In the 2012 June issue of Hydrocarbon Processing, our readers will find a highly informative article that should remind equipment specialists of their professional and ethical responsibilities. These professionals have the responsibility to detect, question and resolve repeat failure events. Human lives may be at stake.
Fig. 1 is a fitting reminder that pumps were involved in the still incomprehensible Bhopal tragedy. The event occured due to serious equipment reliability issues. Erroneous decisions were made in the interest of coping with, and circumventing, a chronic machinery reliability problem. These decisions included devising alternative operating strategies that introduced unknown and potentially unacceptable hazards.
Creative alternative operating strategies (process optimization steps) may seem justified in the interest of confronting legitimate personal safety concerns. However, their impact on process safety can be disastrous. Focusing instead on resolving equipment reliability defects often makes it possible to eliminate risk-inducing components or elements. Unswerving focus, early remedial action and zero tolerance for unexplained repeat failures of rotating machinery are the most valuable safeguards against a potentially devastating sequence of events.
In the June article The Bhopal disaster, two experienced co-authors apply objective investigation principles, using only information in the public domain. They place before us the exceedingly well-documented sequence of events that preceded this disaster and/or followed in the wake of several process-related decisions.
Engineers should have a questioning attitude, and they should demand from themselves the same conduct expected from the medical profession. All must offer authoritative advice, concern for everyone and complete candor. Meeting this mutual expectation is especially important when there are edicts to purchase from the lowest bidder. Engineers should stand firm in demanding to buy from the lowest bidder that also fully meets responsibly written specification requirements. Needless to say, one of the engineers primary roles must be to write such specifications. That further implies that the engineers avail themselves of all reasonable post-graduation training opportunities. It also implies that they should never become a party to withholding information from the ultimate equipment users.
So, we believe that engineering schools and their industry-training conference adjuncts should make it their business to teach about the sequence of events that resulted in one of the worst industrial disasters in history. The next generations of engineers must be trained in the importance of good engineering judgment.
| A graphic reminder of the most tragic loss of life |
in the history of process plants. Source: Bhopal
Medical Appeal, www.bhopal.org, used with
English critic, essayist and reformer John Ruskin (18191900) knew what would happen if one blindly purchases from the lowest bidder. He stated basic principles and phrased them in common-sense language long before the business schools of the late 20th and early 21st centuries began dispensing their often misguided and also widely misinterpreted and rarely contested wisdoms. Paraphrasing Ruskin:
It is unwise to pay too much, but is worse to pay too little. When you pay too much, you lose a little moneythat is all. When you pay too little, you sometimes lose everything, because the thing you bought was incapable of doing the thing it was bought to do ... The common law of business balance prohibits paying a little and getting a lotit cannot be done. If you deal with the lowest bidder, it is well to add something for the risk you run, and if you do that, you will have enough to pay for something better.
There is no way that John Ruskin could have foreseen the events in Bhopal on Dec. 3, 1984. Bhopal was an unmitigated disaster that involved disregarding warning signs, disabling critical safeguards and permitting normalization of deviances. The record shows deviations of huge consequences, including choices in materials technology and pump component selection. As modern industry benefits from examining the many historical facts relating to process safety failures, it should be noted that process safety trumps all manner of process optimization.
About the Bhopal article, it simply and convincingly makes use of material that is now freely available in the public domain. The topic will be fully appreciated by those professionals who, by virtue of seeing it as their responsibility to avoid similar incidents, draw the right conclusions and take advantage of the information presented. HP
|The author |
Heinz P. Bloch is Hydrocarbon Processings Reliability/Equipment Editor. He greatly elaborates on avoiding repeat failures in his 18th and most recent book, Pump Wisdom: Problem Solving for Operators and Specialists, John Wiley & Sons, Hoboken, New Jersey, 2011.