Wednesday, April 24, 2013

Uncovering the unknown

The Chemical Engineer, March 2013 by Richard Gowland

The European Process Safety Centre (EPSC) has been looking at events such as BP Texas City, Buncefield and Fukushima in or to determine whether they were so unusual that they "somehow escaped the risk management process of the responsible operators."  They concluded that there is a problem because scenarios are often considered to be impossible or very unlikely when assessing risk, yet after the event we find that there was information available that could have shown the accident was credible.

The work carried out has identified four categories of events as follows:
* Known knowns
* Known unknowns
* Unknown knowns
* Unknown unknowns

We know we have processes that can be effective at capturing the first two of these, including Process Hazard Reviews (PHR) and Hazard and Operability (HAZOP), but unless we can also address the unknown knowns/unknowns we will continue to experience accidents like the ones mentioned at the start.

The paper concludes that actually there are very few unknown unknowns and hence we need to work harder and be more creative when identifying hazards and assessing risks.  As a minimum we need to:

* make sure we address steady state situations comprehensively with a range of 'what if' analysis;
* cover non-steady state situations (particularly start-up and shutdown) with the same rigour, whether that involves using HAZOP or a complementary approach;
* consider worst case scenarios at a very early stage of our analysis.

"There is also much to be gained from critical task analysis and human error analysis in predicting atypical events and managing them better.  They should exploit the 'known knowns,' 'known unknowns,' and 'unknown knowns;' and use a creative approach to imagine the 'unknown unknowns,' which can be studied with 'bow-tie' analysis and perhaps, controversially, a 'reverse HAZOP' where we start with the worst-case consequence and work out what can initiate or fail for the full impact to be realised."

Friday, April 19, 2013

Sat-nav mix up leaves pupils in Towyn not Tywyn

BBC Website 19 April 2013

A sat-nav mix up left a coach load of school pupils almost 80 miles from home after a trip to Paris.
The children from Tywyn, on the west coast of Wales in Gwynedd, ended up a couple of hours away at Towyn, on the north Wales coast near Rhyl.

The coach firm said the driver inputted the wrong place in his sat-nav.

Ysgol Uwchradd Tywyn head teacher Helen Lewis said the mistake was common, with deliveries sometimes wrongly sent to Towyn.

The 37 children, aged 11 to 14, had spent three nights in the French capital and were heading home overnight.
Louise Hughes Parent and governor

Pupils woke up after the 13-hour journey and phoned parents to say they were in the wrong town.
Ms Lewis said: "The driver, when he was told Tywyn, had made the incorrect assumption it was Towyn.
"It is something that happens a lot here although it is the first time we had a group of pupils end up in the wrong place.

"We have had deliveries wrongly sent to Towyn.

"The children were tired because it was a long journey anyway so the extra couple of hours wouldn't have made a difference. They'd had a brilliant time."

It is thought the mistake happened after the coach had changed drivers at Shrewsbury.
Some parents were said to be angry about the incident but others were less concerned.

Gwynedd councillor Louise Hughes, a school governor whose daughter was on the trip, said: "I wouldn't want anyone to lose their job over this - that would be an over-reaction.

"The main thing is they all got back safely.

"Delivery drivers make the same mistake and people ring saying 'we can't find you, we're in Towyn'. It happens all the time."

Monday, April 08, 2013

10 Very Costly Typos

Mental Floss by Jennifer Wood on 8 April 2013


The damage: $80 million
A single dash led to absolute failure for NASA in 1962 in the case of Mariner 1, America’s first interplanetary probe. The mission was simple: get up close and personal with close neighbor Venus. But a single missing hyphen in the coding used to set trajectory and speed caused the craft to explode just minutes after takeoff.


The damage: $502,996
A missing ‘P’ cost one sloppy (and we’d have to surmise ill-informed) eBay seller more than half-a-mill on the 150-year-old beer he was auctioning. Few collectors knew a bottle of Allsopp’s Arctic Ale was up for bid, because it was listed as a bottle of Allsop’s Arctic Ale. One eagle-eyed bidder came across the rare booze, purchased it for $304, then immediately re-sold it for $503,300.


The damage: $4590 (and eternal damnation)
In 1631, London’s Baker Book House rewrote the 10 Commandments when a missing word in the seventh directive declared, “Thou shalt commit adultery.” Parliament declared that all erroneous copies of the Good Book—which came to be known as “The Wicked Bible”—be destroyed and fined the London publisher 3000 pounds.


The damage: $20,000
An unfortunate blunder in The Pasta Bible, published by Penguin Australia in 2010, recommended seasoning of tagliatelle with sardines and prosciutto with “salt and freshly ground black people.” Though no recall was made of the books already in circulation, the printer quickly destroyed all 7000 remaining copies in its inventory.


The damage: $175 million
Online trading was still in its relative infancy in 1994, a fact Juan Pablo Davila will never forget. It all started when the former copper trader—who was employed by Chile’s government-owned company Codelco—mistakenly bought stock he was trying to sell. After realizing the error, he went on a bit of a trading rampage—buying and selling enough stock that, by day’s end, he had cost the company/country $175 million. Davila was, of course, fired. And Codelco ended up filing suit against Merrill Lynch, alleging that the brokerage allowed Davila to make unauthorized trades. Merrill coughed up $25 million to settle the dispute—but not before a new word entered the popular lexicon: davilar, a verb used to indicate a screw-up of epic magnitude.


The damage: $340 million
In December 2005, Japan’s Mizuho Securities introduced a new member to its portfolio of offerings, a recruitment company called J-Com Co., nicely priced at 610,000 yen per share. Less than a year later, one of the company’s traders made more than a simple boo-boo when he sold 610,000 shares at one yen apiece. No amount of pleading to the Tokyo Stock Exchange could reverse the error.


The damage: $50 million (or $250,000 in Walmart dollars)
In 2007, a New Mexico car dealership mailed out 50,000 scratch tickets, one of which would reveal a $1000 cash prize. But Atlanta-based Force Events Direct Marketing Company mistakenly upped the ante when they printed said scratch tickets, making every one of them a grand-prize winner, for a grand payout of $50 million. Unable to honor the debt, the dealership instead offered a $5 Walmart gift certificate for every winning ticket.


The damage: $1.4 million
In 2006, New York City comptroller William Thompson admitted that a typo—an extra letter, to be precise—caused its accounting software to misinterpret a document, leading the city’s Department of Education to double its transportation spending (shelling out $2.8 million instead of $1.4 million).


The damage: $500,000
New York City’s Transportation Authority had to recall 160,000 maps and posters that announced the recent hike for the minimum amount put on pay-per-ride cards from $4.50 to $5.00. The problem? A typographical error that listed the “new” price as $4.50.


The damage: $10 million (plus $230 per month)
Banner Travel Services, California-based travel agency decided, to market its services in the phone book ... only to find that the final printing advertised its specialization in exotic destinations as a forte in “erotic” destinations. The typo certainly piqued the interest of some new customers, just not the kind of clientele the company was hoping to attract. The printer offered to waive its $230 monthly listing fee, but Banner sued for $10 million anyway.

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