Major Hazards Risks and

their Amelioration
Dr Tony Green, PhD., BSc.,
Independent researcher,
Director, ARGSAB Pacific
Are these both Major Hazards risks?
What distinguishes the two risks?
What are the similarities in the risks?
How can they be controlled?

Source: S. E. Rigby et al, Shock Waves (2020) 30:671–675

https://doi.org/10.1007/s00193-020-00970-z
 What are Major Hazards?
Major hazards are a hazard that if it occurs will cause :
• Death and Injury within an organisation and outside
the organisation
• Collapse and Damage to property outside the
organisation
• Collapse of societies support structures
Problems with Dealing with Low probability of occurrence
with High impact Ikonos satellite image, Lhoknga,
• Maintaining a state of safety that fails safely Sumatra, 29 Dec 2004
• Inadequacy of controls that are maintained
• Organisations tend to focus on efficiency (usually only
monetary) rather than safe operation at all times
• Downsizing of personnel – numbers and technical skills
• Effect of technology change on the hazards
• Focus on Immediate timescales rather than long term
resilience
• Ignore human behaviour in maintaining safe environments
 Types of Risk System
ESTABLISH THE CONTEXT
* The Strategic Context
Tame Risks: (Independent Risks) * The Organsational Context
* The Risk Management Context
A basic assumption: System being analysed is considered
independent of other systems and there is no risk feedback from the C
Develop Set the structure
Criteria
other systems into the system being analysed. O
N
S
Benefit: allows a description of risk in terms of likelihood and U
IDENTIFY RISKS
L * What can happen?
consequence on a continuous spectrum. T * How can it happen? M
O
N
A I
N ANALYSE RISKS T
D O
R
Wicked Risks: (complex and complicated Risks) C
O A
Determine existing controls

M S
Substantial feedback mechanisms that lead to long tail risks if the M
U
S
E
Determine
Likelihood
Determine
Consequences
A
N
D
system is inappropriately analysed as a “tame risk” (low probability N
I
S
S
C
high impact events) or from high impact risks which only occur when A R
I
Estimate Level of risk R
E
T V
certain conditions are met that usually lead to the failure of the E
S
K
S
I
E
W
system. EVALUATE RISKS
* compare against criteria?
* set risk priorities?

Standards for Organisations and Governments:

YE
ACCEPT
S
NO
ISO 31000: Risk management – provides principle and guidance as to
how to manage risks in organisations TREAT RISKS
Evaluate treatment option:
ISO 31010:Risk management – Assessment Techniques. >30 * Select treatment methods
* Prepare treatment plans

techniques are identified * Implement plan

ISO 31022: Risk management – Managing legal Risks

Definition of risk from ISO 31000
Risk: Effect of uncertainty on
objectives
• An effect is a deviation from the
expected — positive and/or negative.
• Objectives can have different aspects
(such as financial, health and safety,
and environmental goals) and can
apply at different levels (such as
strategic, organization-wide, project,
product and process).
• Risk is often characterized by reference
to potential events and consequences,
or a combination of these.
• Risk is often expressed in terms of a
combination of the consequences of an
event (including changes in
circumstances) and the associated
likelihood of occurrence.
• Uncertainty is the state, even partial, of
deficiency of information related to,
understanding or knowledge of an
event, its consequence, or likelihood.
Reason’s Swiss Cheese Model (1990)
Uncertainty with Major Hazards
• Missing information on causal factors that will initiate
the hazard.
• Insufficient data on frequency of causal factors where
known – including coupling between different parts of
an organisation or outside agencies or environment.
• Insufficient data on scale of impact
• Insufficient data on escalation of impact
• Limitation in Modelling the hazard
• Controls are inadequate for the magnitude of the
impact
• Controls do not stop escalation of impact
• Impact of behaviour on cause not well understood
 Cygnus Atratus Events
(Black Swan events)
• Supposedly unforeseen consequences
• Not within experience
• The deduction is
Ø It won’t happen
Ø Cannot be foreseen
Ø Cannot be controlled

Ø Uncertainty in complex and complicated systems Source: Blair Wainman 2008

Ø Rarity leads to little analysis (inverse Pareto law)
Ø Rationalised after the event
Ø Historically considered as outliers Out of sight
Ø Reality
Ø Factors which lead to catastrophe are dynamic
Out of mind
Ø Dynamic behaviour is poorly understood
Ø Ignored because there is no immediate impact
Doomed to Failure
Ø Assessment focuses on static assumptions
Ø Politically difficult to fund adequate control
Hurricane Katrina
(Considered a black swan event)
Unpredictable in:
Ø Strength
Ø Landfall
Ø Storm surge height
Ø rainfall
But:
Ø 5 categories of increasing
strength Source: AP/ David J. Phillip 26/08/2005
Ø Estimates of wind
strength, storm surge
height, rainfall
Ø Better tracking gives
estimates of landfall
Levee construction equivalent to
Hurricane III
Ø 1950’s construction
Ø Known to be vulnerable in 90’s
Ø No review
Ø Political expedience to the
immediate Source: Getty Images / Mario Tama 24/08/2010
 Tohoku Tsunami
“The homes on higher places will guarantee
the comforts of the descendants, remind
the horror of the tsunamis, do not build
homes below this point.
We suffered tsunamis in 1896 and also in
1933, only 2 villagers in the former disaster
and 4 in the latter survived. Keep on your
Source: AP http://www.cbsnews.com/news/ancient-stone-
guard even years pass by.” markers-warned-of-tsunamis/
Source: Mark Willacy – personal communication

An intergenerational warning How do your

Ø There are hundreds of such stones
Ø Most date from 1896 Meiji Sanriku and 1933 managers behave?
Showa Sanriku tsunamis. DO they ignore
Ø 25% built since 1896 disappeared in the Tohoku
tsunami warning signs?
Three generations to Calamity
Ø Those who experienced it don’t tend to repeat
Ø The teaching to their offspring provide adequate warning
Is it consistent with
to be cautious your risk history?
Ø The third generation take more risk often ignoring history
 The Millennium Bug: fact or fiction?
1-01-1999 use of dates one year in advance
Addition 99+1 = 00 9-09-1999 End of file marker
1999+1 = 2000 1-01-2000 Y2k
Subtraction 00 – 1 = -1 29-02-2000 File length
1-10-2000 File length
2000-1 = 1999 10-10-2000 File length
Some 20 other dates in future years to 2038
Ø First identified as a problem in late 70s.
Ø Gained traction in early 90s:
Ø Multi national energy companies and banks,
governments
Ø Concern over embedded processors (PLCs)
Ø How may and where
Ø By 1998 software solutions for networks and connected
applications
Ø 1999
Ø 33% FTSE 500 reported problems
Ø 90% believed serious disruption would have resulted
Ø 2000
Ø 4000 events worldwide
Ø Most serious on Nuclear plant in Japan
Ø Under reporting – reputation loss
 SARS-coV-2 (Covid-19 Pandemic)
• Thought to originate in bats
• First case Identified in Wuhan, China, Dec 2019
• Now spread to 122 million people worldwide
• No immunity in the population
Source: CDC
• No vaccines at the start of the pandemic
• Given the urgent need for COVID-19 vaccines,
unprecedented financial investments and scientific Source: https://www.worldometers.info/coronavirus/
collaborations are changing how vaccines are developed.
• Currently 7 vaccines being rolled out worldwide with over
200 vaccine candidates under development

This Virus mutates rapidly

• Some 200 different mutations have been identified
• Phylogenic trees show relationships between mutations
• Some mutations have 17 or more changes to the spike
protein.
• Some of these have been associated with increased
transmission rates (and possibly increased severity).
• The current vaccines seem to be slightly less effective against
the highly mutated strains Source: https://www.ecohealthalliance.org/
All are examples of
Major Hazards
Hurricane Katrina
Ø Knowledge changes over time
Ø Allows for alternative decisions
Ø Human decision based on expediency
Ø Failure to adapt systems to new knowledge
is very costly
Source: Ciba-Geigy
Tohoku Tsunami
Your critical Systems:
Ø History is gradually lost unless
Ø Have you analysed your system
compensated for
without control?
Ø The maximum event must be considered
Ø What changes in systems will lead
Y2K to disaster?
Ø Early identification Ø What critical controls have you
Ø Critical mass to do something identified?
Ø Action limits loss Ø How do you ensure critical
controls are maintained?
Covid-19 Pandemic
Ø How do you capture and retain
Ø Early identification of the genetic structure
critical decisions in your
Ø Reduced time for vaccine development
organisation?
Challenges for Risk Quantification – Identifying Risk
Highly complex New
More complex Develop methods,
Knowledge
Methods metrics,
of Feasibility needs
for perceived
Connectivity Trade offOther
between
Value Poorly disciplines cope values to be considered
Perception
Interdependencywith many
security and
methods and risk
freedom inwith diverse
interdependence
parallel to objective
Correspondenceunderstood
Interdependencies have methods
broader thinking
in social
needsgroups
to be improved
methods Coupling
Vehicle Power
accidents Generation
Aircraft
Chemical
Plant
Common
Medical Workers
Oil Water
conditions CompProduction transmission
fields
Electricity
Insurance Transmission
Tsunami

Food
Actuarial
Chains Good data in
Tools Gaps need to
Consequence some
generally be filledInternet
assessment environments
available
Supply
Chains? Individual Terrorism
Use aggregated
Probability of events poorly
events
events and Airlines
quantifiedGlobal Warming
Requires
boundary new tools
Cyber Attacks
definitions Motivation
Geographical New methods
Poorly measured
Extent
 Challenges for Risk Qualification – Identify Risks
Causal event Unwanted
Events

Domains of Influence
Politics and Economics System Operations and
regulation & Finance Design emergency procedures

Planning, Investment, Technical, Control,

Consumers, Workplace Construction, Procedures,
Factors
Contracts, policies, Materials, Automation,
affecting
Procurement, Debtors, Processes, Internet,
influence
Board members, Loan, Utilities, communications,
…etc. …etc ..etc …etc

Hazards & Corruption, Bankruptcy Failure of supply, Cyber attack

Threats Change, …… Fraud, ….. Defective materials, … Explosion, ….
Source: https://www.youtube.com/watch?v=BEUsOdvPqXE

Source: https://atlanticleak.com/wp-
content/uploads/2011/10/g13e0000000000000003d2c7f0c058c26369a1cfcc9097920312
4e20c7f.jpg

Source: columbustelegram.com
 Cause of critical
event
Rim seal fire

Lack of drainage on
tank roof causing Full surface fire
Source:
https://www.youtube.com/watch?v=_c42s6rrYU4 collapse Source:
https://pbs.twimg.com/media/Cge
ws6nUAAAwpXU.jpg

Too much water Too much water causes

causes overfill of accumulation in the
the tank bottom of the tank
Source:
https://i.ytimg.com/vi/9
6QIUh1zWoI/hqdefault.j Lack of cooling
pg Bund fire Boilover
water

2nd Tank rupture

Bund overflow
and fire spread
 Layout Alternative
Visibility Surveillance Targets and
Criticality Weapons

Resources
Clustering Replacement Redundancy
Use of
Access Specific
Design Availability
interconnections
Analysis 3DPaths
Space Target

Resources
Logistics Emergency
Protection
Specific Response
Practice
Access Information
Routes Weapon

Assets
People
Timing Impact
Information
Alternative Attack Operation

Prevention Targets
Target Response
 Bow Tie Analysis

Escalation Factors
Escalation Factors
Preventive Controls Recovery Controls

Escalation Escalation
controls controls
CO
T1 NS
H EQ
UE
A NC
Top
Z T2 Event
ES

A
R
D T3 Undesirable event with
potential for harm or damage

Engineering activities
Maintenance activities
Operations activities
 Basic Error
Types Attentional Failure
Intrusion
Omission
Slip
Reversal
Misordering
Unintended Mistiming
Action
Memory Failures
Omission
Lapse
Place-losing
Forgetting Intentions
Unsafe
Acts

Rule Based Mistake

Misapplication of a known rule
Mistake Application of a Bad rule

Knowledge Base mistake

Intended
Action
Routine Violation
Violation Exceptional Violation
Deliberate Act
 Active
Failure

Susceptible Error Task Monitoring

Accident
to Error occurred Failure of systems
1-PR Latent
PR Self Failure
Monitoring

PR
Unsafe Detection Corrective
Interruption Condition Engineering Action
Management
Task
Loading
Psychological
Shaping Factors Dependent on Actions of
others
(Heuristic Loop)
Reflexive Response:
Limbic system and
normalised behaviours Reflexive Attitudes:

Reflexive
Perceptions
Emotion:
Hormonal and Reflexive
Sensory response Behaviours
Reflexive
Motivation
Instinct, Sensory
Information and Brain
Chemistry
Reflective
Beliefs and Motivation
Personality: Reflective
Behaviours
Reflective
Perceptions

Reflective Response: Reflective Attitudes:

Memory of similar
situations
 Beliefs Perceptions
Accumulated
Knowledge
and Behaviour:
Information
Attitudes Motivation Goals
Selection
Direction:
Justification Strategy
Deception
Energy:
Persistence process
Intensity
Needs:
Persistence
Physical and
Instinct and Emotional
Sensory
Information
Emotions
Personality
 Framework for Risk Evaluation
Arrow
represents Distribution
aggregated represents
“control state of
state” individual
control

Politics

Economics F
& finance E
Factors of
E
influence
Regulations D
B
Hazards and
A
Threats Operations &
C
emergency procedures
K

System design

System performance (measured)

 Simulacron: Intelligence Module
INFLUENCE Groups Environment Individual
The Shill

INDIVIDUAL
Impact
ATRIBUTES Individual
of
The Rube Belief
Actions

RESISTANCE
TO Resistance to
INFLUENCE influence
Throw of the
die

OBSERVED Normal Individual Group

BEHAVIOUR Action Action Action
Appropriate and
Inappropriate
outcomes
 High
Aggression Fast movement towards exit

High Training in First Aid

Move into event area
Imminent
Empathy
Danger

Stunned confused Behaviour

Warn Others

Evacuation to familiar exit

Event
Trigger
Low

Seek further Information Change behaviour on receipt of warning

Threat Not
Normal Behaviour
Imminent

Low
 Microsimulation Dr. Tony Green

Applications Scientific Challenges

• Biological Agents: • Stochastic Real time Simulation
• Multi vector • Currently achievable with
• Multiple States Biological Agents
• Chemical and Radiological Dispersion, • Currently achievable for some
Explosions dispersion and explosion
problems
• Particle description of dispersion
and explosion • Not currently available for urban
dispersion and explosion
• Direct calculation of individual problems.
exposure or injury
• Scalable
• Crime and Terrorism
• Seamless
• Vulnerability Analysis
• No lessening of calculation speed
• Interdiction
• Integration with incoming data
• Emergency response for multiple
hazards • Intelligence
• Sensor
• Inter-agency data
Benefits of Discrete Behaviour Modelling
• Analysis of population movement
• Threat analysis within any population
• Infection
• CBRN
• Natural Disasters
• Food distribution and logistics
• Security
• Real time response
• Integration with Sensor and Surveillance

• Decision Support Tools

• Forensic Support Tools
 Thankyou

Any Questions or Discussion?