I imagine this will interest just a smaller sub-set of people, but this study used FRAM to analyse the dust explosion at the Chinese Kunshan factory accident, which killed 146 people.
They were able to examine the coupling and variability in key activities, and the initial and triggering parameters for the explosion.
Note: There’s a kazillion FRAM studies and more comprehensive ones than this – but I found it fairly to the point and accessible. It’s also one of several that focus the FRAM more on the analysis of barriers and provides a decent overview of breaking down an activity into functional units.
If you’re interested in the topic then I’d suggest just checking out the open access paper.
Not much I can summarise here given the findings all relate to their specific FRAM, but some points:
· Some of the modelled production functions departed from the expected performance, resulting in functional resonance
· They highlight that some changes in production functions related to monitoring the environmental parameters and on-site inspection
· E.g. “The change of F7 and F8 results in the operation system failing to timely monitor the abnormal state of temperature and dust concentration in the dust collecting bucket, culminating in reaching the ignition temperature of the aluminum powder”
· And “The staff continue to work as no abnormality is detected, and an aluminum dust cloud is formed above the dust collecting bucket. This series of functional changes are coupled and force the production system towards a critical state with the possibility of a dust explosion, which ultimately leads to the occurrence of the aluminum dust explosion”
· The analysis highlights opportunities for barriers to enforce control actions at different functional areas
Ref: Zhang, M., Zhang, L., Cao, X., Li, B., & Zhou, A. (2023). FRAM-based causal analysis and barrier measures to mitigate dust explosions: A case study. PLoS one, 18(6), e0287328.
Study link: https://doi.org/10.1371/journal.pone.0287328
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