Big disasters
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Big disasters
- 1. Big Disasters Learn how to Fail from World’s Top Experts Gwen Shapira, Senior Consultant
- 2. Lessons from Really Big Disasters. © 2012 – Pythian
- 3. Swiss Cheese Model “For a catastrophic error to occur, the holes need to align for each step in the process.” Sometimes this is the right models. Other times the causes are fairly simple. Sometimes there is a “Swiss Cheese Illusion” – Many theories about cause make it seem like there are many causes. © 2012 – Pythian
- 4. 1986 was a Bad Year © 2012 – Pythian
- 5. Chernobyl © 2012 – Pythian
- 6. Sequence of Events 1. Critical test planned for day shift 2. Gradual shutdown initiated before day shift 3. Test delayed and re-starts at 11PM 4. Night shift took over, with no time to prepare 5. Due to mistake, power dropped too low for the test 6. Attempt to restore power 7. Unstable core temperature and coolant flow 8. Lots of alarms and emergency signals 9. No control rods, coolant close to boiling. 10. … and the test began! © 2012 – Pythian
- 7. More events… 1. Turbines shut down and Diesel engines started 2. Decreased water flow, increased vapors 3. Which causes a positive feedback loop in this reactor 4. More steam -> more power -> more heat -> more steam 5. Automatic system inserting control rods 6. Emergency shutdown initiated 7. All rods inserted. Displacing some fluid 8. Massive power spike and first explosion © 2012 – Pythian
- 8. And there is more! 1. Some rods broke and blocked. 2. Rise in power, increased temperature, steam buildup 3. Last reading on control panel – 30GW output 4. Probably steam explosion 5. Destroying reactor casing and 2000 ton upper plate 6. Total water loss caused even higher power output 7. Another explosion 8. Dispersing radioactive material. 9. Graphite fire burning by now 10. Inaccurate dosimeters indicate reactor is still working © 2012 – Pythian
- 9. Causes • Bypass of many procedures • Operator errors • Operator lack of training • Operator lack of experience • Non-intuitive reactor design • Dangerous reactor design • Non-compliance with standards • Total belief in in-accurate monitors • Disabled safety features © 2012 – Pythian
- 10. Challenger © 2012 – Pythian
- 11. Sequence of Events • Destroyed on minute two of tenth mission • Flame leaked from SRB to external fuel tank • Damage to tank caused released of hydrogen • Pushing hydrogen tank into liquid oxygen tank • Resulting in massive explosion • Caused by O-Ring Failure • Due to unusually low temperatures during lift-off © 2012 – Pythian
- 12. Causes • NASA organizational culture and decision making are key cause • Problem with O-Ring was known • Disregarded warnings from engineers • O-Ring not certified for low temperatures • No test data for these conditions • Customer intimidation • Lack of clarity in information presentation © 2012 – Pythian
- 13. K219 © 2012 – Pythian
- 14. Sequence of Events • K219 was patrolling near Bermuda • Seal in missile hatch failed and water went in • Causing poison gas, explosion, fire and war-head ejection • One missile hatch was already disabled • Vessel surfaced. Nuclear reactors shut down. • One seaman died while securing reactor • Towing attempts unsuccessful • Poison gas leaks • Captain evacuates ship against orders • Submarine sunk. Maybe on purpose. © 2012 – Pythian
- 15. Admiral Nakhimov © 2012 – Pythian
- 16. Sequence of Events • Passenger ship • Minutes into voyage, pilot noticed collision course with bulk carrier • Radioed warning. • Answer: “Don’t worry. We will take care of everything”. • Carrier didn’t take care of anything • Kept radioing the carrier • Eventually both carrier and Admiral Nakhimov changed course. Hard. • Too late. • Unofficial root cause: Both captains were drunk. © 2012 – Pythian
- 17. Mikhail Lermontov © 2012 – Pythian
- 18. Sequence of Events • Left Picton, Australia toward Marlborough Sounds • Experienced Australian Captain… • …Who believed Cape Jackson was twice its real width • And that there are no dangerous rocks • And that he doesn’t need a chart • So he made last minute decision to go through the passage • Despite advice from officers • Hit rocks, water poured in. • Ship was beached and eventually sank from damage • One crew member died. Passengers rescued. © 2012 – Pythian
- 19. Ufa © 2012 – Pythian
- 20. Sequence of Events • Engineers noticed drop of pressure in gas pipeline • To solve the problem, pressure was increased • No additional checks or analysis was done • Leaked gas formed a flammable cloud • Ignited by two passenger trains passing through • Estimated explosion of 200 to 10,000 tons of TNT • 575 dead, 800 injured • Monitoring by “Robot Pigs” was added after the disaster to detect leaks. © 2012 – Pythian
- 21. Bhopal © 2012 – Pythian
- 22. Sequence of Events • History of leaks in plant since 1979. Many events 1982- 1984. • Warning by engineers never reached management • Safety systems not functioning • Tank contained more MIC than regulation allowed • During night, water entered the tank • Exothermic reaction. • Pressure was vented • Releasing poison gas • No consensus on how water entered the tank © 2012 – Pythian
- 23. Top Tips to Avoid Disasters 1. Avoid being the USSR 2. Communicate. Over-communicate. 3. If your engineers say there is a problem – There is a problem. 4. Fix all issues ASAP 5. Never ignore “almost accidents” 6. Never ignore monitors 7. Always troubleshoot 8. Follow processes and procedures 9. Escalate to the most qualified employees ASAP 10. Have a DR plan. Many of them. © 2012 – Pythian
- 24. Thank you and Q&A To contact us… sales@pythian.com 1-866-PYTHIAN To follow us… http://www.pythian.com/news/ http://www.facebook.com/pages/The-Pythian-Group/ http://twitter.com/pythian http://www.linkedin.com/company/pythian © 2012 – Pythian
Editor's Notes
- Disaster bingo?
- There was no time to launch the lifeboats. Hundreds of people dived into the oily water, clinging to lifejackets, barrels and pieces of debris.The Admiral Nakhimov sank in only seven minutes. Rescue ships began arriving just 10 minutes after the ship went down. It determined that both Captain Markov of the Admiral Nakhimov and Captain Tkachenko of the PyotrVasev had violated navigational safety rules. Despite repeated orders to let the Admiral Nakhimov pass, Tkachenko refused to slow his ship and only reported the accident 40 minutes after it occurred. Captain Markov was absent from the bridge. The inquiry took place in 1987 in Odessa. Both Captains Markov and Tkachenko were found guilty of criminal negligence and sentenced to 15 years in prison. Both were released in 1992.
- At 5.37 pm, travelling at 15 knots, Mikhail Lermontov struck rocks about 5.5 metres (18 feet) below the waterline on her port side. Water poured up into the decks, and the seriously damaged ship limped towards Port Gore. Jamison hoped he could beach the ship to stop it floating out to sea.Jamison beached Mikhail Lermontov successfully, but lowering the anchors to keep her there was impossible as the electricity in the ship had failed. As a result, the ship drifted into deeper waters. Water-tight doors were broken open by the pressure of the sea water gushing into the ship. Mikhail Lermontov was doomed.The passengers were put onto several ships in the area, including the LPG tanker, MV Tarihiko, (Capt Reedman) and the SeaRail road-rail ferry Arahura (Capt John Brew). By 8.30 pm, many passengers were being loaded on to these rescue ships of their own accord, but the Russian crew refused to disembark.As darkness set in, Wellington Radio ordered all passengers to disembark as MS Mikhail Lermontov listed further to starboard. Within 20 minutes of the last passenger being rescued, the ship had disappeared completely. Crew member PavelZagladimov died, while 11 of those rescued had minor injuries.[5]
- The Ufa train disaster was an explosion on the Kuybyshev Railway on June 4, 1989 at 1:15 (local time) in the Soviet Union, about 50 kilometers from the city of Ufa. It was the most deadly railway accident in Soviet history. Both trains were carrying many children: one was returning from a holiday vacation on the Black Sea and the other was taking children there
- 1984. Poison gasses leaked from pesticide plant in India. Spreading over the nearby towns. Around 3000
- Factors leading to the magnitude of the gas leak mainly included problems such as; storing MIC in large tanks and filling beyond recommended levels, poor maintenance after the plant ceased MIC production at the end of 1984, failure of several safety systems due to poor maintenance, and safety systems being switched off to save money— including the MIC tank refrigeration system which could have mitigated the disaster severity The situation was worsened by the mushrooming of slums in the vicinity of the plant, non-existent catastrophe plans, and shortcomings in health care and socio-economic rehabilitation.[5]Workers cleaned pipelines with water and claimed that they were not told to isolate the tank with a pipe slip-blind plate. Owing of this, and the poor maintenance, the workers considered that water might have accidentally entered the tank.UCC believed that a "disgruntled worker" deliberately connected a hose to a pressure gauge connection and was the real cause.[5][17]