h2g2 The Hitchhiker's Guide to the Galaxy: Earth Edition

Entry: Risk in and Industrial Society - Some Case Histories - A778395
Author: JD - U103235

This was part of the original (but too-long) "Risk in an Industrial Society" article that I already put up. I've split off these case histories because they illustrate two of the most spectacular and tragic accidents of the past 40 years as well as some real-world examples of the two primary types of failures in the Risk Analysis and Management process.

I would appreciate any other suggestions for case histories. I've considered adding the Mexico City LPG BLEVE that happened the week before Bhopal (and thus is lesser-known though not much less spectacular).

thanks!

- JD

Hi JD!

I really liked the description of the Vaiont Dam - really well described and easy to follow. I had more trouble in following the Bhopal story. At present, without going back over it (I'll check back on this later, when I've more time), all I can say is it's less easy to follow and understand. Sorry if this sounds fuzzy.

Two more case histories that come to mind are both Spanish, I think. The lorry carrying chemicals that exploded over a caravan site, killing about 300, I think and the tainted cooking oil one that affected thousands. Again, sorry for the lack of detail - they stand out in memory - maybe another researcher has a better memory than I do.

it might be useful to explain what a thing arch damn is for those that havent got a clue. or write a quick entry on it and link to that.

fABT

ZSF: I'll try to clean up Bhopal a bit more, but it's difficult to summarize it in such a short space. That's a big part of the problem of what went wrong in the first place, a complex system with many other complicated issues around it. There could (maybe should) be an entire entry written on Bhopal alone.

Thanks for the tips on the Spanish accidents. I'll definitely have to do some more research. My initial thought was to present large-scale accidents that have unique characteristics or are good examples of some of the chief problems involved with risk assessment and management. Several television programs have been produced about many of the more spectacular accidents, and I might use some of them to help - but most of the most sensational can (and should eventually, I think) have their own entries. I just wanted to use summaries of certain examples in order to illustrate certain specific "lessons learned" that resulted in rules and laws and changes in business that have drastically affected it, and (in a way) created my job.

Being American, I'm much more familiar with and have access to more data about those that have happened in the USA - but I don't necessarily want to ignore European (or any other continent's) ones out of hand. I might use an offshore oil rig disaster in the North Sea that I remember something about, and I'm still considering adding the Mexico City BLEVE (Boiling Liquid Expanding Vapor Explosion - a very nasty explosion, to be plain). I've thought about adding the Challenger Space Shuttle explosion and the Three Mile Island (TMI) accident, but both of those are extremely difficult to summarize clearly. They are just too complex.

Anyway, I'll take a stab at clearing up what I've got, and perhaps add Mexico City and something from a North Shore oil rig that's ringing a bell from one of my course notes.

- JD

I'll add this to the entry, thanks for the comment!

An arch dam is a dam that is curves inwards from the downstream side, or is convex from that point. The term "arch" is used because the chief engineering principle that allows the structure to hold back such a massive force of water is the principle of the arch. Virtually all modern dams that are of the "whoa, that's huge!" size are arch dams, and they are almost always very tall.


- JD

Hi JD!

Yes, the Challenger would be a good one. I've heard recently that around 11,000 people potentially knew about the 'O' ring, but either ignored the information or weren't listened to.

I might have a scout around for more info on the ones I suggested. I remember they were treated as being both very serious and very scandalous.

Here's a link for the Spanish cooking oil disaster. There are loads more. I searched on 'Spanish cooking oil disaster deaths'/

http://education.guardian.co.uk/higher/research/story/0,9865,542111,00.html

Well, my searches didn't turn up anything on the lorry accident and the aravan site deaths - maybe it's too long ago and too few people died (there were over 300).

However after I posted the Spanish cooking oil disaster link, I read it thoroughly and was surprised by the contents. This (like Bhopal) could be an entry on its own.

Tell me what you think of it.

thanks for the arch footnote, makes things a lot clearer to dunces!

Hmmm, interesting article. Definitely a conspiracy accusatory tone to it, I must say. With regard to the actual incident, I have a hazy memory of all that when I should have a better one: I was living in Sicily, Italy in 1981, and as it turned out, even visited Madrid and Barcelona among a few other in-between towns in the Spring of 1983. Furthermore, I was in New Mexico attending college (or 'at university' I think is how it's said on that side) between 1989 and 1995, so maybe I shouldn't comment for fear of raising conspiracy theories.

In all seriousness, with regard to the Guardian article, it does a good job in casting doubt on the original explanation but offers a very poor and sketchy explanation of its own. The alternative pesticide theory is supposed to be accepted on faith, or at least is summarized to the point that we have no other alternative; accepting something on faith (being something the article itself has just roasted as being ludicrous, and rightfully so) is inappropriate in accident analysis. A much more accurate documentation of what actual symptoms were, along with what specific health hazard associated with the wide ranging class of organo-phosphate pesticides (there are a lot of them) they're talking about, what permanent disabilities were suffered by the victims exactly, etc and so on. In short, to make any meaningful validation or invalidation of an accident analysis such as this one requires some education of the nature of health and toxicity as applicable to the substances in question, and more information surrounding the event that is not readily apparent in this article. These problems are very very common in media reports surrounding events like this. People rarely want, or "have the time," to be educated to the point where they can understand the true nature of an accident. I have no other comments on the article or the incident other than those, really.

Back to the point, I'm not completely certain the incident makes a very good "case history" for illustrating the problems of industry and the lessons learned that lead to the improvement of the industrial risk assessment process - perhaps that's just because I don't know enough about the incident, though. From what I've read, I think it illustrates very well the classic difficulties in performing accident analysis on major catastrophes, as well as in reporting them subsequently (the same problems existed and indeed continue to exist with Bhopal, TMI, Chernobyl, Space Shuttle Challenger, just to name a few). It certainly is an excellent subject for an article all to itself, but the way the article presents the case, it's mostly about the accident analysis side of things, something I want to avoid getting into detail as that is really another discipline separate from risk assessment. It is very complicated, as you can see by the length of my response here alone. I do acknowledge that for a risk analyst involved in the Food and Agriculture industry that it represents quite a serious case for improving risk assessment and management, if for no other reason than to provide documentation to the public and government of food growers' and inspectors' policies on controlling and inspecting for potentially toxic contaminants, be they pesticides or pollutants or dangerous microbes or whatever. It is through the documentation of such that the best compliance can be achieved and tragedies avoided, whatever the cause of such tragedies may be. One might well argue that the somewhat chaotic condictions infecting the fledgling Government of Spain at the time were as much root causes of the whole fiasco as whatever toxin poisoned those people.

So, perhaps it can be a decent example, with some digging. I'll look into it. Thanks!


- JD

Hey, no problemo! It's very easy not to know what an arch dam is, so don't feel bad. Logic would seem to suggest that the top of the dam be arched or something like that, which obviously leads to confusion - why arch the top of a dam? It's not necessarily common knowledge anyway, your modern dam types.


- JD

Hey JD, is this article ready for recommendatio yet as far as you're concerned - I've recommended your other one (we're not supposed to say actually so don't think that means it will be accepted - I've had a few picks of mine rejected by the eds) and am keen to recommend this one too but it seems from this thread that a few more case studies may be in the pipeline...

Piper Alpha was the british oil rig that went "whoof" in the North Sea a few years back.

One thing I find in my job (I have to sign risk assessment forms of students studying for organic chemistry PhD's) is that laziness plays a big part in lack of proper risk assessment. People simply can't be arsed to do the paperwork and consequently often have no idea of the hazards of the chemicals they are using.
They use glib phrases like "treat chemical as an irritant, toxin and carcinogen" but in fact don't treat them that way at all.
It's a continuous fight to get them to actually realise what they're dealing with and it drives me up the wall - I'm glad I'm not the department's safety officer!

Orcus

In short, I want to revise the part about Bhopal so it is a bit more clear why I'm using it for a case study. I've been thinking about Piper Alpha (thanks for reminding me of the name) and the Mexico City BLEVE, but I'm not sure if they (or any others) will add much to the points I'm trying to make about the challenges facing risk management. I like your comments about the all-too-common laziness (or maybe "complacency" is a better word) among those who work with hazardous stuff routinely. That's perhaps the biggest problem with actually maintaining the risk assessment's requirements. I'll add a bit about this too, I think. THEN it will be ready! Sometime today (USA, Mountain time, which is -7 hours from Greenwich Time I think).


- JD

Yeah, complacency is a good word.

I've seen that in threads around here about innoculating against disease. Oh, that disease isn't a problem anymore {because we do vacccinate} so why vaccinate now {because it will come back otherwise}.

Popular lack of risk assessment is weird as well. You mention the car thing in the other article -some will drive quite happily but won't fly. There is also the vCJD thing that always stuns me. People will smoke 60 cigarettes a day but won't eat beef because of the astronomical unlikelihood of contracting vCJD (although this is fading now I think). I wonder where the risk factor numbers would come in there?

Okay, I've finished updating the "case histories" side of things. See what you think of it now.

- JD

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Well there you go JD - nice one

Kewl beans! Thanks!

- JD