Analyzing organizational gaps in process accidents with FRAM: The case of the Imperial Sugar refinery explosion (2008)

Abstract

Abstract This study presents a reanalysis of the Imperial Sugar refinery accident that occurred in February 2008, in Georgia, USA, using functional resonance analysis method (FRAM) and based on technical‐scientific materials and the official reports. This explosion was fueled by sugar dust in the packaging building of the refinery, causing 14 fatalities and injuring 38 workers. The purpose of this reanalysis is to seek factors and interactions that could not be well analyzed or evidenced using traditional accident investigation techniques, which are primally designed to analyze linear systems. This reanalysis with FRAM allowed us to perceive the influence of organizational elements, such as culture, in the accidental chain of the event, highlighting the need of a broader approach for accidents involving high‐tech process industries. In this sense, FRAM enabled a more comprehensive analysis of the complex functioning of process plants, for both normal operation and in emergency. 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 in this case.