RISK MANAGMENT

Normal Accident Theory

A quick Quiz?

A Day in Your Life

·         You have an important decision meeting downtown.

·         Your spouse has already left. Unfortunately he/she left the glass coffee pot on a lit burner and it cracked.

·         You desperately need your coffee so you rummage around for an old drip coffee pot.

·         You pace back and forth waiting for the water to boil while watching the clock. After a quick cup you dash out the door.

·         You get in your car only to realize that you left your car and apartment keys inside the house.

·         That’s okay. You keep a spare house key hidden outside for just such emergencies.

The Answer----- All of the above reason, Life is a complex system

What Characterizes a Complex System?

A complex system exhibits complex interactions when it has: Unfamiliar, unplanned, or unexpected sequences which are not visible or not immediately comprehensible

Design features such as branching; feedback loops Opportunities for failures to jump across subsystem boundaries.

A complex system is tightly coupled when it has:

1.    Time-dependent processes which cannot wait

2.    Rigidly ordered processes (as in sequence A must follow B) only one path to a successful outcome very little slack (requiring precise quantities of specific resources for successful operation).

What should we do to protect against accidents or mission failure?

Safety is the primary organizational objective.

Redundancy enhances safety: duplication and overlap can make “a reliable system out of unreliable parts.” Decentralized decision-making permits prompt and flexible field level responses to surprises which might occur without notice.

A “culture of reliability” enhances safety by encouraging uniform action by operators. Strict organizational structure is in place, continuous operations, training, and simulations create and maintain a high level of system reliability.

Trial and error learning from accidents can be effective, and can be supplemented by anticipation and simulations.

Normal Accidents - The Reality

Safety is one of a number of competing objectives.

Redundancy often causes accidents. It increases interactive complexity and opaqueness and encourages risk-taking. Organizational contradiction: decentralization is needed for complexity and time dependent decisions, but centralization is needed for tightly coupled systems.

A “Culture of Reliability” is weakened by diluted accountability. Organizations cannot train for unimagined, highly dangerous, or politically unpalatable operations; denial of responsibility, faulty reporting, and reconstruction of history cripples learning efforts of future events that might have or will occur.

What Are We Doing?

Redundancy is no longer the automatic answer. Risk management planning provides alternate approaches. Program responsibility has been moved to the Centers. They are most capable to determine the appropriate level of centralized decision-making. Government’s move from oversight to insight places accountability where it belongs.

Understanding Complexity

      I.        Accident investigators generally focus on: Operator error

    II.        Faulty system design

   III.        Mechanical Failure

  IV.        Procedures

   V.        Inadequate training

  VI.        Environment (including management organization)

 VII.        Many times there is a tendency to cite “operator error” alone as the cause of an accident.

Close-Call Initiative

The Premise: Analysis of close-calls, incidents, and mishaps can be effective in identifying unforeseen complex interactions if the proper attention is applied.

Root causes of potential major accidents can be uncovered through careful analysis. Proper corrective actions for the prevention of future accidents can be then developed.

Human Factors Program Elements

1. Collect and analyze data on “close-call” incidents: Major accidents can be avoided by understanding near misses and eliminating the root cause.

2. Develop corrective actions against the identified root causes by applying human factors engineering.

3. Implement a system to provide human performance audits of critical processes -- process FMEA.

4. Organizational surveys for operator feedback.

5. Stress designs that limit system complexity and coupling.

Summary

Risk Management nominally works with the theory that accidents can be prevented through good organizational design and management. Normal accident theory suggests that in complex, tightly coupled systems, accidents are inevitable. There are many activities underway to strengthen our safety posture.

Risk Management’s new thrust in the analysis of close-calls provides insight into the unplanned and unimaginable.

BUILDING A KPI FROM AN EMPLOYERS VIEW

Key objectives of funding the project will be based on grants, non-governmental organizations and social welfare clubs that would want to impact a meaning to the lives of Africans. A grant is a great way to get a project off the ground and is possibly the best source of funding available. There is no interest to be paid and funds are generally non-returnable (except in exceptional circumstances, where grant terms and conditions are not met). Grants are often referred to as ‘free money’, but there are usually a number of strings attached; although they are the hardest to obtain but with so much flexibilities. It is hard work convincing the awarding body that you deserve such support, and a considerable amount of effort and time is involved in making an application. Grants are provided by a myriad of sources, and may come from central, regional and local government, the European Commission, or various other national and local bodies such as Regional Development Agencies, charities and community foundations.

The KPI provides the most important information that enables a stakeholder to understand if the organization is on track or not. The key performance index is based on four action plans;

a.     Act – Monitor, collect data, progress report	b.    Plan –Customer need, determine drives, define indicators
C.   Check—Develop review, collect data,                Create improve plan	D. Do—Find owners, store, prioritize

The aim is the action taken at the appropriate time which gives a satisfying success, it focus on the actions (aim of the project), get value, get success, get momentum this will give you us a path; while on the path we will collect data which needs to be analyzed this ultimately create a process; with the progress part known, then we need to understand our customer’s need. The end user of the services provided give an insight to how the quality and quantity of service defers from, clients to clients. The right drives or motivations need to be spelt out correctly so that the focus is not let out of sight. A good KPI should have room for continuous improvements on a daily basis this calls for a periodic check. The check ensures that the process is up to date; conforming to requirements, with a stated standard, reviewed quarterly and improvement added. By prioritizing, our aim is to improve reporting externally and demonstrate compliance, monitor and control by making sure that the project stated mission is in accordance with the stated standard.

For every good system there must be a method or means of measuring the project progress, the KPI serves to reduce the complex nature of organizational performance, simple homilies can easily be corrected to a small number of key indicators in order to make performance more understandable and digestible for us. It is also a good tool for monitoring people and their personal activities in the project. These could be as performance assessment, performance indicator, performance measurement, use of bench marks as against an expected outcome, added value to customer and project teams and feedback.

Most measurement tools comes with the need to show what is to be measured (from what to what), they usually comprises of work force and management, which can be calculated to meet the budget of the project, a level of improvement is visible, a communicated statue, used to connect the customer to the process, the use of bench mark to track progress, performance expectations which would be measured on a quarterly basis and immediate action to save the situation should in-case need be. The expectation of each team lead would be spelled out correctly so that each party is aware and responsible for his/her team mates. With this few key points in place the project will and effectively be control and concluded.

FISH SUPPLY AND DEMAND IN NIGERIA

Fish constitutes about 41% of the total animal protein intake by the average Nigerian hence there is great demand for fish in the country. Nigeria requires about 2.66 million metric tons of fish annually to satisfy the dietary requirement of its citizens (150 Million). Regrettably, the total aggregate domestic fish supply from all sources (capture and culture fisheries) is less than 0.7million metric tons per annum. Nigeria has to import about 0.7 million metric tons of fish valued at about $500 million annually to augment the shortfall. This massive importation of frozen fish in the country has ranked Nigeria the largest importer of frozen fish in Africa. The huge sum of money spent by Nigeria annually in fish importation could be used to invest in fish farming. Nigeria can substitute fish importation with domestic production to create jobs, reduce poverty in rural areas where 70% of the population lives and ease the balance of payments.

A review of the various food production systems reveals aquaculture (fish farming) as an important strategy in the global fight against hunger, malnutrition and poverty, particularly in the developing nations including Nigeria. Aquaculture is considered as the provider of the direly needed high quality animal protein and other essential micronutrients because of its affordability to the poorer segments of the community in addition to the provision of employment opportunities and cash income. The Food and Agriculture Organization of the United Nations (FAO) classified aquaculture as the World’s fastest growing food production sector for nearly two decades globally; the sector has shown an overall average growth rate of 11.0% per year since 1984, compared with 3.1% for terrestrial farm animal meat production. Nigeria has the capacity to attain the desired fish self‐sufficiency within a short of time if the numerous aquaculture potentials (land 1.7 million Ha and water, 14 million ha), which abound the nation is adequately utilized. These potentials are estimated at about 2.5 million metric tons of fish annually

POWERFUL PLASMA, THE HOPE OF CLEANING OUT CANCER

Beside the familiar solid, liquid and gas, matter has a fourth state: plasma, an immensely hot state of matter where electron is stripped from gas atoms. Very hot flames and lighting are made up of plasma, as are the sun and the stars. Here on earth, the field of plasma physics march forward, Marc Ramsey a PhD  research student has created a small device that creates plasma that can be studied, with results that can extrapolated to the larger scale. Cold plasma is another area of study, particularly for medical applications are created by trapping and cooling neutral atoms and then ionizing the atoms.

Fig1: Plasma Production Courtesy: Ph.D. Marc Ramsey THE LAB mechanical engineering graduate laboratory, Vanderbilt University, Nashville

Scientist at the Plasma and laser engineering institute at Old Dominion University have found that cold plasma kills cancer cell from leukemia sufferers. These streams of ionized gas are thought to trigger a self-destruct mechanism in the cancerous cells while the healthy cells remains unscathed said Mounir Laroussi, who directs the Institute. He and his researchers believe it may be possible to develop a dialysis-style treatment where the blood leukemia patient is passed through the low- temperature cancer cells.

Fig2: Plasma appears inside a common plasma lamp; the matter has many potential applications in physics and astrophysics

Leukemia is the most common childhood malignancy and accounts for approximately one out of every three cancer in children, he said. The researchers expose leukemia cells to a four-minute blast plasma. The cell died around 12hours after being treated.

Fig 3: Ph.D. Marc Ramsey’s cut out section of the high-energy-density plasma for study

Many researchers thick cold plasma produces highly reactive molecules that interact with the cells and that as the cancer cell takes up more cell up, more molecules from the blood than healthy cells, they will be more affected by the plasma than will healthy cells and will die. Cancer cell multiply rapidly and are much more likely to take up the molecules generated by the plasma.

PIPE LINE EXPLOSION: A NEW LOOK BASED ON THEORY

Perhaps the most publicized industrial accidents of recent times occurred at the nuclear reactors at Chernobyl, Three miles island, , Macondo well in the Gulf of Mexico and Oil spills in Niger Delta. They and numerous other less noted accidents share common theme. They involve accidental explosions in industrial piping systems not all the cases of pipe vandalism.

Numerous industrial explosions share several common factors: fluid transients were known to occur; trapped flammable gases were known to collect in the piping system; fluid transient sometimes cause pressures exceeding 1000psi which meet the required pressures for auto ignition of gases and explosion in piping occurred with causes that are not yet well understood.

A theory developed by Robert A. Leishear a fellow engineer and member of ASME that many explosions. The theory states that if piping contains a flammable gas and there is an inrush of fluid (or fluid transient) in to the piping, the gas can adiabatically compress to its auto ignition point( similar to a diesel engine) and then the gas, given sufficient quantity and pressure, can ignite and explode. Although further researches are required to support the theory, the safety and environment implications of this theory are significant.

Consider the accident summaries for Chernobyl, Three Mile Island and Fukushima Daiichi cite the presence of fluid transients’ plus flammable hydrogen and oxygen in the piping systems. Each of these accidents was caused by events other than explosions, but explosions were reported following accidents onsets.

At Fukushima Daiichi, loss or of reactor coolant followed flooding due to an earthquake induced tsunami. According to this theory, hydrogen and oxygen were generated in the piping through the radioactive decomposition of coolant water. A subsequent inrush of sea water used to cool the reactors could have provided conditions required to cause explosions.

How might the accident at the Macondo Well be related to explosions in nuclear reactor piping or even and oil spill? An explosion at an oil rig was accompanied by shearing of the piping near the sea floor. The new theory may provide a relationship between these seemingly disparate explosions. Flaming gases are known to contribute to fires and explosions in oil pipelines. “Swiss, run, boom” is a common refrain reported by operators describing fires and explosion on offshore rigs. If upward –traveling gas collects between two separate slugs of liquid during the transfer of oil up through a pipeline, conditions may exist to ignite the gas. One slug of liquid can lose momentum and slow down if a large gas pocket is present. The other slug of liquid may accelerate and compress the trapped gas. Depending on the volume of the gas flow rates of the two liquid slugs, auto ignition conditions may exist.

“Swish” would be the sound that would be heard if the gas in the pipeline explodes and accelerates one of the oil slugs in the pipeline up towards the drilling rig. One would have time to “run” before the “boom” occurs, which may damage undersea piping as well as the oil rig. That is the conditions to initiate observed explosions and fire was potentially present during past explosions in pipe lines.

Overall there exist certain similarities between these different explosions to be coincidence. Spills in populated areas often spread out over a wide area, destroying crops and aquaculture through contamination of the ground water and soils. People in the affected areas complain about health issues including breathing problems and skin lesions; many have lost basic human rights such as health, access to food, clean water, and an ability to work which in a way is similar to the other accidental areas although not with mutation issues.

Oil spills are a common event in Nigeria and occur due to a number of causes, including: corrosion of pipelines and tankers (accounting for 50% of all spills), sabotage (28%), and oil production operations (21%), with 1% of the spills being accounted for by inadequate or non-functional production equipment. The largest contributor to the oil spill total, corrosion of pipes and tanks, is the rupturing or leaking of production infrastructures that are described as, "very old and lack regular inspection and maintenance". A reason that corrosion accounts for such a high percentage of all spills is that as a result of the small size of the oilfields in the Niger Delta, there is an extensive network of pipelines between the fields, as well as numerous small networks of flow-lines—the narrow diameter pipes that carry oil from wellheads to flow-stations—allowing many opportunities for leaks. In onshore areas most pipelines and flow-lines are laid above ground.
 Pipelines, which have an estimate life span of about fifteen years, are old and susceptible to corrosion. Many of the pipelines are as old as twenty to twenty-five years. Most of the facilities were constructed between the 1960s and early 1980s to the then prevailing standards. SPDC [Shell Petroleum and Development Company] would not build them that way today.” Sabotage is performed primarily through what is known as "bunkering", whereby the saboteur attempts to tap the pipeline. In the process of extraction sometimes the pipeline is damaged or destroyed. Oil extracted in this manner can often be sold.
Sabotage and theft through oil siphoning has become a major issue in the Niger River Delta states as well, contributing to further environmental degradation.  Damaged lines may go unnoticed for days, and repair of the damaged pipes takes even longer. Oil siphoning has become a big business, with the stolen oil quickly making its way onto the black market . While the popularity of selling stolen oil increases, the numbers of deaths are increasing. In late December 2006 more than 200 people were killed in the Lagos region of Nigeria in an oil line explosion.

This new theory is based on the fundamental physics of fluid and gas dynamics and its consistent with explosions. Ordinarily, it is logical when pipe lines are vandalized however, with certain conditions it could be seen theoretically that fluid pressure in pipe could bring about certain burst causing oil spills and explosion.