are related to individual physiological and psychological limitations,
inadequate experience for the complicated situation, etc.
which adversely affect the performance
The operator is unprepared physically or mentally for duty, including the inadequate awareness
of chemical hazards relevant to the job
Adverse operational environment affects the operator’s performance
Adverse technology-related issues affect the operator’s performance, such as the poorly designed
process facilities, process indicators monitoring tools, human–machine interfaces and checklist
layouts
Automatic behavior of an operator with little or no conscious thought, presenting as attention or
memory failures; the manner and technique used by the operator to perform a task are also
included as technique errors
The planned, goal-intended and designed behavior of the operator; however, the behavior is
inadequate or inappropriate for the situation. There are three areas of concern: procedural
errors, poor choices and problem-solving errors
Failure occurs when an operator’s sensory inputs differ from the reality; therefore, the operator
makes an incorrect decision based on the faulty perception
Willful and habitual disregard of operating procedures or regulations used to control the chemical
hazards, which is usually tolerated by supervisory authorities
Isolated violation which is neither an operator’s habitual behavior nor condoned by governing
authorities

Note: HFACS-HC = Human Factors Analysis and Classification System-Hazardous Chemical; MI = mechanical integrity; PSM =
process safety management; TNG = training.

The consequent fires burned out of control until finally 304 buildings, 12,428 commercial automobiles and 7533
being quelled on August 14, 2015 at 16:40. This catas- containers. The direct economic losses of this accident
trophic accident resulted in 165 fatalities, 798 injuries and amounted to CNY 6.866 billion1 , the costliest industrial
8 missing people and caused damage to or destruction of disaster in China in recent years [26].
 International Journal of Occupational Safety and Ergonomics (JOSE)
After the disaster, an accident investigation team was
put together with the approval of China’s State Council,
and the final accident inquiry report [27] was published on
the SAWS website. As mentioned in the report, the initial
fire was due to the spontaneous ignition of nitrocellulose
(C12 H16 N4 O18 ) in containers in the storage yard at Ruihai
Company. Nitrocellulose is a highly flammable, explosive
chemical material that can slowly decompose and generate
heat at room temperature. When the temperature exceeds
40 °C, decomposition accelerates and heat accumulates,
resulting in spontaneous ignition at 180 °C without dis-
sipation. Manufacturers usually add ethanol and water to
nitrocellulose as a wetting agent and manually package it
into plastic bags that are further sealed with ropes. When
the nitrocellulose containers were transported to and stored
at Ruihai Company, they were moved and loaded roughly
by the forklift drivers, breaking open the packages. The
temperature in the containers on the day of accident was
as high as 65 °C, which made the wetting agent volatile,
causing the nitrocellulose to rapidly decompose. Because
of the poor ventilation in containers, the heat accumu-
lated and reached the spontaneous ignition temperature,
sparking the initial fire. The fire spread and ignited chemi-
cals (refined naphthalene, sodium sulfide, furfuryl alcohol,
etc.) in nearby containers, accelerating the stored ammo-
nium nitrate decomposition that eventually caused the first
explosion at 23:34:06, the power of which was equivalent
to 15 t of trinitrotoluene (TNT). Because of the spreading
fire and the shock wave from the first explosion, contain-
ers with flammable solids, oxidizers and corrosives located
about 20 m northwest of the first explosion exploded at
23:34:37 with a power equivalent to 430 t of TNT.
3.2. Methodology of accident analysis
The modified HFACS-HC was applied for a complete anal-
ysis of human and organizational factors involved in this
accident. For this study, two specialists familiar with the
HFACS-HC and the Tianjin Port accident were asked to
independently review the accident inquiry report and iden-
tify human and organizational factors on the basis of the
HFACS-HC framework. The presence or absence of each
HFACS-HC category was evaluated based on the infor-
mation in the following seven sections of the report: (a)
narrative of the accident; (b) immediate cause analysis;
(c) emergency response narrative; (d) issues in Ruihai
Company; (e) issues in government departments and inter-
mediary organizations; (f) accident lessons; (g) prevention
measures and recommendations. It is very important to
point out that as it was not possible to reinvestigate this
accident, the two specialists were asked to identify the pos-
sible reasons on the basis of the information in the inquiry
report and not to indulge in subjective over-interpretation.
When the independent analysis was completed, the results
were discussed by the specialists until a consensus about
the HFACS-HC classifications was reached.
333
3.3. Analysis results
3.3.1. Unsafe acts
Although the investigators identified that the spontaneous
ignition of nitrocellulose was the immediate cause of this
accident, the errors of the forklift drivers when moving
and loading the nitrocellulose packages deserved more
attention. The inquiry report showed that some of the fork-
lift drivers working at Ruihai Company were not trained
in the knowledge and skills required for handling con-
tainers filled with hazardous materials, which led to the
rough operations when they moved and loaded the con-
tainers. The rough operations resulted in the damaged
nitrocellulose packages because of container collisions and
rollovers. Since the acts of the forklift drivers while mov-
ing and loading the containers were planned behaviors
and not intentional or habitual disregard of the rules and
regulations, these acts were identified as ‘decision errors.’
The improper responses of employees under an emer-
gency situation were identified. As the employees in Rui-
hai Company were not trained for emergency situational
action, they were unable to take the proper action when the
fire occurred. As a result, they neither informed the inter-
ested parties to evacuate in a timely manner nor gave the
firefighters relevant information about the burning materi-
als when the firemen arrived, which deteriorated the acci-
dent’s consequences; therefore, these were also classified
as ‘decision errors.’
3.3.2. Preconditions for unsafe acts
The preconditions for the unsafe acts of the forklift drivers
and employees should be noted. Because of inadequate
training, the forklift drivers did not have the competence
to handle the containers safely in accordance with rele-
vant safety operational procedures, which meant that they
were not prepared for work. In addition, as the employees
were not trained in emergency preparedness and response,
they were not fully prepared for emergency situations.
Therefore, these errors were classified under ‘personal
readiness.’
3.3.3. Unsafe supervision
There were two types of errors in ‘inadequate supervision.’
Firstly, the inquiry report stated that there were no supervi-
sors on the scene when the containers with the flammable
and explosive chemicals were moved and loaded, and some
of the cargo handling managers had failed to obtain the
relevant job qualifications as required by the law. There-
fore, it can be inferred that the forklift drivers were given
inadequate oversight during the handling operations and
poor or no guidance about handling the containers safely.
Secondly, the flaws in ‘personal readiness’ of forklift
drivers and employees implied that their supervisors did
not provide proper training in the daily work.
334 L. Zhou et al.
The sub-category ‘planned inappropriate operations’
referred to the poor worker pairing; this was also evident
as the inadequately trained forklift drivers were arranged
by poorly qualified managers to handle the containers with
no supervisors on the site.
3.3.4. Organizational influences
Failures in ‘resource management’ were identified. Both
the forklift drivers and the managers had inadequate train-
ing and job qualifications as required by Chinese laws
(i.e., Hazardous Chemicals Control Ordinance [28]), and
there were no supervisors on the site when the contain-
ers were being moved and loaded; therefore, there were
severe human resource management deficiencies. The acci-
dent inquiry report also noted that the forklifts being
used were inappropriate for moving and loading contain-
ers with inflammable and explosive goods as they were
non-explosive-proof forklifts. Thus, there were holes in
‘equipment/facilities resource management.’
In the sub-category ‘organizational process,’ failures
in PSM as well as the operating pressure faced by Rui-
hai Company were identified. The accident inquiry report
noted that Ruihai Company did not take any supervi-
sory responsibility for the subcontracted transportation
and handling operations, which can be considered as the
inadequate implementation of CONT in PSM. As was evi-
denced in the performance of employees when the fire
occurred and the severe casualties in nearby organiza-
tions and communities, failures also occurred in the ER
element. Ruihai Company did not register and file the
stored hazardous chemicals with the relevant authorities,
and employees did not know information about the stored
chemicals when firefighters arrived, from which can be
inferred that Ruihai Company did not complete a compi-
lation of safety information about hazardous chemicals,
which indicates inadequate implementation of PSI. Cur-
rent Chinese laws and regulations prohibit the stacking of
containers with ammonium nitrate in the port; however,
on the day of the accident, around 800 t of ammonium
nitrate was being stored in Ruihai Company warehouse.
In addition, more than the specified maximum amounts
of some other permitted hazardous chemicals (e.g., potas-
sium nitrate, sodium sulfide and sodium cyanide) were also
stored together at unsafe distances and were even stacked
up to four or five layers high. These massive containers
were instrumental in the fire spread when the nitrocellulose
spontaneously ignited and blocked the fire escape, hinder-
ing the fire engines. These situations revealed deficiencies
in PHA, i.e., the organization neither identified the chem-
ical hazards nor assessed the risks they faced; in addition,
they also indicated that the organization was operating
under a high pressure that exceeded its capacity to balance
safety and its warehousing business.
In terms of the ‘organizational climate,’ failures existed
in the organization’s culture related to safety. The safety
culture elements proposed by Fu [29] were applied to
assess the safety culture in the organization. During daily
operations, various illegal management decisions were
made. For example, top managers decided to reconstruct
the hazardous chemical container yard and conduct a haz-
ardous chemical warehousing business without the local
government approval since they thought the long approval
time would delay the operation. These situations revealed
the weak safety culture in the organization from three
aspects: firstly, top managers neither demonstrated their
leadership and commitment to safety nor put safety first
in the business processes; secondly, top managers over-
looked the roles that safety laws and regulations played
in accident prevention; thirdly, managers did not realize
that excellent safety performance and excellent profitabil-
ity can be mutually supportive. Moreover, the deficient
implementation of PSM elements implied that the orga-
nization did not cultivate a culture to support a PSM
program.
3.3.5. Outside factors
Two kinds of government supervision failures were clas-
sified. The first was that the authorities did not perform
their supervisory responsibilities, e.g., the Tianjin Munici-
pal Transportation Commission gave Ruihai Company the
approval to conduct its hazardous chemical warehousing
business even though the company did not have a qualified
operational condition. In total, 22 government departments
on different levels failed in their duties, becoming contrib-
utory factors to the catastrophe. The second failure related
to government supervision was the confused and overlap-
ping functions of the different responsible authorities, e.g.,
Hazardous Chemicals Control Ordinance [28] states that
transportation authorities at different levels are responsible
for regulating chemical management during transporta-
tion, which means these authorities should supervise the
hazardous chemical transport enterprises, whereas Work
Safety Law of the People’s Republic of China [30] states
that the Administrations of Work Safety at different lev-
els must inspect and regulate the organizations (including
hazardous chemical transport enterprises) in their jurisdic-
tions to ensure operational safety. Therefore, the ambigu-
ous assigned roles and responsibilities in two government
departments led to the inadequate daily supervision of
Ruihai Company.
For the ‘other factors,’ two causes were considered.
The first was the failures from intermediary institutions.
For example, they provided false design proposals and
safety assessment reports to Ruihai Company. The second
cause was the absence of legal requirements for the pro-
duction of nitrocellulose, which failed to provide guidance
for relevant organizations and led to the improper opera-
tion: the nitrocellulose was simply packaged in plastic bags
that were then sealed with ropes during the manufacturing
process, which increased the accident risk.
 International Journal of Occupational Safety and Ergonomics (JOSE)
4. Comparison of results between the HFACS-HC
and the official accident inquiry report
The prior case study indicated the applicability of the
HFACS-HC in Chinese HCAs; a comparative study was
conducted to determine the differences between the analy-
sis results garnered through the HFACS-HC and the official
accident investigation. As distributed across the seven sec-
tions in the official accident inquiry report, there were no
systematic or comprehensive conclusions regarding human
and organizational factors associated with this catastrophe;
therefore, the relevant information of causes was sorted out
as official accident inquiry results as presented in Table 2.
According to Table 2, it is evident that the HFACS-
HC provides a clear causal taxonomy to reclassify the
causes mentioned in the official inquiry report. The anal-
ysis results from two methods overlapped in some aspects,
because the HFACS-HC analysis was conducted on the
basis of the inquiry report information. However, there
were still significant differences between them. At the
‘unsafe acts’ level, the errors of front-line workers were
classified from a cognitive perspective in the HFACS-HC
[9], whereas in the official inquiry report, the investiga-
tion stopped when the unsafe acts performed by workers
were identified. On the ‘preconditions for unsafe acts,’ the
precursor factors which could provoke and shape unsafe
acts were inferred based on the information in the inquiry
report; however, they were not fully considered in the orig-
inal investigation. As for deficiencies related to the line
management, ‘inadequate supervision’ was mentioned as
an underlying causal factor in the inquiry report; while
in the HFACS-HC, the issues related to the inappropriate
work planning from line managers were also obtained by
reasonable inferences. On the ‘organizational influences,’
the distinct differences can be illustrated from the fol-
lowing two aspects. Firstly, in the official investigation,
the organizational factors were identified on the basis of
legal requirements; in other words, a series of illegal oper-
ational activities in Ruihai Company were presented to
illustrate the deficiencies in upper-level management. In
the HFACS-HC, however, categories based on manage-
ment theories and practices (e.g., elements in PSM) were
used to analyze organizational failures. Secondly, the offi-
cial inquiry report neglected to investigate the deficiencies
in the organizational climate which was an essential con-
tributory factor to the safety performance [33]. At the
fifth ‘outside factors’ level, the HFACS-HC reclassified
the causes in the official inquiry report into new causal
categories.
5. Discussion
Since few chemical accidents in recent years are led by
unknown physical or chemical hazards, the failures related
to human factors need to be addressed [34]. A modi-
fied HFACS framework, namely the HFACS-HC, which
335
highlights the roles of human errors and underlying orga-
nizational failures in Chinese HCAs, was applied to reana-
lyze the ‘8.12’ Tianjin Port fire and explosion accident. The
causes mentioned in seven sections of the accident inquiry
report were reclassified into five causal levels using the
HFACS-HC. This case study clearly supported the appli-
cability of the HFACS-HC in Chinese HCAs investigation
and analysis. From Table 2 it can be seen that some of the
factors in the HFACS-HC were not identified (e.g., viola-
tions, condition of operators), which was due to the lack
of detailed information in the inquiry report. The analysis
results reveal that deficiencies at different levels in Rui-
hai Company and outside factors were intertwined to lead
this catastrophe, so that multiple countermeasures should
be adopted to prevent such a catastrophe. For the outside
level, the clearly assigned responsibilities and authorities
should be communicated to and strictly enforced by all lev-
els of relevant government departments. In addition, the
technical standards related to the manufacture of nitrocel-
lulose need to be set and released as soon as possible.
At the organizational level, the PSM program as well as
resource management programs should be planned, imple-
mented, audited and improved effectively, avoiding the
deficiencies identified in the case study; educational inter-
vention can be applied as an effective way to develop a
robust safety culture in the organization [35,36]. At the
line management level, the competent supervisors should
be arranged to provide adequate guidance and oversight to
front-line operators, while the issues related to crew pairing
in the workplace should be noted in accident prevention.
At the individual level, the employees and forklift drivers
should be trained and educated adequately to ensure they
could work safely and respond to emergency situations
properly in order to prevent their human errors.
The comparative study of the HFACS-HC and the offi-
cial inquiry report shows limitations in the official investi-
gation related to human and organizational factors, which
can be discussed from two aspects.
Firstly, the official accident investigation neither com-
prehensively identified human and organizational factors
involved in the HCA nor revealed the accident mecha-
nism. Following ‘what-you-look-for-is-what-you-find’ [8],
the theories and methods applied in the official accident
investigation decide what causes should be focused on
and what causes should be ignored, even though they
might exist. The comparative study results indicated that
deficiencies in precursors of unsafe acts and the line man-
agement did not receive enough attention from investiga-
tors. As precursors, various workplace conditions as well
as individual physiological or psychological states can
directly provoke and shape a set of unsafe acts, while the
incompetent line management could exacerbate the conse-
quences of fallible top-level decisions or even make good
decisions have bad results [11]. Therefore, the causal fac-
tors from these two levels need to be considered. When
 336
Table 2. Comparison between the HFACS-HC and the official accident inquiry.

HFACS-HC result
Error type Identified error Official accident inquiry result

Unsafe acts Errors Decision errors Forklift drivers moved and loaded the containers roughly Forklift drivers moved and loaded the containers roughly
Employees improperly responded to the emergency Employees improperly responded to the emergency
situation situation: they neither knew about the burning materials
nor informed organizations nearby when the accident
occurred
Precondition for Personnel factors Personal readiness Forklift drivers did not have adequate training and job Not identified
unsafe acts qualifications
Employees did not have adequate emergency Not identified
preparedness and response training

L. Zhou et al.
Unsafe supervision Inadequate supervision Inadequate guidance and oversight were provided There were no specific supervisors when loading and
unloading containers with flammable and explosive
chemicals, which violated Standard No. JT397–2007
[31]; some cargo handling managers did not have the
relevant job qualifications, which violated Hazardous
Chemicals Control Ordinance [28], etc.
Supervisors failed to provide proper training to forklift Not identified
drivers and employees
Planned inappropriate operations Inadequately trained forklift drivers were arranged by Not identified
poorly qualified managers to handle the containers
with no supervisors on site
Organizational Resource Human resources Forklift drivers and managers without adequate training Forklift drivers and some cargo handling managers did
influences management and job qualifications; there were no supervisors on not obtain adequate training and qualifications, which
site during containers handling violated Hazardous Chemicals Control Ordinance [28],
etc.; there were no specific supervisors on site when
loading and unloading containers with flammable and
explosive chemicals, which violated Standard No.
JT397–2007 [31]
 Equipment/facilities Unsuitable facilities were used. Non-explosive-proof forklifts were used when moving
resources and loading containers with inflammable and explosive
goods, which violated Standard No. JT397–2007 [31]
Organizational PSM CONT Ruihai Company did not take supervisory responsibility for
process some subcontracted transportation and handling business
ER Ruihai Company did not establish or periodically exercise
emergency response plans, which violated Rules for Fire

International Journal of Occupational Safety and Ergonomics (JOSE)

Management of State Organs, Organizations, Enterprises,
and Public Institutions [32]; Ruihai Company did not
implement safety notification and mutual safety insurance
agreement with the organizations nearby
PSI Ruihai Company did not register and file the stored
chemicals with authorities, which violated Hazardous
Chemicals Control Ordinance [28], etc.
PHA Ruihai Company violated Standard No. JT397–2007 [31],
Operations High operating pressure etc., by storing ammonium nitrate in port, and storing
containers with chemicals together at unsafe distances;
the stored chemicals exceeded the permitted amount
Organizational Organizational Poor leadership and commitment to safety Not identified, only the illegal operations in Ruihai
climate culture Company were stated
Safety was not the first priority in the business processes
The roles of safety laws and regulations were overlooked
That excellent safety performance and excellent
profitability can be mutually supportive was not
realized
Poor culture to support the implementation of PSM
Outside factors Government Authorities did not perform their regulatory responsi- The specific failures of 22 government departments in
supervision bilities; confused and overlapping functions in the accordance with the laws and administrative regulations
different responsible authorities were stated; overlapping functions existed in the different
government departments
Other factors Intermediary institutions provided illegal services for Intermediary institutions conducted the safety review, safety
Ruihai Company; absent legal requirements for the assessment and safety acceptance test illegally; absent
production of nitrocellulose legal requirements related to the safety management of
nitrocellulose

Note: CONT = contractors; ER = emergency response; HFACS-HC = Human Factors Analysis and Classification System-Hazardous Chemical; PHA = process hazard analysis;
PSI = process safety information; PSM = process safety management.

337
338 L. Zhou et al.
investigating the fallible decisions from upper-level man-
agement, the investigators mainly focused on the extent
of the conformity of legal requirements in Ruihai Com-
pany, which is because the purpose of Chinese accident
investigations is to find out who is to blame [37,38]. In
this case, the investigation results are possibly influenced
by the degree of perfection in the legal system, i.e., orga-
nizational factors which are important for the occurrence
of the accident but not required in the current laws and
regulations are easily omitted in the investigation, e.g.,
poor organizational culture in Ruihai Company. The cat-
egories of ‘organizational influences’ in the HFACS-HC
are established on the basis of the actual operations in the
organization, which would help investigators to review the
holes in top management decisions from every perspective
of organizational activities, not just from the conformity
of legal requirements. In addition, the complex relation-
ships among various human and organizational factors
were not fully illustrated in the inquiry report. For exam-
ple, the inquiry report considered ‘forklift drivers were
not adequately trained and qualified’ as a causal factor
to directly explain why the forklift drivers moved and
loaded the containers roughly, which unreasonably sim-
plified the actual organization structure between front-line
operators and top management and the mechanisms of
the occurrence of an accident in sociotechnical systems
[11,39]. In the HFACS-HC framework it can be seen that
flaws in ‘unsafe supervision’ and ‘preconditions for unsafe
acts’ could also result in the unsafe acts of forklift drivers
either alone or in combination. Therefore, the HFACS-
HC, which better presents organization structure, can guide
investigators to verify the flaws at different levels in the
organization until the detailed causes of the accident are
achieved.
Secondly, because of the limited investigation findings,
the official inquiry report provided inadequate lessons for
organizations in the chemical industry. How much can
be learned from the accident depends on how deeply the
accident analysis can be conducted; therefore, the superfi-
cial investigation on human contributions to the accident
in the inquiry report provided limited recommendations
for similar organizations. For example, in order to pre-
vent the unsafe acts of the operator who moves and
handles the containers with hazardous chemicals, the pre-
ventive measure achieved from the inquiry report would
possibly focus on the implementation of training pro-
grams in the organization; however, the results of the
HFACS-HC analysis illustrated that the control measures
from ‘supervision’ and ‘precondition of unsafe acts’ were
equally essential. Besides, in the HFACS-HC, confirming
the unsafe acts as errors or violations was also important
since different interventions were required [9]. Moreover,
since the official accident inquiry focused on the non-
conformity of legal requirements in Ruihai Company, the
issues of its safety management were not adequately iden-
tified. In the HFACS-HC, however, the PSM elements
were integrated into ‘organizational influences’ so that
the analysis results can guide organizations to implement,
monitor and improve the relevant elements in their PSM
program to prevent such accidents in a systematic and
proactive way.
The limitations in the official inquiry report show the
needs to introduce the HFACS-HC into future accident
investigations. Although the taxonomic nature determines
that the HFACS-HC would have the same shortcomings
as the framework is applied to other domains [16], its
specialty on the identification of human errors and orga-
nizational failures meets the need to gain a deeper insight
into Chinese HCAs to better prevent such accidents in the
future.
6. Conclusions
Comprehensive analyses of human and organizational fac-
tors in Chinese HCAs are essential for the future pre-
vention; however, how much we could learn depends on
the accident model we apply. In this study, a modified
HFACS-HC was proposed to analyze human and organi-
zational factors in Chinese HCAs and its feasibility was
proved through a case study focusing on the 2015 Tianjin
port fire and explosion catastrophe. In addition, a com-
parative study between the results of the HFACS-HC and
the official inquiry report was conducted to illustrate the
limitations in the current accident investigation related to
human and organizational factors and the necessity to rec-
ommend the HFACS-HC as a part of future Chinese HCA
investigations.
Further studies could be conducted based on three
aspects. Firstly, the taxonomic nature of the HFACS-HC
allows for quantitative analyses, therefore, the statistical
characteristics of each causal category in Chinese HCAs
need to be studied. Secondly, given that its taxonomic
nature could also expose an ignorance of the contributory
factors out of the HFACS-HC framework, some further
accident analyses are needed to make the causal cate-
gories become more specific and detailed, especially on
the outside factors level. Thirdly, an in-depth study on
the characteristics of accidents that occur during different
activities involving hazardous chemicals (e.g., production,
storage, transportation and disposal) is required, so that
more accurate frameworks could be developed based on
the HFACS-HC and be applied to analyze and investigate
various kinds of HCAs.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the National Natural Science Foun-
dation of China [Grant No. 51534008].
 International Journal of Occupational Safety and Ergonomics (JOSE)
Note
1. EUR 100 = CNY 786.44 and USD 100 = CNY 661.99
ORCID
Lin Zhou http://orcid.org/0000-0001-6124-543X
Gui Fu http://orcid.org/0000-0001-8461-3717
Yujingyang Xue http://orcid.org/0000-0001-6570-6803
References
[1] He G, Zhang L, Lu Y, et al. Managing major chemical acci-
dents in China: towards effective risk information. J Haz-
ard Mater. 2011;187(1–3):171–181. doi:10.1016/j.jhazmat.
2011.01.017
[2] Gao ZM. [The number of hazardous chemical accidents
and casualties both decreased in 2015]. Chinese Chemical
Industry News [Internet]. 2016 Mar 9 [cited 2016 Oct 26].
Available from: http://www.ccin.com.cn/ccin/news/2016/
03/09/330693.shtml. Chinese.
[3] Fan Y, Li Z, Pei J, et al. Applying systems thinking approach
to accident analysis in China: case study of ‘7.23’ Yong-Tai-
Wen high-speed train accident. Saf Sci. 2015;76:190–201.
doi:10.1016/j.ssci.2015.02.017
[4] Zhang H-D, Zheng X-P. Characteristics of hazardous
chemical accidents in China: a statistical investigation.
J Loss Prev Process Ind. 2012;25(4):686–693. doi:10.1016/
j.jlp.2012.03.001
[5] Hou Y, Zhang T-z. Evaluation of major polluting acci-
dents in China – results and perspectives. J Hazard Mater.
2009;168(2–3):670–673. doi:10.1016/j.jhazmat.2009.02.
094
[6] State Administration of Work Safety (SAWS). [Guideline
for process safety management of petrochemical corpora-
tions]. Beijing: SAWS; 2010. Standard No. AQ/T 3034–
2010. Chinese.
[7] Zhao J, Suikkanen J, Wood M. Lessons learned for pro-
cess safety management in China. J Loss Prev Process Ind.
2014;29:170–176. doi:10.1016/j.jlp.2014.02.010
[8] Lundberg J, Rollenhagen C, Hollnagel E. What-you-look-
for-is-what-you-find – the consequences of underlying acci-
dent models in eight accident investigation manuals. Saf
Sci. 2009;47(10):1297–1311. doi:10.1016/j.ssci.2009.01.
004
[9] Wiegmann DA, Shappell SA. A human error approach to
aviation accident analysis: the Human Factors Analysis and
Classification System. Aldershot: Ashgate; 2003.
[10] Shappell SA, Wiegmann DA. The Human Factors
Analysis and Classification System-HFACS. Washington
(DC): Office of Aviation Medicine; 2000. (Report No.
DOT/FAA/AM-00/7).
[11] Reason J. Human error. New York (NY): Cambridge Uni-
versity Press; 1990.
[12] Reason J. Managing the risks of organizational accidents.
Aldershot: Ashgate; 1997.
[13] Reinach S, Viale A. Application of a human error frame-
work to conduct train accident/incident investigations.
Accid Anal Prev. 2006;38(2):396–406. doi:10.1016/j.aap.
2005.10.013
[14] Patterson JM, Shappell SA. Operator error and system
deficiencies: analysis of 508 mining incidents and acci-
dents from Queensland, Australia using HFACS. Accid
Anal Prev. 2010;42(4):1379–1385. doi:10.1016/j.aap.2010.
02.018
339
[15] Chauvin C, Lardjane S, Morel G, et al. Human and organi-
sational factors in maritime accidents: analysis of collisions
at sea using the HFACS. Accid Anal Prev. 2013;59:26–37.
doi:10.1016/j.aap.2013.05.006
[16] Salmon PM, Cornelissen M, Trotter MJ. Systems-based
accident analysis methods: a comparison of Accimap,
HFACS, and STAMP. Saf Sci. 2012;50(4):1158–1170.
doi:10.1016/j.ssci.2011.11.009
[17] Gong Y, Fan Y. Applying HFACS approach to accident
analysis in petro-chemical industry in China: case study of
explosion at Bi-benzene Plant in Jilin. In: Pedro A, editor.
Proceedings of the AHFE 2016 International Conference on
Safety Management and Human Factors; 2016 Jul 17–22;
Walt Disney World, FL. Basel: Springer; 2016. p. 399–406.
doi:10.1007/978-3-319-41929-9_37
[18] Schröder-Hinrichs JU, Baldauf M, Ghirxi KT. Accident
investigation re-porting deficiencies related to organiza-
tional factors in machinery space fires and explosions. Accid
Anal Prev. 2011;43(3):1187–1196. doi:10.1016/j.aap.2010.
12.033
[19] Helmreich RL, Merritt AC, Wilhelm JA. The evolu-
tion of crew resource management training in com-
mercial aviation. Int J Aviat Psychol. 1999;9(1):19–32.
doi:10.1207/s15327108ijap0901_2
[20] Salas E, Burke CS, Bowers CA, et al. Team train-
ing in the skies: does crew resource management
(CRM) training work? Hum Factors. 2001;43(4):641–674.
doi:10.1518/001872001775870386
[21] Laberge JC, Bullemer P, Whitlow SD. Communication
and coordination failures in the process industries. Pro-
ceedings of the Human Factors and Ergonomics Soci-
ety 52nd Annual Meeting; 2008 Sep 22–26; New York,
NY. Los Angeles (CA): SAGE; 2008. p. 498–502.
doi:10.1007/978-3-319-41929-9_37
[22] Center for Chemical Process Safety. Guidelines for
investigating chemical process incidents. 2nd ed. New
York (NY): American Institute of Chemical Engineers;
2003.
[23] Mohd Shariff A, Abdul Aziz H, Abdul Majid ND. Way
forward in process safety management (PSM) for effective
implementation in process industries. Curr Opin Chem Eng.
2016;14:56–60. doi:10.1016/j.coche.2016.08.006
[24] Aziz HA, Shariff AM, Rusli R. Interrelations between
process safety management elements. Process Saf Prog.
2017;36(1):74–80. doi:10.1002/prs.11824
[25] Kennedy R, Kirwan B. Development of a hazard and
operability-based method for identifying safety man-
agement vulnerabilities in high risk systems. Saf Sci.
1998;30(3):249–274. doi:10.1016/S0925-7535(98)00025-3
[26] Huang P, Zhang J. Facts related to August 12, 2015
explosion accident in Tianjin, China. Process Saf Prog.
2015;34(4):313–314. doi:10.1002/prs.11789
[27] State Administration of Work Safety (SAWS). [The inquiry
report of Tianjin Port ‘8·12’ Ruihai International Logis-
tics Co. Ltd. extraordinary serious fire and explosion acci-
dent] [Internet]. Beijing: SAWS [cited 2016 Nov 10].
Available from: http://www.chinasafety.gov.cn/newpage/
newfiles/201600812baogao.pdf. Chinese.
[28] The State Council of the People’s Republic of China.
[Hazardous Chemicals Control Ordinance] [Internet]. Bei-
jing: The State Council of the People’s Republic of
China [cited 2017 Aug 5]. Available from: http://www.
gov.cn/flfg/2011-03/11/content_1822902.htm. Chinese.
[29] Fu G. [Safety management: a behavior-based approach
to accident prevention]. Beijing: Science Press; 2013.
Chinese.
340 L. Zhou et al.
[30] The NPC Standing Committee. [Work safety law of the
People’s Republic of China] [Internet]. Beijing: The NPC
Standing Committee [cited 2017 Aug 5]. Available from:
http://www.npc.gov.cn/wxzl/gongbao/2014-11/13/
content_1892156.htm. Chinese.
[31] The Ministry of Transport of the People’s Republic of China
(MOT). [The safety rules for handling dangerous goods
container in port]. Beijing: MOT; 2007. Standard No. JT
397–2007. Chinese.
[32] The Ministry of Public Security of the People’s Republic of
China (MPS). [Rules for fire management of state organs,
organizations, enterprises, and public institutions] [Inter-
net]. Beijing: MPS [cited 2017 Aug 5]. Available from:
http://www.mps.gov.cn/n2254314/n2254409/n2254
443/n2254450/c3940186/content.html. Chinese.
[33] Neal A, Griffin MA, Hart PM. The impact of organiza-
tional climate on safety climate and individual behavior. Saf
Sci. 2000;34(1–3):99–109. doi:10.1016/S0925-7535(00)00
008-4
[34] Knegtering B, Pasman HJ. Safety of the process indus-
tries in the 21st century: a changing need of process safety
management for a changing industry. J Loss Prev Process
Ind. 2009;22(2):162–168. doi:10.1016/j.jlp.2008.11.005
[35] Ginsburg L, Norton PG, Casebeer A, et al. An educa-
tional intervention to enhance nurse leaders’ perceptions
of patient safety culture. Health Serv Res. 2005;40(4):997–
1020. doi:10.1111/j.1475-6773.2005.00401.x
[36] Jiang W, Fu G, Liu Y, et al. [Study on safety culture train-
ing of enterprises different levels staff]. J Saf Sci Technol.
2011;7(8):181–185. Chinese.
[37] Zeng M, Wang X. [Comparative research on reporting,
investigation and disposal of work safety accidents in China
and EU]. J Saf Sci Technol. 2015;11(5):148–153. Chinese.
doi:10.11731/j.issn.1673-193x.2015.05.023
[38] Xue L, Shen H, Wang Z. [Lesson of major accident on
7–23: improvement and perfection of China safety
accident investigation system]. J Chin Academy Gov.
2012;(2):23–28. Chinese. doi:10.14063/j.cnki.1008-9314.
2012.02.002
[39] Rasmussen J. Risk management in a dynamic society:
a modelling problem. Saf Sci. 1997;27(2–3):183–213.
doi:10.1016/S0925-7535(97)00052-0