MODULE 3 - CASE STUDIES OF INTERNATIONAL MAJOR NEGATIVE AND FATAL EVENTS

CASE STUDIES OF INTERNATIONAL MAJOR NEGATIVE AND FATAL EVENTS

In this module, reduced versions of major negative events, fatalities, and other types of events are presented.

There are links with information about these events, which require authorization to access, others, I left open.

If you are interested in accessing links in this module, which require authorization, send an email to:

washington. fiocruz@gmail.com

Some of the Case Studies of Big Negative Events that you will find in this module.

International:

Seveso, Fukushima, Challenger, Columbia, Texas City Refinery, Port of Beirut Explosion, Bophal, Air France 447, Piper Alpha, Deep Water Horizon Platform, Boeing 737 Max.

There are also in this module, highlights with indication of books, articles and other publications.

1 - INTERNATIONAL:

Nuclear:

- Fukushima;


Figure - Devastation by the Tsunami in Fukushima and the Explosion at the Nuclear Power Plant in Fukushima

The authorities responsible for the plant knew of the possibility of larger waves than those designed to contain the flooding of the plant by tsunami waves. A historical study revealed that a major tsunami occurred in the middle of the 9th century, estimated at 869 AD, and that a researcher had made a strong recommendation for refurbishment of the plan in 2006, but the recommendation was supposedly turned down for the reason, that the tsunami was hypothetical, and because the claimed evidence was not accepted by experts in the nuclear sector.

Lessons learned from the Fukushima accident:

The IAEA 2015 report's recommendations included a few that specifically address the issue of overconfidence:

“The assessment of natural hazards needs to be sufficiently conservative. The consideration of mainly historical data in establishing the design basis of nuclear power plants is not enough to characterize the risks of extreme natural hazards. Even when comprehensive data are available, due to relatively short observation periods, large uncertainties remain in predicting natural disasters.

The safety of nuclear power plants needs to be periodically reassessed to take account of advances in knowledge, and the necessary corrective actions or compensatory measures need to be implemented promptly.

Operational experience programs need to include experience from national and international sources. Security improvements identified through operational experience programs need to be implemented promptly. The use of operational experience needs to be evaluated periodically and independently.

For more information send an email to washington.fiocruz@gmail.com

Vídeo 10 Years After Fukushima, Safety Is Still Nuclear Power’s Greatest Challenge:


Vídeo Fukushima's nuclear emergency - by Nature Video

Onagawa: The Japanese nuclear power plant that didn’t melt down on 3/11:

More information at:



-TMI;


Figure - The Three Mile Island nuclear disaster is the worst ever on US soil

Three Mile Island (TMI) - Man-machine communication error

Three Mile Island and the Credibility Meltdown

The accident

The Three Mile Island Crisis began in the early hours of June 28. A cooling valve remained open when it should have been closed. The operator in the control room triggered several safety operations, under the mistaken assumption that the valve was closed. A chain of physical and chemical reactions was then produced, which the operators did not understand. All measures to stop the reaction of the reactor were unsuccessful, since they started from the understanding that the valve would be closed. The accident resulted, therefore, from a succession of human errors.

Realizing something unusual, the technicians alerted a vice president of Metropolitan Edson, the plant's administrator, and the engineers who built it. As of 7:00 am, the Met Ed notified the Pennsylvania emergency department, the Nuclear Energy Regulatory Commission (NRC), the governor of Pennsylvania and several other agencies about the condition of the plant.

Below, links to videos about the TMI accident:


Vídeo 1


Vídeo 2

This assessment does not cover organizational factors and exogenous variables (see Module 2 of the Proactive Safety Risks and Emergencies course), it would be good to expand this analysis.

For more information send an email to washington.fiocruz@gmail.com

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Video:

A journalistic look at the TMI accident:

More information at:

- Chernobyl;


Figure - Chernobyl Nuclear Power Plant

Chernobyl - Violation of Safety Regulations and Chernobyl Disaster: What Happened and Long-Term Impacts

The accident at a nuclear power plant in the Soviet Union shocked the world, permanently altered the region and left many questions unanswered.

BY ERIN BLAKEMORE

On April 25 and 26, 1986, the reactor of a nuclear power plant exploded and caught fire in what is now northern Ukraine, triggering the worst nuclear accident in history. Shrouded in mystery, the disaster was a watershed moment in both the Cold War and the history of nuclear power. More than 30 years later, scientists estimate that the area around the ancient plant will remain uninhabitable for up to 20,000 years.

The disaster occurred near the city of Chernobyl, in the former Soviet Union, which invested heavily in nuclear power after World War II. Beginning in 1977, Soviet scientists installed four RBMK nuclear reactors (high-power piped reactors) at the power plant, located just south of the present-day border between Ukraine and Belarus.

On April 25, 1986, routine maintenance was scheduled to take place on the fourth reactor at the V.I. Lenin. Engineers planned to use the occasion to test whether the reactor could still be cooled if the power plant lost power. During the test, however, operators breached safety protocols and the reactor was overloaded. Despite attempts to completely shut down the reactor, another overload triggered a chain reaction of explosions inside. Eventually, the reactor core was exposed, releasing radioactive material into the atmosphere.

This assessment does not cover organizational factors and exogenous variables (see Module 2 of the Proactive Safety Risks and Emergencies course), it would be good to expand this analysis.

For more information send an email to washington.fiocruz@gmail.com

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Video:

Other references:

More information at:

https://drive.google.com/drive/u/2/folders/1hLRs8ke1rbKv6DEkvEZNA9nH9tn2X7_6

Aerospace:

- Challenger;

Figure - Explosion of the Space Shuttle Challenger

Causes of the Accident and Developments:

After six postponements, due to weather instabilities and technical problems, the Challenger launch was confirmed for January 28th.

NASA's management decided to proceed with the launch of Challenger, even with the warning that the temperature at the Kennedy Space Center, Florida, was far below ideal for launch, which is why the mission's engineers warned their superiors about the risks posed by the launch. low temperatures would cause on the ship.

The launch took place at 11 hours and 39 minutes. About 73 seconds after launch, Challenger was enveloped in a huge fireball, and its two solid-fuel booster rockets separated in front of thousands of people watching on TV, as well as relatives of the astronauts present at the launch site.

Iconic major negative event on exogenous pressures (see module 2 of the Proactive Safety course), and well analyzed by the sociologist Vaughan (1996) who created the expression “normalization of deviations”, and was initially used by this sociologist during the analysis of the causes of the explosion that occurred with the space shuttle Challenger, during its launch on 01/28/1986.

For more information send an email to washington.fiocruz@gmail.com
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Article:

Part 1 meeting for launch decision:

Part 2 meeting for launch decision:

Launch:

Investigation:

New Rocket Project to Columbia:

More information at:

https://drive.google.com/drive/u/2/folders/1yJIWv-sfj1nGLKVWw63AuDFFDb6Tjlu7

- Columbia;

                            Figure - Explosion of the Space Shuttle Columbia and its Crew

Like most accidents and disasters, the Columbia disaster did not have a single cause. Many historical, social, political and technological factors interacted at different organizational levels and in different subsystems to create conditions, unrealistic expectations and faulty decision making, for example: unbalanced goals and ineffective learning combined with production pressures and fragmented problem solving.

The disaster occurred in a work environment that featured time pressure, and decisions were made to protect the continued survival of NASA and the space shuttle program. Supported by political-economic coalitions, these first decisions crystallized. However, they were creating problems. For example, the outpouring of foam from the external tank has a long history dating back to Columbia's first flight in 1981.

For more information send an email to washington.fiocruz@gmail.com
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Article:

More information at:

https://drive.google.com/drive/u/2/folders/1L4D9-lAxqkNTcnAQNVt0halSlBIxXk6l


Petrochemical:

- Texas City Refinery;

Figure - Accident at the Texas City Refinery

On March 23, 2005, a catastrophe in American industrial history took place at the BP refinery in Texas City, Texas. Explosions of hydrocarbon vapors, followed by fires, left 15 dead and 180 injured.

The Texas City Refinery was the second largest oil refinery in the state, and the third largest in the United States, with an input capacity of 437,000 barrels (69,500 m3) per day as of January 1, 2000. BP acquired the Texas City Refinery as part of its merger with Amoco in 1999.

Financial losses amounted to 1.5 billion dollars, 43,000 people could not leave their homes. Buildings were damaged in a perimeter of around 1,200m around the refinery.

For more information send an email to washington.fiocruz@gmail.com

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Article:

James Reason, pathogens, organizational, technical factors in the Texas City Refinery accident:

More information at:

https://drive.google.com/drive/u/2/folders/1q5H2EsZWy8nlCcu9RDgmOkxhBO7FZVVo


- Piper Alpha;


Figure - Piper Alpha Platform on Fire in 1988

The end of Piper Alpha was the result of a series of systemic failures that culminated in the deaths of 167 people, the loss of billions of dollars and the total destruction of the platform. The accident occurred on July 6, 1988 after a series of explosions and fires.

Piper Alpha was a platform located in the North Sea approximately 200 km northwest of Aberdeen, Scotland. Located in waters up to 144 m deep.

In a stricter approach, this leak was due to failures in communication involving the work permit system between teams from different shifts at that unit. The event caused the death of 167 of the 226 workers and an oil leak whose blockage required plugging (closing) 36 wells, over 22 days (Figueiredo, 2016).
However, in accidents with such characteristics, it is essential to turn our attention to the organizational factors - which contributed, to a greater or lesser extent, to the occurrence/worsening of the disaster - in a broader perspective. And an extremely relevant fact, which strongly contributed to the intense worsening of the accident, refers to the delay of the manager of the Tartan platform in ordering the closure of its production (controlled closure of the unit), as this was interconnected to Piper Alpha and continued to pump oil in its direction, even after the first explosions, thinking that the situation might not be extremely serious. If the manager had taken the decision to close more quickly, as the operator in the control room had already insisted, there were good possibilities that the Piper accident would not have become the worst tragedy in the history of the offshore world, in terms of the number of of dead. In a statement given in a video entitled “The Piper Alpha accident”, which summarizes some of the main aspects involved in this catastrophe, Tony Barrell (former chief executive of Safety in the North Sea) returns to the well-known potential conflict between production and safety.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

Videos:

Video of the drilling decision-making process, before the blowout:

Remembering the Deepwater Horizon Accident – ​​12 Years After:

Organizational factor in the Piper Alpha platform accident – ​​Marcelo Figueiredo:

More information at:


- Deep Water Horizon Platform:




Figures - Deep Water Horizon Platform Explosion

On April 20, 2010, the Deepwater Horizon marine platform exploded off the coast of Louisiana, killing 11 and causing the largest oil spill in US history.

Oil spilled into the waters of Texas, Louisiana, Alabama, Mississippi and northern Florida, devastating not only marine life but also coastal economies in the southeastern part of the country.
Lessons that can be derived from the accident:

For businesses:

• Where there is potential for catastrophe, companies should focus on the risk of serious danger, regardless of the risk to personal safety.

• Business risk can create security risk.

• The team must understand and act in accordance with the defense-in-depth philosophy.

• There should be centralized functional lines of authority going all the way to the top of the company.

• Major hazard risk indicators cannot be generic and must be specific to certain hazards.

• Compensation systems must include relevant indicators of risk of serious danger.

• The accountability of a single individual for decisions must be a social reality, not just a legal formula. This means, among other things, that decision-making must be differentiated from consultation.

• Behavioral safety programs must be expanded to cover the risk of serious harm.

• Anomalies that resolve on their own without immediate negative consequences should not be ruled out; they should be treated as warnings.

• The number of authorized deviations from standards and the number of safety deviations in place should be treated as indicators of performance to be reduced.

• Executive managers need to get out in the field and ask the right questions to find out if their policies are working in practice. These questions may be designed to elicit input from lower-level employees and/or may be directed towards auditing major hazard risk controls.

• Companies need to develop better learning strategies.

• Risk assessments for low-probability catastrophic scenarios often contain critical assumptions that need to be highlighted and perhaps challenged.

• These lessons need to be understood by people at the top of the corporation, as they are the ones with the power to implement them.

For governments:

• Governments should establish well-resourced security case regimes.

For regulatory bodies:

• Regulators need to carefully scrutinize and challenge company risk assessments.

• Regulators should ask companies to demonstrate that their compensation systems effectively address the risk of serious harm. In particular, they should require companies to demonstrate that key executive performance agreements are properly focused on serious risks. (There is a good argument that top executive performance agreements should be made public, subject to editing to remove truly confidential information.)

• Regulators should challenge companies to demonstrate that their organizational structures are adequate for managing serious risks.

Andrew Hopkins


More information at:

Book:

Hopkins presentation about this accident:

https://drive.google.com/drive/u/2/folders/1IiciVTYf0VjuaZEGru2TyBOiRndx2fXi

Video of the Decision-Making Process:

https://drive.google.com/drive/u/2/folders/1kBOqQr-qmsHV-bIxR05ytobhEj5aVFqQ


Disaster:

- Explosion of the Port of Beirut:



Figure - Explosion of the Port of Beirut

From 2014 to 2020, documents were presented to the authorities of the Port of Beirut, the Prime Minister and the President of Lebanon, as will be presented in this article, evidence of the organizational factor of government structures as a precursor to this great tragedy in which more than 200 people died and 6 thousand were injured in an explosion in the port of Beirut, Lebanon, which completed a year on 04/08/2021.

The explosion was caused by ammonium nitrate that had been unsafely stored in the port for years.

No government official was ever penalized for the explosion. The investigation stalled after there were requests to gather data on politicians.

For more information send an email to washington.fiocruz@gmail.com

Articles:

More information at:

https://drive.google.com/drive/u/2/folders/1n6jy-qTS5RCmDT24Q1UHf1t3jYWiF3f3


Aviation:

- Air France 447:


Figure - AF-447 Airplane Parts Rescue Operation

Incidents very similar to that of the Air France Airbus A330-200 occurred the year before the accident, with two identical planes from a Caribbean airline, Air Caraïbes. They were caused by the formation of ice in the Pitot tubes when passing through zones of storm and turbulence. These tubes have been pointed out in recent days as possibly being responsible for the crash of flight AF447 into the Atlantic Ocean, on the last day of the 31st. Airbus headquarters in France from the problem. An internal report by Air Caraïbes states that Airbus was studying, in December last year, changing the Pitot tubes of all similar planes manufactured by the company.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

Video:

More information at:


- Boeing 737 Max:


 

Figure - Accident with the 737 Max

Where does it start

It all starts in 1997, when the company buys McDonnell Douglas and, with it, absorbs a board more concerned with money than with the safety culture that made Boeing what it was.

From that moment on, Boeing went from being an engineering company where every employee who tightened a nut had the chance to say “we have a problem”, to a corporate monster that made shareholders happy because there were always profits and fat dividends.

It was the beginning of a time when Quality Departments began to fear because bad news was “paid” with resignation telegrams – nothing very different from many other stories in the corporate world.

The manufacturer is notably exposed in embarrassing internal messages and it is clear that it was even more responsible for the second accident than the first because it could have taken measures to suspend the operation of the MAX for safety and did not, for “fear of losing money”.

For more information send an email to washington.fiocruz@gmail.com

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Article:

737 Max pilots unaware of MCAS in the first accident:

Other publications:

Video about the recertification of the Boeing 737-Max and the tragedy of this plane's accidents:

More information at:


Chemical:

- Seveso;

Figure - Children with Accidents, Dead Animals, the Factory, Emergency Operation

The accident

 On July 10, 1976, in Seveso, a province of Milan, Italy, a leak of dioxin caused the contamination of 320 hectares, affecting thousands of people and animals. It was one of the biggest ecological disasters in the world.

Around 12:30 pm on the day of the accident, a reactor safety disk ruptured, resulting in the emission of a large toxic cloud into the atmosphere.

The reactor was part of the TCP (trichlorophenol) manufacturing process and the toxic cloud formed contained several components including TCP itself, ethylene glycol and

2,3,7,8-tetrachlorodibenzoparadioxin (TCDD). The cloud spread over a large area, contaminating people, animals and the soil in the vicinity of the industrial unit.

The plant operated on a batch basis and, at the time of the accident, was paralyzed for the weekend. However, the reactor contained material at a high temperature. Probably, the presence of ethylene glycol with sodium hydroxide caused an uncontrolled exothermic reaction, causing the internal pressure of the vessel to exceed the rupture pressure of the safety disk, causing the emission. The reaction that occurred, associated with a temperature between 400 and 500 ºC, contributed to the formation of TCDD.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

More information at:

https://drive.google.com/drive/u/2/folders/1i2nhYvWn7VMo92IC9LWZr18QXyz8IWwQ


- Bhopal;


Figures - Factory and Victims of the Bophal Accident

Vídeo Bophal

Largest industrial crime in history totals 600,000 victims and affects 3rd generation in India

Gas that leaked from a US pesticide factory in 1984 contaminates children and grandchildren of survivors

Praveen S.

The biggest industrial crime in history took place almost 36 years ago in Bhopal, central India, and it continues to claim victims. About 27 tons of methyl isocyanate gas leaked from a disused agrochemical factory owned by the US company Union Carbide in the early hours of December 3, 1984. At least 2,200 people died immediately after inhaling the toxic substance, and there is no prospect of prevent the contamination of future generations.

The International Campaign for Justice in Bhopal estimates that the total number of deaths as a result of the spill is over 25,000 and warns that the number of those affected is increasing day by day, approaching 600,000. The last official statistic from the Indian government is from 2006 and recognizes 558,000 victims.

A survey conducted by the Scientific Advisory Committee of the Medical Research Council of India in 2017 showed that women who inhaled the toxic gas in 1984 have a 9% chance of giving birth to babies with genetic malformations. The incidence of disorders is almost six times lower among children of mothers not exposed to methyl isocyanate.

Contaminated Lives

Since 1984, those affected have tried to call the attention of the media and the courts to the worsening impacts in Bhopal. After marching 770 km to New Delhi and holding protests every anniversary of the leak, they raised funds to maintain clinics and rehabilitation centers in the city, as well as guaranteeing investments in basic sanitation in the region.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

More information at:

https://drive.google.com/drive/u/2/folders/1fMMqj9q0loRDEqS6Zjx7j-EBBZN9jjQ5


- Flixborgh;


Figure - Flixborgh Accident

At approximately 5:00 pm on 01/06/1974, an explosion occurred in the caprolactam production plant of the Nypro Ltd. factory, located in Flixborough. The explosion occurred due to the leak of cyclohexane, caused by the rupture of a temporary pipe installed as a "by-pass" due to the removal of a reactor to carry out maintenance services. The leak formed a cloud of flammable vapor that ignited resulting in a violent explosion followed by a fire that destroyed the industrial plant.

The rupture of the 20-inch pipeline was attributed to a poorly designed project, since the structure installed to support the pipeline could not support its movement, due to the pressure and vibration to which the pipeline was subjected during operation.

It was estimated that about 30 tons of cyclohexane leaked, rapidly forming a cloud of flammable vapor, which found a source of ignition between 30 and 90 seconds after the start of the leak. The effects of the overpressure that occurred were estimated to be equivalent to the explosion of a mass varying between 15 and 45 tons of TNT.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

More information at:

https://drive.google.com/drive/u/2/folders/1rC0MnnCHs_q19AHB8wj5T8jl1VMsD6Cm


Mining:

- Brumadinho:


Figure - Failure of the Vale dam in Brumadinho

Failure of the Córrego do Feijão mine dam in Brumadinho, lessons that should have been learned:

• The effectiveness of the drainage system must be improved until the minimum FS established in norms and regulations is obtained;

• Auscultation or monitoring instruments (such as piezometers, water level indicators and inclinometers) must be properly maintained and replaced whenever necessary;

• The Risk Chart, a document that points out the reference levels for the auscultation instruments, must be revised whenever new instruments are installed;

• Surge in surface structures, on slopes and at the foot of dams must be taken into account, as they indicate the failure of the internal drainage system;

• The width of the tailings beach must be respected as determined in the dam operation manual;

• Geotechnical investigations must be deepened so that the parameters that characterize the residues and soils of dikes and foundations are in fact known;

• The emergency communication system, to alert workers and the community downstream of the dams, must be activated immediately after finding a failure;

• Audit companies must be careful when using soil and waste resistance parameters, in view of their great variability; It is

• The top management of companies must be quick in taking decisions after the recommendations made by the audits.

Reference:

Rompimento das barragens de Fundão e da Mina do Córrego do Feijão em Minas Gerais, Brasil: decisões organizacionais não tomadas e lições não aprendidas

From Marcos Ribeiro Botelho et al.

For more information send an email to washington.fiocruz@gmail.com

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Articles:

More information at:

https://drive.google.com/drive/u/2/folders/1yx0xkFHTmbbQNYuH7PpW0sMVf4EuseTn

This text continues in Module 4:

Module 4, EXERCISES AND ACTIVITIES, TO UNDERSTAND AND PREVENT TRAGEDY:



 
RISK MANAGEMENT modules, AND THE PROACTIVE SAFETY METHOD, RISKS AND EMERGENCIES.

Module 1, UNDERSTANDING AND PREVENTING TRAGEDY:


Module 2, THEORY OF THESE TRAGEDY - SHORT VERSION:


Module 3, CASE STUDIES OF THESE TRAGEDY:


Module 4, EXERCISES AND ACTIVITIES, TO UNDERSTAND AND PREVENT TRAGEDY:



Greetings,

Washington Barbosa

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