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RISK MANAGEMENT
Hazard & Risks

Pooya Arjomandnia 2015

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

LECTURE 2 PLAN:
Some history why risk management?
Hazard and risk the concepts
Terminology, a way of thinking
Risk perception

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

RESOURCES USED FOR

DISCUSSIONS

Books & Journals

Skelton, Bob Process Safety Analysis: an

introduction chapters 1 & 2

Cameron I and Raman R. - Process Systems Risk

Management chapter 1

Lees loss prevention in the process industries:

hazard identification, assessment and control,
edited by Sam Mannan, free electronic resource at
Curtins library Ch. 1, 2 & Appendices

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

NATURAL DISASTERS

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

INDUSTRIAL DISASTERS

Atofina, Toulouse

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

SOME MAJOR DISASTERS - CASE

STUDIES
Flixborough, UK, 1974

PEMEX, Mexico City, 1984

UCIL, Bhopal, India, 1984

Piper Alpha, UK, 1988

Deepwater Horizon, 2010

Fukushima Daiichi, Japan,

2011

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

FLIXBOROUGH, UK 1974

The Process
Manufacture of caprolactum via the oxidation of liquid
cyclohexane. Reaction product contained 94% cyclohexane
which was subsequently separated.
Reaction carried out in six reactors (20 tonnes each) in series,
operating at 8.8 barg and 155C.
Heat of reaction removed via vaporization of cyclohexane
which was recovered from the off-gas system by condensation.
Atmosphere in reactors controlled via nitrogen supply
Safety valves (11 barg) vented vapour into the relief header of
the flare system
Trip to operate if high oxygen level encountered in the off-gas.
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

FLIXBOROUGH, UK 1974

Chronology of Events
27 March: crack located in 13mm steel plate of Reactor 5.
Decision to take Reactor 5 out of service.
A by-pass constructed between Reactors 4 and 6. Done with
500mm pipe. Openings were 710mm. Dog-leg design, because
of different reactor levels. Bellows installed at each end. Bypass pneumatically tested to 9.0 barg.
29 May: Isolation valve leaking. Shutdown for repairs.
1 June: Startup of plant. Reactors subjected to higher than
normal design pressure.
early am: sudden rise to 8.5 barg in Reactor 1 during
startup
late am: pressure reaches 9.1-9.2 barg at normal
operating temperature
late pm: vapour release via pipe rupture
4.53 pm: massive vapour cloud explosion (VCE)
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

FLIXBOROUGH, UK 1974

Extent of Disaster
Death and Injury
28 killed (within plant)
54+ injured

Plant and Equipment

complete destruction of
processing facilities ($60-70
million)

Plant Environs
1821 houses badly damaged
167 shops damaged

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

FLIXBOROUGH, UK 1974

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

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(Lees, 1996)

FLIXBOROUGH, UK 1974

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

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(Lees, 1996)

FLIXBOROUGH, UK 1974

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Lessons from the Incident:

1. Inventory of Hazardous Materials
large volumes stored on site
(1.5 million litres cyclohexane plus 450,000 litres of other highly
flammables)

2. Design and location of control room and other buildings

18 out of 28 deaths were in the control room

3. Siting of Major Hazards

higher casualties avoided due to relative isolation

4. Public Controls of Major Hazard Installations

ACMH (Advisory Committee on Major Hazards) also CIMAH (Control of
Industrial Major Accident Hazards) regulations

5. Management Aspects
safety versus production
hazard analysis of modifications
management safety system essential
planning for emergencies
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

PEMEX, MEXICO CITY, 1984

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Extent of Disaster
Death and Injury
542 killed (mainly outside plant)
> 7000 injured

Plant and Equipment

majority of LPG installation destroyed

Plant Environs
severe damage area out to 400m
fragments out to 1200m
100 delivery trucks destroyed
200 houses destroyed
1800 houses damaged
200,000 evacuated

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

PEMEX, MEXICO CITY, 1984

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

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PEMEX, MEXICO CITY, 1984

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The Facility
LPG storage and distribution centre, located in a north-eastern
suburb of Mexico City.
Storage at San Juan Ixhuatepec was:
Type

Number

Capacity
(tonnes)

Pressure
(bar)

Total
(tonnes)

bullet
bullet
sphere
sphere

44
4
4
2

50
90
575
1250

9
9
13.5
13.5

2200
360
2300
2500

54

7360

Surrounding residential area started 130m from storage tanks

Feed via 3 underground lines (300mm) from refineries up to 500
km away
LPG distributed to local gas companies and others via
underground lines, cylinders and rail-tankers.
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

PEMEX, MEXICO CITY, 1984

Chronology of Events
Sunday18 November, late pm: facilities almost empty.
Afternoon shift begins tank filling from refineries.
Monday 19 November, early am: filling of bullets and 2
largest spheres completed; 2 smaller spheres about 50%
full.
Sudden pressure drop at pumping station 40 km away.
Rupture of an 8 in. pipe between a sphere and cylinders
5.20 am: escape of liquefied gas with deafening noise 2m
high cloud 200m x 150m
5.40am: cloud ignited by flare at bottling plant. Flash fire
and local overpressures
5.45am: first major explosion (BLEVE)
5.46 am: first small sphere explodes with 300m fireball.
Raining LPG.
up to 7.30am: 9 major explosions
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

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PEMEX, MEXICO CITY, 1984

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Lessons from the Incident

Layout
PEMEX facilities very confined
cylinders very close and walled-in leading to increased overpressures

Location
closeness to major residential areas (130 metres)
local authority planning strategies

Maintenance
poor quality gas detection and emergency isolation
often postponed
seldom recorded
failure of the overall system of protection

Disaster Planning
total confusion reigned
inadequate disaster management
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

UCIL, BHOPAL, INDIA, 1984

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Extent of the Disaster

Death and Injury
3000 fatalities
>250,000 injured
(159 orphaned children, 169
widows, 1000 cases of
blindness)

Plant and Equipment

closure of facility

Plant Environs
major long-term devastation of
local community

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

UCIL, BHOPAL, INDIA, 1984

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The Process
Tails

Phosgene
stripping

Tails

rude
Pyrolysis
MIC

MIC
refinin
g
Product

Residues
Phosgene

Reaction
system

MIC
storag
e

Monomethylamin
e
Chlorofor
m

Hydrogen
chloride

MIC
destruction
VGS/flare

Product

MIC
derivativ
es
Unit vents

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

UCIL, BHOPAL, INDIA, 1984

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Chronology of Events
Sunday 2 December
8.30pm: operator asked to wash piping around tank 610
10.55pm: pressure in tank 610 rises to 10 psig. Operator
assumes it is due to nitrogen pressurization
11.30pm: operators sense eye irritation due to small amount of
MIC
Monday 3 December
12.00 midnight: pressure continues to build. Water sprays used
to cool tank but ineffective
12.30 am: pressure rises to full scale . Bursting disc and safety
valve blows. MIC released via scrubber and vent (40 tonnes in
total) scrubbing, refrigeration & flare not working!
1.00am: alarm activated
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

UCIL, BHOPAL, INDIA, 1984

Lessons from the Incident
Storage of hazardous
intermediates?
is it necessary?

Non-adherence to
recommended plant
procedures
Inoperative safety systems
vent gas scrubber
flare stack
water curtain
refrigeration system

Multinational safety
standards
common standards
worldwide
adequate training
Local Government actions
local community
awareness
suitably planned buffer
zones
Sabotage of operations ?

spare storage tank

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

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Ian Cameron

PIPER ALPHA, UK, 1988

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Extent of Disaster
major oil platform
destroyed
167 deaths
major oil production
disruption for Occidental
Petroleum
Cullen Report leads to
major off-shore safety
system changes

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

PIPER ALPHA, UK, 1988

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The Process
platform operations separated fluid
from wells into gas, oil and
condensate
oil pumped to Flotta Terminal,
Orkneys
gas sent to MCP-01 platform for
compression for discharge to St.
Fergus
gas received from Tartan
gas line link to Claymore

Pipeline connections
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

(Lees, 1996)

PIPER ALPHA

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Chronology of Events
Condensate pump was taken out of service for maintenance by
day shift
PSV of the pump was taken out of service; blind installed loosely
(bolts not tight)
21:45 2 condensate pumps tripped, one restarted by night shift
(not knowing what the day shift did)
Leak and large amount of condensate released vapor cloud
22:00 first explosion
22:20 - rupture of gas riser from Tartan
death in accommodation module
22:50 & 23:20 third and fourth explosion
24:15 - platform Piper disappears

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

PIPER ALPHA

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Lessons from the Incident

quality of safety management lack of control, poor
permit to work systems
quality of safety auditing
isolation of plant for maintenance
training of contractors no proper training!
disabling of protective systems by fire/explosion
safe refuge for workers
planning for emergencies emergency induction not provided,
no drills of exercises to test emergency preparedness

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

Deepwater horizon, april 2010

Extent of the Disaster

Drilling rig sank after

explosion and fire
11 fatalities
Many injured
(126 total workers)

Environment

major long-term devastation

the largest offshore oil spill in
US history

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

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Deepwater horizon

Chronology of Events

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20 April 2010
9:45: a geyser of seawater erupted from the marine riser onto the rig (73 m into the air)
Very soon: eruption of slushy combination of mud, methane gas and water
The gas ignited into a series of explosions and firestorm
Attempt to activate the blowout preventer failed and rig burned for 36 hours
22 April 2010
The rig sank
The oil spill continued until 15 July when temporarily sealed by a cap
Relief wells used to permanently seal the well
19 September 2010 declared effectively dead!

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Possible causes

2009 not required to fill a

scenario for a potential blast

Instructions to remove
drilling mud from the riser
prior to capping and replace
with seawater

Disregarded anomalous pressure

test readings prior to explosion

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The BOP had a dead battery in

its control pod and leaks in its
hydraulic test

Declared the blowout

preventer (BOP) fail-safe;
Transocean listed 260 failure
modes
2011 report BPs lack of
safety culture

Maker of BOP

To be continued
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Flawed cementing job to cap the well just prior

to blowout
The cement plug was never set

Fukushima, Japan, march 2011

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Extent of the Disaster

Level 7 nuclear disaster

Equipment failures
Nuclear meltdowns
Release of radioactive materials
No deaths or cases of radiation
sickness

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Fukushima

Chronology of Events

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Earthquake loss of power supply; reactors 1-3 shut down

Emergency diesel generators started up
Two tsunamis (8 min apart)
Submerged and damaged the seawater pumps required for condenser and cooling
circuits
Drowned the diesel generators, inundated the electrical switchgear and batteries
Damaged and obstructed roads
Reactors isolated from any heat sink
Nuclear emergency declared
Evacuation

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Fukushima

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Lessons from the Incident

Seismic design countermeasures for the external power supply
were inadequate
Tsunami the scale considered in design was inadequate; poor
design of critical safety systems
Station blackout safety guidelines only assumed short term
blackout
Loss of ultimate heat sink
Accident management inadequate for station blackout; confusion;
inadequate responsibility system
Hydrogen explosion outside the containment vessel, not taken
into consideration
Safety design approach - inadequate

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

How to conduct a simple incident safety and risk

assessment

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

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US CHEMICAL PROCESS LOSSES

All
Losses

Explosion
Fire
All other
Windstorm

Losses > $100 000

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

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LOCATION OF LOSSES

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Enclosed
building
Open
structur
e
Other

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

CAUSE OF LOSSES

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Chemical reaction
Boiler and furnace explosion
Other explosions (including vapour cloud
explosions)
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

LOSS ANALYSIS REACTION &

EXPLOSION
Cause

Frequency (%)

Accidental reactiona

33.3

Uncontrolled reactionb

40.0

Decomposition of unstable materials

13.3

Other causes

13.4

Due to accidental contact of material(s)

Intended reactions which become uncontrollable

Type of Process

Frequency (%)

Batch reaction

60.0

Continuous reaction

13.6

Recovery unit

6.6

Evaporation unit

6.6

Other

13.2

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

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MOTIVATION FOR RISK

MANAGEMENT

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Regulatory requirements
International, national and state

Common Law Duty of Care

Avoiding criminal liability

Commercial incentives
Business continuity
Corporate reputation

Evaluating alternatives for design and location

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Ian Cameron

KEY CONCEPTS

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HAZARD - DEFINITIONS
Hazard = a physical situation with a potential for: human injury,
damage to environment or both
Hazard analysis =
the identification of undesired events that lead to materialisation of
hazard
the analysis of the mechanisms by which these undesired events could
occur
the estimation of the extent, magnitude & likelihood of any harmful
events

a potential for harm/loss NOT a realised

harm/loss
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Skelton chapter 1

KEY CONCEPTS
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HAZARDS CONTRIBUTING FACTORS
Material factors
toxicity (LD50, TLV, ERPG, )
flammability (Flash point, Auto-ignition, UEL/LEL)
explosion (deflagration, detonation)
Operational factors
process deviations
time
sequence
human factors
Environmental factors
ignition density
weather/meteorology
RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Cameron chapter 1

KEY CONCEPTS

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RISK - DEFINITIONS
Risk = the probability of occurrence of an event that could
cause a specific level of harm to people, property,
environment over a specified period of time
Process risk categories:
Occupational risks - safety & risk of employees
Plant property loss
Environmental risk s&h of public, heritage
Liability risks - public, product, failure to service
Business interruption risks
Project risk design, contract, delivery

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Cameron chapter 1

KEY CONCEPTS

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RISK DEFINITIONS

Two dimensions:
Severity / magnitude of the loss
Likelihood / probability of occurrence
Broad concept:
Risk = Undesirable consequences x Uncertainty
Risk = Hazard / Protective measures
Risk = Hazard + Outrage

RISK MANAGEMENT AND PROCESS SAFETY Lecture 2

Cameron chapter 1

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RISK MANAGEMENT AND PROCESS SAFETY Lecture 2