The purpose of this study was to analyze the underlying causal factor and root causes which contribute to the accident occurrence using several tools from Root Cause Analysis (RCA). The two major accidents analyzed in this study were Kaohsiung gas explosion, which happened on 31st August 2014; and blackout accident which happened on 15th August 2017. The data collected through the accident report, news, and several papers; then analyzed using seven RCA tools that consist of STEP analysis, task analysis, change analysis, control barrier analysis, event and causal factor chart, Accimap analysis, and onion model. The tools were applied into three different stages, which are data collection, analysis, verification and recommendation
The result shows that there were five root causes from the Kaohsiung accident which were no regulation regarding property development near gas pipelines; lack of pipelines data integration; no resource allocation for gas pipelines maintenance; work not coordinated carefully; and emergency procedure not followed correctly. Subsequently, there were four root causes from the blackout accident, lack of supervision in risk management; lack of DCS control training; poor design DCS controller; and emergency procedure not followed correctly. In addition, several strengths and weaknesses of each tool were pointed out. The importance of the risk assessment; regulation and data integration of gas pipelines; clear and strict maintenance procedure; and emergency response training were suggested as recommendation.

The purpose of this study was to analyze the underlying causal factor and root causes which contribute to the accident occurrence using several tools from Root Cause Analysis (RCA). The two major accidents analyzed in this study were Kaohsiung gas explosion, which happened on 31st August 2014; and blackout accident which happened on 15th August 2017. The data collected through the accident report, news, and several papers; then analyzed using seven RCA tools that consist of STEP analysis, task analysis, change analysis, control barrier analysis, event and causal factor chart, Accimap analysis, and onion model. The tools were applied into three different stages, which are data collection, analysis, verification and recommendation
The result shows that there were five root causes from the Kaohsiung accident which were no regulation regarding property development near gas pipelines; lack of pipelines data integration; no resource allocation for gas pipelines maintenance; work not coordinated carefully; and emergency procedure not followed correctly. Subsequently, there were four root causes from the blackout accident, lack of supervision in risk management; lack of DCS control training; poor design DCS controller; and emergency procedure not followed correctly. In addition, several strengths and weaknesses of each tool were pointed out. The importance of the risk assessment; regulation and data integration of gas pipelines; clear and strict maintenance procedure; and emergency response training were suggested as recommendation.

ABSTRACT
ACKNOWLEDGMENT
Table of Contents
List of Figures
List of Tables
CHAPTER 1 INTRODUCTION
CHAPTER 2 LITERATURE REVIEW
CHAPTER 3 METHODOLOGY
CHAPTER 4 RESULT
CHAPTER 5 DISCUSSION AND CONCLUSION
REFERENCES
APPENDIX: CAUSAL FACTOR CATEGORY LIST

Ahmad, R., & Kamaruddin, S. (2012). An overview of time-based and condition-based maintenance in industrial application. Computers & Industrial Engineering, vol. 63, pp. 135–149.
Ammerman, Max (1998). The root cause analysis handbook: a simplified approach to identifying, correcting, and reporting workplace errors. Quality Resources, New York.
API (2003). Public Awareness Programs for Pipeline Operators, API Recommended Practice 1162. Washington, D.C.
API (2004). Guidelines for Property Development. Washington, D.C.
API (2007). Pressure Testing of Steel Pipelines for the Transportation of Gas, Petroleum Gas, Hazardous Liquids, Highly Volatile Liquids or Carbon Dioxide. Washington, D.C.
Beata Starzyńska & Adam Hamrol (2013). Excellence toolbox: Decision support system for quality tools and techniques selection and application. Total Quality Management & Business Excellence, vol. 24, issue 5-6, pp. 577-595.
Beavers, J & Thompson, Nichola. (2006). External corrosion of oil and natural gas pipelines. ASM Handbook, vol. 13, pp. 1015-1026.
Ben-Tzion Karsh, Patrick Waterson, Richard J. Holden (2014). Crossing levels in systems ergonomics: A framework to support ‘mesoergonomic’ inquiry. Applied Ergonomics, vol. 45 (1), pp. 45-54.
Buys, J.R. and Clark, J.L. (1995), “Events & Causal Factors Analysis”. US Dept. of Energy. Ref. DOE 76-45/14, SSDC-14. http://tis.eh.doe.gov/analysis/trac/14/trac14.pdf
Castaneda, Homero & Rosas, Omar. (2015). External Corrosion of Pipelines in Soil. Doi: 10.1002/9781119019213.ch20.
Chao Wu, Lang Huang (2019). A new accident causation model based on information flow and its application in Tianjin Port fire and explosion accident. Reliability Engineering & System Safety, vol. 182, pp. 73-85.
Chun-hung Chen, Yeong-Nain Sheen, Her-Yung Wang (2016). Case analysis of catastrophic underground pipeline gas explosion in Taiwan. Engineering Failure Analysis, vol. 65, pp. 39-47.
Curry, L. (1983). An organisation of learning styles theory and construct. The Professional Geographer banner, vol. 35 (2), pp. 149-157.
DOE. (1999). Conducting Accident Investigations: DOE Workbook (Revision 2, May 1, 1999). Washington, DC: U.S. Department of Energy.
Duffuaa, S., Ben-Daya, M., Al-Sultan, K., & Andijani, A. (2001). A generic conceptual simulation model for maintenance systems. Journal of Quality in Maintenance Engineering, vol. 7, pp. 207–219.
Eva Cools, Kim Bellens (2012). The onion model: Myth or reality in the field of individual differences psychology?. Learning and Individual Differences, vol. 22 (4), pp. 455-462.
Haddon, W. J. (1980). The basic strategies for reducing damage from hazards of all kinds. Hazard Prevention, pp. 8-12.
Hendrick K., Benner L., (1986). Investigating accidents with STEP. Ed. M. Dekker, New York/Basel.
Hollnagel, E. (1999). Accident analysis and barrier functions. Halden, Norway: Institute for Energy Technology.
Hollnagel, Erik & Speziali, Josephine. (2008). Study on Developments in Accident Investigation Methods: A Survey of the "State-of-the-Art.
Hollnagel, Erik. (2019). Accidents and barriers.
Hsieh HR., Lee CS., Teng MC., Su WR., Li WS. (2017). Lessons Learned from the 0801 Petrochemical Pipeline Explosions in Kaohsiung City. In: Harada K., Matsuyama K., Himoto K., Nakamura Y., Wakatsuki K. (eds). Fire Science and Technology 2015. Springer, Singapore.
Hui-Ning Yang, Jen-How Chen, Home-Jo Chiu, Ting-Jia Kao, Hsiao-Yun Tsai, Jenq-Renn Chen (2016). Confined vapor explosion in Kaohsiung City – A detailed analysis of the tragedy in the harbor city. Journal of Loss Prevention in the Process Industries, vol. 41, pp. 107-120.
I Svedung, J Rasmussen (2002). Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety Science, vol. 40, Issue 5, pp. 397-417.
I.A. Herrera, R. Woltjer, (2010). Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis. Reliability Engineering & System Safety, vol. 95, issue 12, pp. 1269-1275.
J. Giovanni Ramírez-Camacho, Federica Carbone, Elsa Pastor, Roberto Bubbico, Joaquim Casal (2017). Assessing the consequences of pipeline accidents to support land-use planning. Safety Science, vol. 97, pp. 34-42.
Jens Rasmussen (1997). Risk management in a dynamic society: a modelling problem. Safety Science, vol. 27, Issues 2–3, pp. 183-213.
Jepperson, Ronald and John W. Meyer (2011). Multiple Levels of Analysis and the Limitations of Methodological Individualisms. Sociological Theory, vol. 29(1), pp. 54–73.
Joerg Schoenfisch, Christian Meilicke, Janno von Stülpnagel, Jens Ortmann, Heiner Stuckenschmidt (2018). Root cause analysis in IT infrastructures using ontologies and abduction in Markov Logic Networks. Information Systems, vol. 74, Part 2, pp. 103-116.
Jon T. Selvik and Linda J. Bellamy (2019). Addressing human error when collecting failure cause information in the oil and gas industry: A review of ISO 14224:2016. Reliability Engineering & System Safety.
Justin W. Kung, Olga R. Brook, Ronald L. Eisenberg, Priscilla J. Slanetz (2016). How-I-Do-It: Teaching Root Cause Analysis. Academic Radiology, vol. 23 (7), pp. 881-884.
Knop, Krzysztof & Mielczarek, Krzysztof. (2018). Using 5W-1H and 4M Methods to Analyse and Solve the Problem with the Visual Inspection Process - case study. MATEC Web of Conferences. 183. 03006. 10.1051/matecconf/201818303006.
Li, S.Y., Jung, S., Park, K., Lee, S.M., and Kim, Y.G. (2007). Kinetic study on corrosion of steel in soil environments using electrical resistance sensor technique. Materials Chemistry and Physics, vol. 103, pp. 9–13.
Liaw, Horng-Jang. (2016). Lessons in process safety management learned in the Kaohsiung gas explosion accident in Taiwan. Process Safety Progress. DOI: 10.1002/prs.11818.
Little, C. (2008). Regulation of oil and natural gas pipelines: a legal primer for the layman. The Free Library (March, 1), https://www.thefreelibrary.com/Regulation of oil and natural gas pipelines: a legal primer for the...-a0177451576 (accessed March 03 2019).
Luning Xue, Jianchun Fan, Marvin Rausand, Laibin Zhang (2013). A safety barrier-based accident model for offshore drilling blowouts. Journal of Loss Prevention in the Process Industries, vol. 26 (1), pp. 164-171.
Maxwell Smith L & Stephen Raab S (2011). Assessment of Latent Factors Contributing to Error Addressing Surgical Pathology Error Wisely. Archives of pathology & laboratory medicine, vol. 135.
N. Goode, P.M. Salmon, N.Z. Taylor, M.G. Lenné, C.F. Finch (2017). Developing a contributing factor classification scheme for Rasmussen's AcciMap: Reliability and validity evaluation. Applied Ergonomics, vol. 64, pp. 14-26.
Nano, Giuseppe & Derudi, Marco. (2013). A Critical Analysis of Techniques for the Reconstruction of Workers Accidents. Chemical Engineering Transactions, vol. 31, pp. 415-420.
Newnam, S., & Goode, N. K. (2015). Do not blame the driver: a systems analysis of the causes of road freight crashes. Accident Analysis and Prevention, Vol. 76, pp. 141 - 151.
Norsworthy, R. (2009). Causes of external corrosion on coated and cathodically protected pipelines. NACE - International Corrosion Conference Series.
Paradies, M. and Unger, L. (2000). TapRoot: The system for toot cause analysis, problem investigation, and proactive improvement. Knoxville: System Improvements.
Rasmussen, J., Svedung, I. (2000). Proactive risk management in a dynamic society.
Rausand, Marvin. (2011). Risk Assessment: Theory, Methods, and Applications.
Reason, J. T. (1990). Human Error, Cambridge University Press.
Roche, M. (2005). External corrosion of pipelines: What risk? Society of Petroleum Engineers. Doi:10.2118/93600-MS.
Smits, M., Groenewegen, P.P., Timmermans, D.R., Wal, G.V., & Wagner, C. (2009). The nature and causes of unintended events reported at ten emergency departments. BMC Emergency Medicine, vol. 9, pp. 16 - 16.
Taipei Times (2014). Editorial: Passing the buck on Kaohsiung blasts. http://www. taipeitimes.com /News/editorials/archives/2014/08/06/2003596747/1 (accessed March 03 2019).
Taipei Times (2014). Kaohsiung disaster: Better training for firefighters urged for chemical fires. http://www.taipeitimes.com/News/taiwan/archives/2014/08/06/2003596785 (accessed March 19 2019).
Toivo Niskanen, Kyösti Louhelainen, Maria L. Hirvonen, (2016). A systems thinking approach of occupational safety and health applied in the micro-, meso- and macro-levels: A Finnish survey. Safety Science, vol. 82, pp. 212-227.
Tom Kontogiannis, Vrassidas Leopoulos, Nikos Marmaras (2000). A comparison of accident analysis techniques for safety-critical man–machine systems. International Journal of Industrial Ergonomics, vol. 25 (4), pp. 327-347.
TRB (1988). Special Report 219: Pipelines and Public Safety: Damage Prevention, Land Use, and Emergency Preparedness. National Research Council, Washington, D.C.
Wang, H., (2002). A survey of maintenance policies of deteriorating systems. European Journal of Operational Research, vol. 139, pp. 469–489.
Wei Zhou, Tingsheng Zhao, Wen Liu, Jingjing Tang. (2018). Tower crane safety on construction sites: A complex sociotechnical system perspective. Safety Science, vol. 109, pp. 95-108.
Xue, Luning & Fan, Jianchun & Rausand, Marvin & Zhang, Laibin. (2013). A safety barrier-based accident model for offshore drilling blowouts. Journal of Loss Prevention in the Process Industries, vol. 26, pp. 164–171.
Yang Kai, Lv Shuran, Gao Jiancun, Pang Lei (2017). Research on the coupling degree measurement model of urban gas pipeline leakage disaster system. International Journal of Disaster Risk Reduction, vol. 22, pp. 238-245.
Yeong-Nain Sheen, Her-Yung Wang, Chun-Hung Chen (2016). Investigation on the Key Response Factors of Action Plan in Underground Pipeline Emergency Scenario. Procedia Engineering, vol. 142, pp. 161-165.
Zengzhi Du, Chunxi Li, Wei Sun, Jianhong Wang (2015). A simulation of diesel hydrotreating process with real component method. Chinese Journal of Chemical Engineering, vol. 23 (5), pp. 780-788.
Zeyang Qiu, Wei Liang, Laibin Zhang (2018). Tracing and prediction analysis of an urban pipeline leakage accident based on the catastrophe DBN model. Journal of Natural Gas Science and Engineering, vol. 57, pp. 339-348.