1100 - Amyotte - No Such Thing as a Black Swan Process Incident

8/10/2019 1100 - Amyotte - No Such Thing as a Black Swan Process Incident

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THERE IS NO SUCH THINGAS A BLACK SWAN

PROCESS INCIDENT

Paul Amyotte, Alyssa Margeson & Amelie Chiasson

Dalhousie University, Halifax, NS, Canada

Faisal Khan & Salim Ahmed

Memorial University, St. Johns, NL, Canada

Hazards 24, Edinburgh, UK (May 7-9, 2014)


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Introduction

Scope Low probability/high consequence process

incidents

Motivation These incidents have received considerable

attention recently in the popular and technical

literatureObjective

An examination of warning signs (or signals)

that a low probability/high consequence

process incident could occur


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Hurricane Juan: once-in-a-hundred-year storm

Halifax, Nova Scotia (September 2003)


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Five months later (February 2004)another

once-in-a-hundred-year storm

White Juan: 1 m of snow in 24 h


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Paltrinieri et al. (2012) & Gowland (2013)

Known knowns

events we know about and for which we can plan

Known unknowns

events we can predict even if they have notoccurred yet

Unknown knowns

events that have occurred but are notremembered (re. loss of corporate memory)

Unknown unknowns

events not yet predicted or which have beendismissed as unrealistic


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Taleb (2010)

Black swan is an event that

is not expected (an outlier)

has an extreme impact

is explainable and predictable after the fact

CPI and other examples from Mascone (2013)

terrorist attacks of Sept 11, 2001, Hurricane

Katrina, credit crisis and great recession, Gulfof Mexico oil spill, Fukushima Daiichi nuclear

reactor meltdowns, Superstorm Sandy,

A confusing landscape!


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Black swan (or unknown unknown)?

Incident Yes No

Flixborough (1974) Murphy &

Conner (2012)

Bhopal (1984) Murphy &Conner(2012)

Buncefield (2005) Gowland (2013)

BP Texas City (2005) Gowland (2013)Macondo (2010) Murphy &

Conner (2012)

Murphy &

Conner (2013)

Fukushima (2011) Murphy &

Conner (2012)

Gowland (2013)

Mannan (2013)


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Buncefield

Hertfordshire, UK

Kletz (2010)

UNKNOWN KNOWNThe underlying cause of the explosion atBuncefield was that all the people and

organizations involved in design, operations and

maintenance believed that cold petrol vapour hadnever exploded in the open air. They were

unaware that such explosions had occurred in

Newark, New Jersey in 1983, Naples, Italy in

1995, St Herblain, France in 1991 and elsewhere.


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Aven (2013)

Black swanan extremeevent that is a

surpriserelative to the present

knowledge/beliefs of person(s) to be specified

Black swanfrom an (A,C&U) risk perspective,an extremeevent that is a surpriserelative to

the knowledgedefined by the Aevents of the

risk assessment (an unknown unknown)

atypical accident scenarioa scenario deviating

from normal expectations of unwanted events or

worst case reference scenarios, and thus not

deemed credible by common risk assessment

processes (Paltrinieri et al., 2012)


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How can warning signs be detected?

Many tools available to broadly identify

hazards and accident scenarios, assess

likelihood and estimate consequences over

design life cycle

PHA, QRA, PRA, LOPA, DRA

CCPS (2012): Recognizing Catastrophic

Incident Warning Signs in the ProcessIndustries

integration of warning sign detection and

prevention methods into PSM system


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How can we prevent low probability/

high consequence incidents?

Risk AwarenessImpediment

ImprovementMeans

CCPS PSMConcept

Cognitive

dissonance

Consistency of

behaviours & values

Commitment to

process safety

Lack of

perception of

vulnerability

Workplace appeals

Storytelling

Understanding

hazards & risks

Lack of self-

efficacy

Training

Individual performancestandards

Managing risks

Conjunction

fallacy

Storytelling

Assurance of corporate

memory

Learning from

experience


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How can we prevent low probability/

high consequence incidents?

Inherently

safer design

Knowledge management Information becomes knowledge when it is

interpreted by individuals and given a context

and anchored in the beliefs and commitments

of individuals. (Piirto, 2012)


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1960 1970 1980 1990 2000 2010 Year

P

rocess

Safet

y

Technical Safety Improvements

Human Error/Human Factors

Management Focus on HSE

Safety Management Systems

Safety Culture

Knowledge Management/Communication

Evolution of Safety Performance in the Process

Industries (Updated from Pasman & Suter, 2004;

De Rademaeker et al., 2013)


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Not a black swan process incident

INTERIM INVESTIGATION REPORT

CHEVRON RICHMOND REFINERY FIRE

CHEVRON RICHMOND

REFINERY

RICHMOND,

CALIFORNIA

AUGUST 6, 2012

www.csb.gov


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CSB public meeting (April 19, 2013)

Poster handed out by concerned public


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Far too many warning signs that are in

fact accident precursors

Imperative to act on lessons learned from site

operations, company operations, and more broadly

from what is happening within the industry itself

results from previous corrosion inspections at ChevronRichmond refinery

sulfidation corrosion incidents at other Chevron

refineries including El Segundo refinery

sulfidation corrosion incident and ensuing fire at BPsCherry Point refinery

2006 CSB Safety Bulletin on Positive Material

Verificationproviding further information on specific

matter of corrosion of carbon steel

SAFETY

CULTURE

DAMAGE

MECHANISM

HAZARD REVIEW


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A possible black swan process

incident?

14thInternational Symposium on Loss

Prevention and Safety Promotion in the Process

Industries, Florence, Italy (May 12-15, 2013)

Can dustsdetonate?

West

PharmaceuticalsKinston, NC

2003; 6 dead

(www.csb.gov)


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A dust deflagration (subsonic

speed of reaction front) can occur


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But a dust detonation (sonic or

supersonic speed of reaction front)?

Black swanan extreme event that is a

surprise relative to the present

knowledge/beliefs of person(s) to be

specified (Aven, 2013)

Dust detonations are not common in

industry, and the vast majority of

industrial dust explosions occur asdeflagrations (James, 2001; Exponent,

2012)


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Should a dust detonation be

considered a black swan event?

Black swanfrom an (A,C&U) risk

perspective, an extreme event that is a

surprise relative to the knowledge

defined by the Aevents of the risk

assessment (an unknown unknown)

(Aven, 2013)

Detonations of combustible dust have

been shown to occur under laboratory

conditions that optimize fuel, geometry

and flow criteria for DDT


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Should a dust detonation be

considered a black swan event?

Material (fuel) conditions

high reactivity

fine particle size distribution

low moisture content

ease of dispersion/entrainment

Boundary (geometry and flow) conditions

sufficient run-up distance

wide flow channel

turbulence generated by wall surface roughness

or obstacles on flow path


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A practical, industrial warning sign of

post-ignition turbulence generation


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A dust detonation should not always

be a surprise

These material and boundary conditions

form the basis for dust detonation warning

signs related to, for example

process safety information

risk analysis and management of change

A dust detonation is therefore a credible

scenario in, for example long coal mine galleries (Amyotte et al., 1988)

long, wide lines as may be found in pulverized

fuel power plants (James, 2001)


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Concluding Remarks

Beware of the black swanas some have warned

Move beyond the black swan excuseas others

have advised

Adopt a belief that there should be no black swanprocess incidents if knowledge acquisition and

dissemination are well-managed

Continue to learn from Trevor KletzWhat WentWrong?: Only that shall happen which has

happened, only that occur which has occurred;

There is nothing new beneath the sun [Book of

Ecclesiastes]

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1100 - Amyotte - No Such Thing as a Black Swan Process Incident