If a harmful event can be predicted, it can be prevented. So was the FHS toxic spill predictable ? Yes. Here we show how.
There were three conditions that needed to be fulfilled before a spill was possible. These were -
This is a key component of Avoiding Catastrophe's method. It is known as the 'pre-mortem' technique and is widely used in a variety of contexts, among them intelligence analysis and system safety. By understanding the conditions that need to be met before a catastrophic event of this nature could take place, it provides managers with the ability to KNOW WHAT TO LOOK FOR, where to focus their attention. On this basis it is possible to identify precisely when a situation migrates from a low risk status to a high one, IN TIME to do something about it.
For a fuller illustration of how this works see the book, 'Shoot, Don't Shoot', available for download here), in particular the chapter on the Black Hawk friendly fire shootdown, where the same transition from low to high risk status occurred, and if this had been picked up by the key players then the tragedy could have been averted.
In the case of FHS, we can see how this would have applied, in real time. Here is the risk status of the plant in relation to the possibility of a toxic spill.
Real time risk management of this character is a key feature of Avoiding Catastrophe's approach. Here we can see how each of the three necessary conditions were met, one after another, on April 16th, over a period of several hours. Of the three, the first was a planned event and by following this method management would have been alerted to the change in risk status that would taken place once the test runs of the coking ovens were initiated. This would have allowed for a concentration of focus on the remaining two conditions, and the preparation of contingency plans for such a situation.
In reality, management attention was focused elsewhere and the critical decision to open up the waste water pipe to the sea was taken by contractors acting on their own, dealing with the situation as they saw fit. From their position there was little choice, the water had to go somewhere, but from a plant management perspective other options did exist and could have been put in place beforehand, alongside clear instructions to the contractors as to how the situation should be handled. The spill was both predictable and preventable.
For more on how it could have been prevented, read the full case study into the Formosa Ha Tinh from Avoiding Catastrophe. If you are interested in how this method of handling catastrophic risk could be applied in your context, or in the training programs surrounding this study, then contact us at editor@avoidingcatastrophe.com