Engineering Risk Management (pdf)

Running Head: ENGINEERING RISK MANAGEMENT
Engineering risk management
May 4
2018
Case study of
different man-made
disasters

ENGINEERRING RISK MANAGEMENT 1
Executive summary
The complexity of the industrial activities and production of chemical products crossing
the chemical industry promotes the emergence of risks that must be considered in the
decision making process for the organizational operations. Today risk management is very
important in the era of technology. The advancement of the technology making it easier to
work with the help of technology, it is providing opportunities to go beyond the possibilities
and achieve what we want but at the same operating such technology is complex too. This
complexity of technology sometimes may results in huge accidents or disasters. Such
accidents are hazardous for both the human beings as well as the environment. In this report
there is a complete analysis about such accidents happened in some of the plants related to
chemical industry. These accidents harmed mankind as well as the environment abruptly. To
deal with such accidents we need effective risk management and a communication plan to
mitigate these problems and use them for efficient output. For this assessment, this report is
prepared to introduce the mistakes which were resulted in form of man-made disasters in past
decades. This report provides the essential information about the different accidents took
place in past and their risk management assessment. The risk management assessment of
these accidents has shown the major causes and possible mitigating operation that could be
practice to prevent happening of such accidents in future.

ENGINEERRING RISK MANAGEMENT 2
Table of Contents
Introduction................................................................................................................................4
Risk management.......................................................................................................................5
Case study 1: Bhopal Gas Leakage (1984)................................................................................5
Cause......................................................................................................................................6
Risk management: Bhopal gas tragedy......................................................................................6
Risk assessment..........................................................................................................................8
Identification of the risk.....................................................................................................8
Assessment of the risk........................................................................................................9
Controlling the risk............................................................................................................9
Case study 2: Texas City Refinery Explosion (2005, USA)......................................................9
Causes..................................................................................................................................10
Risk management: Texas City Refinery explosion..................................................................11
Risk assessment........................................................................................................................12
Identifying the risk...............................................................................................................12
Assessment of risk................................................................................................................12
Risk controlling....................................................................................................................13
Case study 3: Deep-water Horizon Oil Disaster......................................................................13
Causes..................................................................................................................................14
Risk management of Deep-water Horizon Oil Disaster...........................................................15
Risk assessment........................................................................................................................15

ENGINEERRING RISK MANAGEMENT 3
Risk identification................................................................................................................16
Risk assessment....................................................................................................................16
Controlling the risk..............................................................................................................17
Conclusion................................................................................................................................17
References................................................................................................................................18

ENGINEERRING RISK MANAGEMENT 4
Introduction
In the world of progression, Risk has become a daily presence for individuals, they
these are or not involved in economic activities. Risk may be for the individual or sometimes
it may be for a group of people. Risks affecting higher number of people called disasters.
These disasters may be natural or man-made. In the world of science these disasters lead to
serious economic losses or casualties (Lee, Park, & Shin, 2009). These risks can be mitigated
by the use of effective risk management system for their assessment and mitigation. In this
report three case studies are discussed about their different aspects for the risk management
assessment and mitigation. Three case studies, this report is discussing, are 1) Bhopal Gas
Disaster (1984, India), 2) Texas City Refinery Explosion (2005, USA), 3) Deep Water
Horizon Oil Disaster (Gulf of Mexico 2010). All the three incidents were man-made disaster
and result of a poor management of assessment and mitigation for the risks associated with
the incidents.

ENGINEERRING RISK MANAGEMENT 5
Risk management
Risk management is a process of identifying, assessing and preparing effective
strategies for the mitigation of these possible risks associates with the respective project or
site. In the man-made disasters like “TIANJIN CHINA EXPLOSION” as discussed in the
previous assignment risk management has follow a systematic management process to avoid
such incidents. The whole process of risk management comprises of three main steps as risk
analysis, risk evaluation, and risk mitigation using proper strategy.
Figure 1 Source by Author
Case study 1: Bhopal Gas Leakage (1984)
The Bhopal gas tragedy was an industrial man-made disaster which took place on 2nd
December 1984 in the night (Mishra, et al., 2009). Uranium Corporation of India Limited, at
that time, was the subsidiary under the Union Carbide Corporation (UCC), the US company
union. This tragedy was the result of leakage of the dangerous methyl isocynate gas and other
toxic products of the plant (UCC, Bhopal Gas Tragedy Information, 2018). In this tragedy the
official immediate death report states that there were 2,259 casualties on the spot and at that
time government of Madhya Pradesh confirmed 3,787 deaths directly or indirectly related to
the incident. In 2010, after 30 years of the incident, the toxic material remains and affected
many lives. This result in leading, the population exposed to that incident, to give birth to
Risk analysis Risk
evaluation
Risk
mitigation

ENGINEERRING RISK MANAGEMENT 6
physically and mentally disable children (Taylor, 2014). Such accidents are hazardous for the
mankind and the environment as well.
Figure 2 Source by https://cdn.theatlantic.com/assets/media/img/photo/2014/12/bhopal-the-worlds-worst-industrial-
disaster-30-yea/b08_41218032/main_1200.jpg?1420576267
Cause
The incident of Bhopal gas leakage happed due to the poor risk management of the
plant. The explosion at site did not only affect the mankind but it also affected the
environment very abruptly. This environmental hazard itself is the cause of birth of
physically and mentally disabled children. The management of the plant did not follow the
standards specified for the chemical plants in such populated area. This management results
in the poor design of the gag scrubber, flare tower, and water curtain which resulted in such a
massive disaster (Narain & Bhusan, 2014). Proper assessment of the risk associated with the
plant was not done by the management therefore, the poor design of the plant elements lead
to the malfunction of hardware used in the plant.

ENGINEERRING RISK MANAGEMENT 7
Risk management: Bhopal gas tragedy
Massive gas tragedy in Bhopal was a result of the miss management of the risks, and it
is very important to predict such incidents and mitigate these using proper strategies by the
risk management of the responsible industry or organization (Singh & Ghosh, 1987). Another
set of the causes responsible for this incident were lack of information, lack of
communication, lack of awareness of toxicity of the chemicals producing in the plant and
many more (Dutta, 2017). This led us to the importance of a complex risk management to
prevent such accidents in future. The tragedy causes birth of physically and mentally disabled
children still after 33 years of the incident (ANI, 2017). Therefore, as per discussed in the
previous assignment such a hazardous chemical plant needs a proper management system to
be practiced in order to prevent such disasters. This management will assess the risks
associated with the organization or unit, and implement the required strategies for the
mitigation of such risks. This whole process can be followed by doing following things
 Formalization of all the steps to be followed in the plant so that operators do not take
any wrong decision on their own.
 From the beginning of the formulation stage the management should be open in any
approach with respect to the hazards associated with the unit and its precautions.
 Management should carry out detailed rehearsal for the emergency situations on the
hazardous facilities or operations with an active involvement of all the managers and
other members of the risk management (UCC, Cause of the Bhopal Tragedy, 2018).
 Forming the casual structure of the facilities prone to the hazardous accidents in such
a manner so that there must be number of the near misses before such a huge
consequence but these near misses must be of such kind that they can be noted easily
without any harm to the workers or people around there.

ENGINEERRING RISK MANAGEMENT 8
 Separating out the conventional management structure formed for the non-hazardous
facilities in order to maintain the high standards of the hazardous facilities
(Bowonder, 1987).
Risk assessment
Bhopal gas tragedy could be controlled or mitigated with an effective risk assessment.
This assessment required to follow three simple steps to prevent the world from such
hazardous accidents. These three steps are as:
Identification of the risk
In this assessment risk management has to identify the possibilities of the hazard that
could take place on the sire. In this process management needs to inspect the unit condition,
their stock of the hazardous material, and check the requirement for hardware repairing or
replacement (Tummala & Schoenherr, 2011). In this way the management can understand the
requirement of the chemical plant and can also find the possibility of any accident on the
basis of condition of the production plant.

ENGINEERRING RISK MANAGEMENT 9
Figure 3 Source by: Author
Assessment of the risk
On the basis of risk identification, management has to assess the risks that could be
associated with the identified possibilities. This assessment took place in the form of analysis
of all the possibilities that could be happened due to each possible accident. The assessment
of risk will provide the necessity of the precautions for further management of the risk
(Wissem, 2013).
Controlling the risk
Once the management know about the possible risk and made their assessment, it is
possible to control or mitigate the risk. When management get to know about the risk and its
possibilities, essential possible precautionary strategies must be implemented by the
management (Miller & Lessard, 2001). This strategy is defined for the precaution that need to
be taken before the accident can take place. Bhopal gas tragedy could be mitigated or
controlled to some extent, if these steps were followed by the risk management of the site.
Risk assessmentControlling the riskRisk identificatio

ENGINEERRING RISK MANAGEMENT 10
UCC finally permitted to undertake the clean-up work in year just peior to sale of its stock by
UCC in 1994 (UCC, Remediation (Clean-up) of Bhopal Plant Site, 2018).
Case study 2: Texas City Refinery Explosion (2005, USA)
The Texas City Refinery Explosion was another man-made disaster occurred on 23rd
March 2005.This time a cloud of hypercarbon vapour was ignited and exploded violently at
the isomerization process unit of the IOSM at British Petroleum’s Texas City refinery in
Texas City. In this tragedy 15 workers were killed and more than 170 people got injured also
damaged several processing units of the refinery (CSB, 2005). This refinery was the second
largest oil refinery in state and the third largest in United States (PM, 2005). The British
Petroleum had accepted the full responsibility for the hazardous explosion and made some
allowances for the victims of explosion directly or indirectly. Till October 2006, company
has settles more than 1000 lawsuits which were related to the claims made by the victims.
The accident costs the company $63,000 in fines (BBC, 2005).
Figure 4 Source by https://hips.hearstapps.com/pop.h-cdn.co/assets/cm/15/05/480x317/54c8162e2a380_-
_pmx0705wrong001a_large.jpg?resize=768:*

ENGINEERRING RISK MANAGEMENT 11
Causes
The accident happened in Texas City, could be blamed on many failures, from
hardware malfunctioning to human process. On 27th October 2005, the Chemical Safety
Board of US issued its preliminary findings at a public meeting.
 The CSB has mentioned that the accident occurred during the start-up process octane-
boosting isomerization (IOSM) unit of the refinery. During this start-up an attached
distillation tower and a blow-down drum have overfilled with the hazardous highly
inflammable liquid of hydrocarbons. This blow-down drum was vented directly to the
atmosphere which made a geyser like highly flammable liquid and vapour in the
nearby atmosphere (EWN, 2018). This vapour cloud of hydrocarbons when exposed
into the atmosphere the atmospheric temperature made an ignition to the cloud and
resulted in a series of explosions and fire.
 Board has mentioned that the alarms and gauges, which were installed to warn about
the overfilling of equipment, failed to operate properly on the day of accident (Laurel,
2013).
 In safety precautions this accident was a result of poor management and breach of the
standards set to be followed in such chemical plants or refineries.
Risk management: Texas City Refinery explosion
The explosion in Texas City Refinery was a man-made disaster, a result of poor
management and lack of communication though out the whole process (Khan & Amyotte,
Incident). The overfilling of the drums was a result of failed alarms and gauges but this
disaster could be prevented or mitigated with the help of an effective communication system
and observation skills (MacKenzie, Holmstrom, & Kaszniak, 2007). Refineries of this level
have their standards to be followed through-out the whole process of refining the crude oil.

ENGINEERRING RISK MANAGEMENT 12
An effective communication plan could have mitigated the accident. In this accident lack of
effective communication plan was the main cause responsible for the incident. The
management has to follow some essential steps to prevent this disaster as
 In this type of refinery the process must follow the chain process suggested by the
standard of chemical safety board.
 The communication system of the units isolated from each other should be effective
in order to confirm or allowing the other unit to operate or not as per the situation.
 Equipment should be repaired or replaced as per necessity, with a regular basis
inspection by the technical authorities (Mogford, 2005).
 Organizations should rehearse for such emergency situations to aware the workers
and providing the essential training required to handle such incidents.
 Organizations should provide basic skill training to the workers to observe things
independently. For example, if equipment is not working then workers or the mangers
should cross check the allowance of process and confirm the suitability to start the
process.
Risk assessment
Risk management system, responsible for such refineries or hazardous units, has to
assess the risk on prior basis. This assessment of risk, as discussed in the previous
assignment, is to be done with a proper analysis and observation skills especially in such
hazardous chemical refineries (Ceryno, Scavarda, Klinebiel, & YuzGulec, 2013). In this case
management has to use its observation skills and should analyse the starting process of unit
before its start-up. Once management got to assess possible risk associated with the start-up
process of IOSM, it could be possible to reduce the impact or the chance of accident

ENGINEERRING RISK MANAGEMENT 13
happened could be mitigated. For this assessment following steps were needed to be followed
by the risk management system.
Identifying the risk
In this step management has to analyse the complete process of any operation which is
going to take place in near future. This step will provide the required information to calculate
the possibilities of risks associated with the upcoming process.
Assessment of risk
Once the risk identified then is can assessed by the management to know its aftereffects
and its impact on the whole system of the unit. This assessment is necessary to get to know
the priorities of different risks to mitigate these. In this process at the possible action which
can prevent the accident are analysed and made to be implemented (Jovanovic, Milijic,
Dimitrova, & Mihajlovic, 2016).
Risk controlling
When risk is identified and assessed, it should be controlled with effective strategy
formation and implementation. In this case if the risk could be identified then it was possible
to prevent the accident to take place by communicating the risk to operating unit of the IOSM
operation (Shao, Yang, Tian, Ju, & Huang, 2013). Once they got to know about the problem
the start-up process could be delayed and the explosion could be prevented.
Case study 3: Deep-water Horizon Oil Disaster
Deep-water Horizon Oil Spill or we called Gulf of Mexico Oil Spill of 2010 is the
largest oil spill in the history. This disaster began on 20th April 2010, and caused an explosion
on the deep-water horizon oil rig which was located in the Gulf of Mexico. The site location

ENGINEERRING RISK MANAGEMENT 14
of the oil rig was approximately 41 miles or 66 kilometres away from the coast of Louisiana.
The Deep-water Horizon Oil Rig, owned and operated by offshore-oil-drilling company
Transocean and leased by the giant oil company British Petroleum, was situated in the
Macondo oil prospect in the Mississippi Canyon. The oil well below the site was located
4,993 feet (1,522 metre) deep in the sea and extended approximately 18,000 feet into the rock
bed. Reports suggest that the explosion was result of poor construction work of sealing the
well for later use. In this accident 11 workers were killed and 17 got injured. After two days
of spilling the oil continuously and a series of explosions, on 22nd April the rig was capsized
and sank down in the sea. After this the drilling mud has been injected through this in order
to counter the upward pressure of oil and natural gas. Before the well was sealed,
approximately 402 million barrels of oil and officials released 108 million gallon of corexit,
kind of chemical dispersant used to break up the oil, dumped into the Gulf of Mexico.
Figure 5 Source from http://www.slate.com/content/dam/slate/articles/health_and_science/Science/
2016/09/160930_SCI_explosion-rig.jpg.CROP.promovar-mediumlarge.jpg

ENGINEERRING RISK MANAGEMENT 15
Causes
Results show that the greatest effect on mental health related to the context of
disruption to participants, lives, work, family, and social engagement, with increased
symptoms of anxiety, depression, and posttraumatic stress (Osofsky, Osofsky, & Hansel,
2011). The largest Horizon Oil Spill in the history was caused due to poor construction of
recently installed concrete core by the contractor Halliburton to seal the well for later use
(Ferris, 2017). These seals are provided to the wells not in use, to prevent the later use of
them and unnecessary leakage of the gas and oil through the well opening. For the same
purpose this well was sealed using concrete core construction over the opening of the well.
The concrete construction was poor in strength to withstand the pressure of natural gas
because nitrogen gas was used, in the composing concrete work, as an admixture. This
addition of nitrogen was as an admixture results in reducing the strength of concrete which
was resulted in such a big disaster. But most of the oversights and mistakes can be
summarised as a single failure, failure of the management. An effective communication plan
could have mitigated the problem as the communication plan would take the matter or design
of concrete into other construction experts of the organization and the issue could have been
discussed and overcome by making required design changes. The accident would certainly
have prevented with a better management of BP, Transocean and Halliburton improving
skills off individual involved. This improvement was necessary to identify, evaluate, and
communicate the risk they faced. This blowout in the deep-water was not a statistical
inevitability (Anderson, et al., 2011).
Risk management of Deep-water Horizon Oil Disaster
The disaster occurred in 2010, was a result of poor risk management and poor
maintenance of the standards. Communication plan is the most important element of risk

ENGINEERRING RISK MANAGEMENT 16
management. The main cause, failure of the concrete core to withstand the pressure of natural
gas, was a lack or seriousness for the risk management. The oil rig was leased to the British
Petroleum, who previously suffered from such incidents, again made a mistake in their risk
assessment process (Vaugham, 2018).
Risk assessment
This accident could be prevented by proper quality checks of the concrete construction
on regular basis. As per discussed in the previous assignment risks associated with any
project must be assessed and an effective strategy in order to mitigate the risk at the initial
stage only.
Risk identification
MMS requires all owners of offshore oil-handling, storage, or transportation facilities to
prepare Oil Spill response plans (Anderson, et al., 2011). This requirement must be fulfilled
by the company. MMS regulations provide details for elements of response plan (for
emergency response plan, oil spill response equipment inventory, a calculation of worst-case
discharge scenario, plan for dispersant use, in0situ burning plan, etc.) (Anderson, et al.,
2011). In case of Dee-water Horizon Oil Spill Disaster, Horicon Rig management has to
operate proactively for the construction work concern. If the management could inspect the
construction work proactively they would be able to find out the risk possibilities. Therefore,
only MMS agency could not be blamed in this particular case. The agency has made certain
essential rules and regulations, now it was management’s responsibility to follow the
regulations and practice the required risk identification process (Anderson, et al., 2011).

ENGINEERRING RISK MANAGEMENT 17
Risk assessment
Risks involved in offshore oil spill rigs can be assessed in similar way as discussed in
the previous assignment of the risk management of “Tianjin China Explosion” case study of a
man-made disaster. The possibility of high pressure generation by the hyddrocarbons and
natural gas deep in the well could have blown the well seal. This must be assessed at the time
of construction designing.
Controlling the risk
BP attempted to activate the rig’s blow-out preventer (BOP), a fail-safe mechanism
which was designed to cut the channel through which oil was drawn, but unfortunately the
device malfunctioned. The forensics analysis of BOP determined that the set of blades called
blind shear arms was designed to slice through the pipe carrying oil. But it had malfunctioned
because the pipe had bent due to high pressure of rising oil and natural gas (Anderson, et al.,
2011).
Conclusion
Unlike the individual project, regional era and management are classified as new
strategies in risk management. In the era of technology, every project has involvement of
both humans and technology. This combination needs an effective synchronization in their
working operations to maintain the healthy working environment. This combination may
results in rise of the risk due to some mismatch of working strategies. This possibility of
arising risk needs to be resolved to mitigate the loss. Risks are the potential loss of life as
well as the assets. These strategies of risk management resolve the multiple uncertainties of
risk sources and their effect to prevent the mankind from such disasters. Every time, this kind
of disasters happen they cause so much loss to the life, nature, and assets. Therefore, these
accidents must be controlled with effective strategies to identify and mitigate the risks.

ENGINEERRING RISK MANAGEMENT 18

ENGINEERRING RISK MANAGEMENT 19
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ENGINEERRING RISK MANAGEMENT 20
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