Catastrophic Incidents: Prevention and Failure

This document was uploaded by one of our users. The uploader already confirmed that they had the permission to publish it. If you are author/publisher or own the copyright of this documents, please report to us by using this DMCA report form.

Simply click on the Download Book button.

Yes, Book downloads on Ebookily are 100% Free.

Sometimes the book is free on Amazon As well, so go ahead and hit "Search on Amazon"

This interesting book offers an analysis of man-made catastrophes and asks why they continue to occur. 87 catastrophes or near-catastrophes, including high profile cases such as the Bhopal gas disaster, Grenfell Tower, Shoreham Air Show crash, Brumadinho dam collapse and Fukushima Daiichi, are described together with the reasons why they occurred and why over 50 different safety management approaches and techniques failed to prevent them.

Featuring 63 eye opening stories from the author’s own personal experience and over 200 pitfalls in safety management approaches, this title is illustrated by 24 hypothetical cases in which the reader is asked to consider the approach they would take. Safety management techniques discussed include operating practices, personnel selection and emergency response. Safety management approaches including safety governance in organisations, along with the role of government and local authorities using the instruments of the law are extensively discussed. The work concludes with imaginative and creative ways forward with the aim to make considerable progress and to potentially eliminate man-made catastrophes for good.

This title will be an ideal read for safety managers and engineers, community leaders in civic duties or labour union roles and professionals tasked with stopping and mitigating the impacts of man-made catastrophes, along with non-technical readers who are curious and concerned.

Author(s): Trevor J. Hughes
Publisher: CRC Press
Year: 2022

Language: English
Pages: 624
City: Boca Raton

Cover
Half Title
Title Page
Copyright Page
Contents
Foreword
Preface
Acknowledgements
Author Biography
Chapter 1: Introduction
Section I: How Do Catastrophes Happen and What Can Prevent Them?
Chapter 2: Man-Made Catastrophes and Safety Risk
What Is a Man-Made Catastrophe?
Catastrophic Risk
Chapter 3: What Makes Risk Tolerable, or Intolerable?
Chapter 4: Fundamental Concepts, Protection Barriers, and Risk Exposure Consequences
Fundamental Concepts
Barrier Analysis and Bow Tie Diagrams
Consequences of Exposure to a Risk
Hazardous Material in Transport
Collision and Impact
Fire
Explosion
Acute Toxicity
Chronic Toxicity
Why Is This Relevant?
Section II: High-Risk Technologies and Their Catastrophes
Chapter 5: Introduction
How to Define a High-Risk Technology?
How Frequently Do We Encounter High-Risk Technologies?
Guide to Section 2
Chapter 6: Oil and Gas
Oil and Gas Upstream (Finding and Collecting Oil and Gas from Underground)
Incident Examples - Oil and Gas Upstream
Piper Alpha, North Sea, 1988 167 Fatalities
Deepwater Horizon, Gulf of Mexico, 2010, 11 Fatalities and Massive Environmental Issues
Montara, Timor Sea, 2009, widespread environmental damage
Oil and Gas Downstream (Taking the Crude Oil and Gas and Turning it into Commercial Products)
Incident Examples - Oil and Gas Downstream
Exxon Longford 1998 - Fire and Explosion with 2 Fatalities
BP Texas City 2005 - Fire and Explosion with 15 Fatalities
Chevron Richmond, CA 2012 - Fire and Explosion. Minor Injuries
Philadelphia Energy Solutions Refinery, 2019 - Fire and Explosion. Minor Injuries
Conclusions
Upstream Oil and Gas - Potential for Future Catastrophes
Downstream Oil and Gas - Potential for Future Catastrophes
Chapter 7: Chemical Industry
Background to the Chemical Industry
Incident Examples - Chemical Industry
Bhopal, India 1984
La Porte, USA 2014 - 4 fatalities
Flixborough (1974), 28 Fatalities
Seveso (1976)
IQOXE (2020), Spain
Conclusions
Chemical Industry - Potential for Future Catastrophes
Chapter 8: Mining and Mine Waste
Introduction to Mining Industry
Open Cast Mines
Underground Mines
Tailings Dams
What Dam Construction Method Is Used?
Incident Examples - Mining and Mine Waste
Buffalo Creek, U.S.A. - 1972 - 125 Fatalities
Brumadinho Dam Disaster - 2019 - 248+ Fatalities
Soma Mine Disaster, Turkey 2014 - 301 Fatalities
Listvyazhnaya Mine, Russia 2021 - 51 Fatalities
Conclusions
Open Cast Mining - Potential for Future Catastrophes
Underground Mining - Potential for Future Catastrophes
Tailings Dams - Potential for Future Catastrophes
Chapter 9: Transportation Industry
Air Transport
Incident Examples - Airports and Aircraft
Shoreham Air Show Crash, 2015 0 11 Fatalities
Incident Involving VFR - Death of High-Profile Footballer
RAF Nimrod MR2 Aircraft XV230, Afghanistan (2006) - 12 Fatalities
Marine Transport
Ships Carrying Hazardous Materials
Incident Examples - Ships
Costa Concordia (2012) - 32 Fatalities
Dona Paz, Philippines, 1987, 4386 fatalities
Marchioness, UK, 1986 51 Fatalities
Transhuron (1974) - Close Call
Ennerdale (2006) L.P.G. Leak
Rail Transport
Incident Examples - Rail Transportation
Viareggio Train Derailment (2009) - 32 Fatalities
Lac-Megantic (2013), Canada
Paddington (1999), London, UK
Carmont (2020), Aberdeenshire, Scotland - 2 Fatalities
Road Transport
Road and Rail Tunnels
Conclusions
Air Transport - Potential for Future Catastrophes
Marine Transport - Potential for Future Catastrophes
Rail Transport - Potential for Future Catastrophes
Road Transport - Potential for Future Catastrophes
Chapter 10: Utilities - Nuclear Power Generation
Nuclear Power - Why the Fear?
Future Development in Nuclear Reactors
Incident Examples - Nuclear Power
Fukushima Daiichi (2011) - Release of Radioactive Materials
Chornobyl (1986) - Upwards of 30 Fatalities, Release of Radioactive Materials
Monju (1995) Japan - Fire
Conclusions
Nuclear Power Generation - Potential for Future Catastrophes
Chapter 11: Utilities - Other
Fossil Fuel Power Generation, Hydroelectric Power, Water, Wastewater, Waste Disposal, Incinerators
Power Generation Using Fossil Fuels
Water, Wastewater, and Effluent Treatment
Hydroelectric Power
Waste Disposal and Waste Recycling
Incinerators
Incident Examples - Power Generation (Fossil Fuels)
Kleen Energy Natural Gas Explosion (2010) - Explosion
Incident Examples - Hydroelectric Power
Sayano-Shushenskaya Power Station (2009), Russia - 75 Fatalities
Laos Dam Collapse, (2018) Laos - Upwards of 45 Fatalities
Incident Examples - Sewers
Guadalajara (1992) - Approximately 250 Fatalities
Incident Examples - Waste Disposal
Currenta (2021), Germany - Six Fatalities
Midland Resource Recovery, (2017), West Virginia - Two Fatalities
Veolia (2009), Ohio
Incident Examples - Incinerators
Tuas Incineration Plant (2021), Singapore - One Fatality
Conclusion
Fossil Fuel Plants - Potential for Future Catastrophes
Water, Wastewater, and Effluent
Hydroelectric
Waste Disposal
Incinerators
Chapter 12: Agriculture, Forestry and Wood Processing, Food and Drink
Overview of This Diverse Sector
Incident Examples - Alcoholic Beverages
MGPI (2016) - Hospitalisation Including Members of the Public
Incident Examples - Wood Processing
Bosley Mill, UK (2015) - Four Fatalities
Whisky and Rum Distilleries
Incident Examples - Food Processing
Foundation Food (2021) - Six Fatalities
Georgia Sugar Refinery, U.S.A. (2008) - 13 Fatalities
Potato Factory, U.K. (2018)
Conclusion
Agriculture, Forestry, Wood Processing, Food, and Beverages - Potential for Future Catastrophes
Chapter 13: Process Industry Infrastructure
Risks Associated with Warehouses, Storages, Terminals, Pipelines
Incident Examples - LNG
Cleveland (1944)
Algeria (2004)
Incident Examples - Warehouses
Beirut Ammonium Nitrate Warehouse Explosion (2020) - Over 200 Fatalities
West Fertiliser Explosion and Fire (2013) - 15 Fatalities Including Public
Incident Examples - Storages - Tank Farms of Liquid or Gaseous Hazardous Material
Freedom Industries 2014 - Toxic Release
Incident Examples - Terminals
Buncefield Oil Storage Facility (2005) - Explosions and Fire
CAPECO Puerto Rico (2009)
Incident Examples - Pipelines
Ghislenghien, Belgium (2004)
Qingdao, China (2013)
Prudhoe Bay (2006)
Conclusions
Process Industry Infrastructure
Chapter 14: Metallurgical, Fabrication, and Product Assembly Industries
Risks Associated with This Diverse Sector
Incident Examples - Steelworks
Port Talbot (2001) - Three Fatalities
Conclusions
Metallurgical, Fabrication, and Product Assembly Industries
Chapter 15: Civil Infrastructure, Small Industrial Estates, Retail, Recreational, Residential
Outline of Risks
Hospitals
Laboratories
Small Scale Industrial Estates
Retail
Recreational
Hotels
Residential
Incident Examples - Laboratories
Bio Lab Chemical Release (2020) - Thermal Decomposition
Marburg Virus Disease (1967)
Incident Examples - Industrial Estates
Plastics Manufacturing on Industrial Estate (2021)
DPC (2002) - Toxic Gas Release
Incident Examples - Residential
Grenfell Tower (2017), London
Conclusions
Hospitals
Laboratories
Industrial
Retail
Recreational
Hotels
Residential
Chapter 16: Explosives Manufacture, Military, and Defence Establishments
Assessing the Risk
AWE Aldermaston Example
Incident Examples - Fireworks
Donaldson Enterprises (2011), Hawaii - Five Fatalities
Incident Examples - Military and Defence Establishments
Los Alamos (1958) - One Fatality
Conclusion
Explosives Manufacture, Military, and Defence Establishments - Potential for Future Catastrophes
Chapter 17: New and Emerging Technologies
Hydrogen
Ammonia
Batteries
Solar Panels and Solar Farms
Carbon Capture
Wind Farms
Driverless Cars and Automated Roads/Motorways
Commercial Space Exploration
Incident Examples - Hydrogen
Fukushima Daiichi (2011)
OneH2 Plant Explosion (2020)
Incident Examples - Ammonia
Minot Train Derailment (2002) - One Fatality, Toxic Release
Potchefstroom, South Africa (1973) - 18 Fatalities, Toxic Release
Incident Examples - Batteries
APS (2019)
UPS Airlines Flight 6, Dubai (2010) - Two Fatalities
Incident Examples - Wind Farms
Derrybrien Wind Farm, Ireland (2003) - Widespread Environmental Damage
Conclusion
New and Emerging Technologies - Potential for Future Catastrophes
LNG
Hydrogen
Ammonia
Batteries
Others
Section III: Catastrophe Prevention and Why It Is Failing
Chapter 18: Introduction
Chapter 19: Operators and Front-Line Personnel
Operator Mistakes
Operating Procedures
Housekeeping
Training
Summary: Causes of Failure in Operating Procedures and Training
Reasons Why Procedures Sometimes Fail in Catastrophe Prevention Include:
Causes of Failure in Operator Training
Chapter 20: Human Factors, Personnel Selection, and Contractors
Human Error
Personnel Selection
Contractors - Selection, Performance, and Control of Work
Summary: Causes of Failure Through Human Factors and in Personnel Selection and Use of Contractors
Reasons Why Human Factors Sometimes Cause or at Least Contribute to Catastrophes Include:
Reasons Why Good Personnel Selection Sometimes Fails to Prevent Catastrophes Include:
Reasons Why Good Contractor Management Sometimes Fails to Prevent Catastrophes Include:
Chapter 21: Equipment Suitability
Equipment Selection and Design
Materials of Construction and Corrosion Considerations
Equipment Controls
Automation
Interlocks and Bypass Control
Human-Machine Interface and Alarms
Failures of Safety Devices
Pressure Relief Valves
Mechanical Interlocks
Electronic Interlocks
Fire and Gas Detectors
Summary: Causes of Failure due to Problems with Equipment Suitability and Reliability
Reasons Why Issues in Equipment Selection and Design Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Materials of Construction and Corrosion Considerations Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Automation Sometimes Causes, or at least Contributes, to Catastrophes Include:
Reasons Why Interlocks and Bypass Controls Sometimes Cause or at least Contribute to Catastrophes Include:
Reasons Why the Human-Machine Interfaces and Alarms Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Safety Devices Sometimes Cause, or at least Contribute, to Catastrophes Include:
Chapter 22: Equipment Maintenance and Inspection
Preparation for Maintenance
Control of Work
Maintenance Planning
Mechanical Repairs and Replacement
Electrical Repairs and Replacement
Inspection and Corrosion
Ageing and End-of-Life
Falsification of Inspection Results
Corrosion Mechanisms
Summary: Causes of Failure due to Improper Maintenance and Inspection
Reasons Why Preparation for Maintenance Sometimes Causes, or at least Contributes, to Catastrophes Include:
Reasons Why Control of Work Sometimes Causes, or at least Contributes, to Catastrophes Include:
Reasons Why Maintenance Activity Sometimes Causes, or at least Contributes, to Catastrophes Include:
Reasons Why Repairs and Replacements Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Inspection Sometimes Cause, or at least Contribute, to Catastrophes Include:
Chapter 23: Emergency Response and Readiness
Emergency Response Plan and Scenarios
Emergency Response Team and Training
Emergency Practices and Drills
Fire and Gas Detection
Firefighting Water and Foam
Emergency Response Equipment - Fixed and Mobile
Impairment of Emergency Equipment
Summary: Causes of Failure due to Issues with Emergency Response and Readiness
Reasons Why Problems in the Creation of an Emergency Response Team and Their Training Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Deficiencies in Emergency Practices and Drills Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Errors in the Provision of Fire and Gas Detectors and Alarms Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Errors in the Deployment of Firefighting Water and Foam Systems Sometimes Cause, or at least Contribute, to Catastrophes Include:
Reasons Why Errors in the Set-up of Emergency Response Equipment Sometimes Cause, or at least Contribute, to Catastrophes Include:
Chapter 24: The Role of the Safety Department and Incident Investigation
The Safety Department
Incident Investigation
Incident Recognition and Reporting
Incident Investigation Process
Summary: Causes of Failure in the Role and Actions of the Safety Department, and of Deficiencies in Incident Investigations
Reasons Why the Activities of the Safety Department Can Fail to Prevent Catastrophes Include:
Reasons Why Deficiencies in Incident Investigation Can Fail to Prevent Catastrophes Prevention Include:
Chapter 25: Risk Assessment Basics and Preparation
Hazard Identification
Introduction to Risk Assessment
Preparing for the Risk Assessment
Bow Tie
Summary: Causes of Problems in Risk Assessment Preparation
Reasons Why the Risk Identification Step Sometimes Fails to Prevent Catastrophes Include:
Reasons Why the Risk Assessment Preparation Step Sometimes Fails to Prevent Catastrophes Include:
Chapter 26: Risk Assessment Techniques - HAZOP, Fault Tree, Event Tree, and Other Methods
Selecting a Risk Assessment Method
HAZOP
Assessing Probability
Assessing Consequence
Introduction to Quantitative Methods
Fault Tree
Event Tree
Other Techniques
Summary: Causes of Failure of Risk Assessment Techniques Including HAZOP
Reasons Why HAZOP and Other Risk Assessment Techniques Sometimes Fail to Prevent Catastrophes Include
Reasons Why the Assessment of Probability and Consequence Assessment Steps Sometimes Fail to Prevent Catastrophes Include
Chapter 27: Assessing Risk Outcomes, Layers of Protection Analysis, and Safety Integrity Levels
Assessing Risk
Quantitative Risk Assessment
Risk Reduction Hierarchy
Designing a Safety Instrumented System
LOPA and SIS
Summary: Causes of Failure to Prevent Catastrophes when Assessing Risk Outcomes and Addressing Risk Reduction
Reasons Why the Assessing Risk Using a Matrix often Fails to Protect against Catastrophes
Reasons Why Quantitative Risk Assessment often Fails to Protect against Catastrophes
Reasons Why the Design of Safety Instrumented Systems Can Fail to Protect against Catastrophes
Chapter 28: Consequence Analysis and Consequence Mitigation
Consequence Analysis and Dispersion Modelling
Expressing Consequences as FN Curves
Consequence Mitigation
Summary: Causes of Failure in Consequence Analysis and Dispersion Modelling
Reasons Why Consequence Analysis and Dispersion Modelling Can Fail to Avert or Predict a Catastrophe Include:
Chapter 29: Software Safety and Cyber Security
Software Safety Analysis
Cyber Security
Summary: Causes of Failure in Software Safety and Cyber Security
Reasons Why Software Safety and Cyber Security Can Fail to Avert or Predict a Catastrophe Include:
Chapter 30: Risk Assessment Conclusions and Implementation
What Are the Conclusions of the Risk Assessment?
Risk Assessment Stage - Gate 1
Risk Assessment Stage - Gate 2
Risk Assessment Stage - Gate 3
Risk Assessment Stage - Gate 4
Credible Scenarios
Summary: Causes of Failure to Prevent Catastrophes when Concluding Risk Assessments
Reasons Why Closure of the Risk Assessment Can Fail to Avert or Predict a Catastrophe Include:
Chapter 31: Governance of Safety
Safety Management System Elements
Management Commitment
Acceptance of Residual Risk
Demonstrating Management Commitment
Management Commitment in Safety versus Management Commitment in Catastrophe Avoidance
Rituals and Safety Culture
Leadership Meeting
Key Performance Indicators
Health Safety and Environment Leadership
Management by Walking Around
Management of Change
Audit - Internal and Third Party
Local Checks
Local Audit
Local Process Safety Audit
Corporate Audit
Audit Results and Actions
Summary: Causes of Failures in the Governance of Safety which Might Allow Catastrophes to Occur
Reasons Why the Structure of the Safety Management System Can Fail to Avert or Predict a Catastrophe Include
Reasons Why the Management Commitment Can Be Ineffective and Fail to Avert a Catastrophe Include
Reasons Why Managements Acceptance of Residual Risk Can Contribute to Failure to Avert a Catastrophe Include
Reasons Why Management by Walking Around Can Fail to Avert a Catastrophe Include
Reasons Why Audits Can Fail to Avert a Catastrophe Include
Chapter 32: Laws, Regulations, Standards, Certification
Safety Laws
The Safety Case
Safety Regulations
Country and International Standards
Corporate or Company Standards
Conformity with Laws and Standards
Certification
Other Third-Party Assessments
Government Regulators
The Pressure for Deregulation
Summary: Causes of Failures in the Application of Laws, Regulations, Standards, and Certification
Reasons Why Safety Laws Can Fail to Avert a Catastrophe Include
Reasons Why Safety Cases Can Fail to Avert a Catastrophe Include
Reasons Why Safety Regulations Can Fail to Avert a Catastrophe Include
Reasons Why Country and International and Technical Standards Can Fail to Avert a Catastrophe Include
Reasons Why Corporate or Company Standards Can Fail to Avert a Catastrophe Include
Reasons Why Certification by a Third Party (e.g. ISO Certification) Can Fail to Avert a Catastrophe Include
Reasons Why Third-Party Assessments Can Fail to Avert a Catastrophe Include
Reasons Why Government Regulators Can Fail to Avert a Catastrophe Include
Chapter 33: Safety Culture and Other Social Structures
Cultural Differences - Are They Important?
What Is Culture?
What Is the Relevance of National Culture to Catastrophe Prevention?
Two Safety Improvement Techniques as Test Cases: 'Management by Walking Around' and the 'Safety Culture Maturity Model'
Relevance of Hofstede's Dimensions
Power Distance Index
Uncertainty Avoidance Index
Individualism vs Collectivism
Long-Term Orientation vs Short-Term Orientation
Role of Organisational Cultures and the Development of a 'Safety Culture'
Safety Culture
Role of Punishment - by an Organisation on Its Members
Role of Punishment - by the State on the Organisation and Its Members
Falsification, Negligence, and Dishonesty
Role of Insurance - Help or Hindrance
Summary: Why Attempts to Improve Safety Culture Can Fail to Avert a Catastrophe
Reasons Why Attempts to Improve or Introduce a Safety Culture Can Fail Include
Reasons Why the Introduction of 'Management by Walking Around', Gemba Walks, Safety Observations Can Fail Include
Reasons Why Organisations Can Fail to Make Progress along the Safety Culture Maturity Model Include
Reasons Why Organisations Are Restricted to Adopting Only Short-term Strategies Include
Reasons Why Punishment (by an Organisation on Its Employees) Can Fail to Avert Future Catastrophes Include
Reasons Why Punishment (by State Authorities on an Organisation or Its Members) Can Fail to Reduce the Potential for Catastrophes Include
Reasons Why Insurers Can Fail to Influence the Prevention of Future Catastrophes Include
Chapter 34: Managing Legacy Issues
What Is a 'Legacy Issue'
Handling Legacy Issues
Why Legacy Issues Don't Get Addressed with Sufficient Urgency
Other Examples of Legacy Issues on a Large Scale
Summary: Why Legacy Issues Fail to Get Addressed before a Catastrophe Occurs
Section IV: Vulnerability to Natural Catastrophes, Sabotage, Terrorism, and War
Chapter 35: Introduction
Chapter 36: Hurricane, Tornado and Flood
Assessing the Risk: Hurricane
Assessing the Risk: Tornado
Assessing the Risk: Flood
Incident Examples - Flood
Arkema Organic Peroxide Decomposition (2017)
Chapter 37: Earthquake
Assessing the Risk
Incident Examples - Earthquake
Earthquake at Refinery with Fire (1999)
Japan (2011)
Ichihara 2011
Whittier Narrows, U.S.A (1987)
Chapter 38: Tsunami and Other Natural Catastrophes
Assessing the Risk: Tsunami
Incident Examples - Tsunami
Tohoku Earthquake and Tsunami (2011)
Indian Ocean Tsunami (2004)
Other Natural Catastrophe Threats to Hazardous Facilities
Wildfires and Bushfires
Volcano
Lightning
Subsidence and Landslip
Temperature Extremes
Thawing of the permafrost
Chapter 39: Diseases
Occupational Diseases
Asbestosis - an occupational disease catastrophe
Other occupational disease catastrophes
Viruses, Bacteria and Pandemics
Chapter 40: Terrorism, Sabotage and War
Assessing the Risk to Hazardous Facilities
Section V: Preventing Catastrophes - Potential Solutions
Chapter 41: Is There a Need for Change?
Appetite and Revulsion
Normal Accidents and Executive Wrongdoing
If You Can't Afford It - Stop It
Politics
Where We Have Found No Answer
Chapter 42: Improvements to Risk Management Methodology
Reducing Operator Failures and Issues with Operating Procedures (Refer Chapter 19)
Making Training More 'Watertight' (Refer Chapter 19)
Neutralising Errors due to Human Factors (Refer Chapter 20)
Selecting and Developing Error-free Contractors (Refer Chapter 20)
Raising the Bar on Equipment Selection and Design (Refer Chapter 21)
Eliminating Errors in Materials of Construction (Refer Chapter 21)
Taking Care of Automation and Interlocks (Refer Chapters 21, 27, 29)
Improving the Effectiveness of Maintenance Activities (Refer Chapter 22)
Elimination Errors in the Control of Work (Refer Chapter 22)
Improve the Robustness of Inspection and Business Sign-Off on Corrosion Risks (Refer Chapter 22)
Credible and Proven Emergency Response Plans (Refer Chapter 23)
Making HAZOP or Other Risk Assessment Techniques Efficient (Refer Chapter 26)
Identifying Common Mode Failures (Refer Chapter 27)
Improvements in the Management of Risk Assessment Conclusions (Refer Chapter 30)
Improvements in Incident Investigation (Refer Chapter 24)
Chapter 43: Changes to Leadership Mindset
Define who Is Ultimately Responsible at the Corporate Level
Define who Is Ultimately Responsible at the Operating/Execution Level
Minimum Essential Certification and Training for the Carrying Ultimate Responsibility
Chapter 44: Changes to Government and Legal Structures
Regulations which Challenge Organisations to Improve
Extend the Requirement for Safety Cases
Make Safety Cases Public Domain Documents
Shrinking the Targets
National and Global Policies of Vulnerability Reduction
Changing the Legal Proof of Criminal Responsibility
Ignorance Is Not an Excuse
Comparisons with Likely Outcomes from the Grenfell Tower Enquiry
Chapter 45: Societal Changes, including Public Disclosure and Education
Potential Changes within the Educational System
Primary Education (children of age up to 11)
Secondary Education (Children of age 12-16)
Tertiary (University and College) Education
Education for and at Work
Adult Education
Risk Disclosure to the Public
Chapter 46: Common Factors with Other 'Catastrophes' such as Climate Change
Other Catastrophes
Process Safety, and System Safety Engineering is Drowning!
Common Factors
Shareholder Value vs Stakeholder Value
Global Reporting Initiative
Is Catastrophe Prevention part of Sustainable Development?
Sustainable Development Reporting-Necessity and Validity
Developing a Reporting Standard for Catastrophe Prevention
Current Company Reporting Process Safety versus Sustainable Development
Materiality
Spills
Process Safety
Risk Matrix
Generalised Statements concerning Risk Management
Chapter 47: In Pursuit of Genuinely High Reliability Organisations
Competing Views on Catastrophe Prevention
Characteristics of High Reliability Organisations
The Defeat of Short-Termism
Chapter 48: Conclusions
Appendix A: Hypothetical Case Exercises - Maps and Diagrams
Appendix B: Seveso-Regulated Site Densities - Examples from Europe
Seveso Sites in Europe
Appendix C: Mine Tailings Dam Failures
Appendix D: Questionnaire used: Likelihood of Future Catastrophes - Your Opinion?
Likelihood of Future Catastrophes - Your Opinion?
Appendix E: Suggested Reporting Standard on Catastrophe Prevention
Contents of the Suggested Standard on Catastrophe Prevention
Disclosure CP 1 - Organisation's Risk Matrix *
Disclosure CP 2 - Hazards
Disclosure CP 3 - Current Residual Risks, including any effect on local communities
Disclosure CP 4 - Planned Risk Reduction Activities
Disclosure CP 5 - Leading and Lagging Indicators of Catastrophic Risk *
Disclosure CP 6 - Significant Spills or unplanned Atmospheric Emissions
Disclosure CP 7 - Fires and Explosions
Disclosure CP 8 - Catastrophic Risk Assessment Status
Disclosure CP 9 - Equipment Inspection Status
Disclosure CP 10 - Major Emergency Response Plans
Disclosure CP 11 - Cyber Security Protection
Disclosure CP 12 - Identified Legacy Issues relating to Catastrophic Risk
Disclosure CP 13 - Protection against Natural Catastrophes, Sabotage and Terrorism
Disclosure CP 14 - External and Internal Audit Status
Generic Suggested Content
Sector Specific Suggestions
Oil and Gas Upstream
Oil and Gas Downstream
Chemical Sector
Mining Sector
Transportation Sector - Air
Transportation Sector - Rail
Nuclear Power Sector
Process Industry Infrastructure Sector (terminals, pipelines, warehouses)
Explosives Manufacture, Military and Defence
Appendix F: Example Responses to Suggested Reporting Standard on Catastrophe Prevention
Hypothetical Fuels Terminal
Disclosure CP 1 - Organisation's Risk Matrix *
Disclosure CP 2 - Hazards
Disclosure CP 3 - Current Residual Risks, including any effect on local communities
Disclosure CP 4 - Planned Risk Reduction Activities
Disclosure CP 5 - Leading and Lagging Indicators of Catastrophic Risk *
Disclosure CP 6 - Significant Spills or unplanned Atmospheric Emissions
Disclosure CP 7 - Fires and Explosions
Disclosure CP 8 - Catastrophic Risk Assessment Status
Disclosure CP 9 - Equipment Inspection Status
Disclosure CP 10 - Major Emergency Response Plans
Disclosure CP 11 - Cyber Security Protection
Disclosure CP 12 - Identified Legacy Issues relating to Catastrophic Risk
Disclosure CP 13 - Protection against Natural Catastrophes, Sabotage and Terrorism
Disclosure CP 14 - External and Internal Audit Status
References
Index
Index: Notes from Trevor's Files
Index to Hypothetical Case Exercises (Whisky Distillery and Fuels Terminal)