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AVOIDING CATASTROPHE

for when failure is NOT an option

Decision making in the face of adversity - incident, emergency, and crisis management, the human factors and organisational inputs that ensure safety, mitigate risk, and minimise error

 
 
  • editor@avoidingcatastrophe.com

Formosa Ha Tinh - What Happened


Here is the timeline of the key events that led up to the toxic spill. The most important point to note is that they begin a full 8 years earlier, with probably the most critical decisions being taken in 2012. It was at this time that the possibility of poisonous chemicals from the plant being dumped out at sea was created by the illegal construction of a waste water pipe.





We can convert this timeline into the 'Scale of Harmful Events' format (see earlier posts on this) for an overview of what went wrong.


We can also combine this with our picture of the line of defences in play at FHS. This allows us to pinpoint the management failures that led to the spill.


From this it becomes clear that the critical failures took place in the design and planning phase, long before the plant became operational. This was followed by a fatal breakdown in the systems surrounding contractor management. The decision to release the waste into the sea was taken by Chinese contractors working on site, and there is good reason to believe that plant managers DID NOT KNOW that this was happening.


The key message here is that effective crisis management is not limited to the second or final lines of defence, when an incident or issue is already in play. It takes place as part of routine day to day operations. In this case there was a failure to set up reporting lines with the contractors, and also to communicate senior management's intent as to how to deal with waste water from the coking ovens should storage capacity be exceeded. This lead to the contractors making their own decisions as they saw fit, in isolation from the reporting chain at the site. This was the principal cause of the disaster.


As with all crises, it was the result of a management failure.



This material is taken from Avoiding Catastrophe's case study of the Formosa Ha Tinh toxic spill. It is also used for our training in crisis management. If you would like a copy of the full report, or wish to discuss training possibilities, contact us at editor@avoidingcatastrophe.com

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