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The Risk Watch Column
By Dr Alan Waring
Most of us in Cyprus are still reeling from the shock of the Mari naval base explosion. Given the scale of the blast, deaths, injuries and damage, the gravity of the event demands a full, independent and public inquiry with a wide brief, regardless of the internal investigations that undoubtedly will be carried out. It is vital that lessons are learned and acted upon, both those specific to this particular event as well as those of a more generic nature that would also apply to other kinds of major hazard.
Accusations are already flying thick and fast and fingers of blame are being pointed, almost exclusively at senior government figures including President Christofias himself. I do not intend to join that fray. Indeed, like most of the general public, I simply do not possess enough factual information to go on.
However, I am in a position to make some general observations and suggestions for good management of such materials, based on my many years input to Major Hazards Risk Management in a variety of industries (oil & gas, petrochemicals, explosives, defence).
A Dark Satanic Mill
Some years ago, one of the world’s leading explosives manufacturers suffered two fatal explosions at different sites within a few months of each other. The company operated a number of sites in the UK, including toluene nitration plants as well as mixing and filling stations. The company was prosecuted and I was commissioned to carry out a company-wide review of its safety systems, in part so that the company could produce a defence report to the court showing that it had already learned lessons and was active in trying to improve its systems.
Among the sites I visited was a manufacturing unit in a remote coastal location in Wales. This explosives factory had been in operation for the best part of 100 years and was, by my reckoning, a place worthy of the description ‘dark satanic mill’. Nevertheless, basic lessons had been learned as the site was remote from habitation and flanked by natural blast barriers. On the one side lay the sea and to the landward side behind the factory was mountainous terrain which separated it from the nearest village. Blast banks and underground bunkers were a feature of the site.
A factory supervisor was assigned to show me round the site, operations and facilities and provide copies of their standing safety procedures and instructions. As we went round this relic of Victoriana, I casually remarked that there seemed to be more than ample car parking lots. ‘Oh no, that’s not a car park’, he answered equally casually, ‘that flattened area over there was where the Biacci filling station blew up. Two people were killed. The new one is that building on the right’. It was with some trepidation that I agreed to enter the new filling station to see the processes.
Apparently, despite metal detectors fitted to the filling hoppers, occasionally stray pieces of metal such as a bolt or a washer got through into the grinding and prilling unit before the blasting explosive was packed into sheaths for the salami-like final product and stray metal was determined to be the proximate cause of the explosion. Improved metal detectors had been fitted but was this enough, I wondered?
The Boiler Acid Patrol
Onward to one of the nitrators! These are the reactors which boil up toluene with concentrated nitric acid to produce tri-nitro toluene or TNT. As I accompanied the supervisor up to the top of the reactor, which fortunately was off-line, I was surprised to learn that he and other employees were still taking samples manually with a long-handled dip ladle. Impressions of Victoriana were now setting fast. I was so relieved to get down from that potential ’rocket launcher’ as I had no desire to be the first man on Saturn.
Mr Supervisor then looked at his watch and blithely announced that it was time for the ‘Boiler Acid Patrol’. He then explained that nitrated toluene is only stable within specific temperature and humidity limits, so it was important for regular checks to be made. The function of the Boiler Acid Patrol was to make these checks by reading thermometers and hygrometers around the site. This ritual had been going on more or less since the site had started. It was a ritual as archaic as lighting gas street lamps in Victorian times. Again, I was amazed that such manual monitoring had not been replaced by modern automatic sensors connected to alarm and shutdown systems.
When I raised these issues, the Plant Director acknowledged that the plant and many of the safety systems and procedures were outdated. However, conscious decisions had been made not to invest new money on such things, as the plant had already exceeded its useful life and was scheduled for closure. When asked what the timetable was for closure, he suggested a vague five to ten years but no actual decision had yet been made. When pressed further on how long these closure plans had been under discussion, he admitted that it was at least ten years. Meanwhile, people had been killed. I had no faith that the company had any real intention of closing this site and concluded that the archaic safety practices would continue for years and possibly decades using the rather feeble excuse of cost and ‘likely’ closure.
Lessons
From the above case, the following key principles may be drawn:
• Explosives facilities, whether manufacturing and/or storage, should be sited remotely from dwellings and other sites, especially those with major hazards of their own or which are critical to the country’s infrastructure.
• Sites should be selected that have as many natural or man-made blast barriers as possible, so as to deflect blast upwards.
• Distance and separation of inventories should be accompanied by storage units and cover that together avoid explosives ‘sweating’ or other adverse temperature/humidity effects.
• Inventories should be kept to a minimum.
• Use modern technology to monitor stability of explosive materials.
• Safety management systems, safety procedures and safety culture need to reflect the actual risks to life and limb and not be diluted to suit commercial considerations.
Fatal Assumptions
It is that last bullet point above which features so predominantly in every major hazard case I have dealt with, in all industries. One needs to remember constantly that so often competent personnel at site level are not matched by equally competent or well-motivated superiors at headquarters somewhere else. Assuming the reported allegations are true, it would appear that senior officers at the Mari naval base expressed on a number of occasions their deep concern to the Defence Ministry about the condition of the particular explosives containers but requests for improved storage were rejected on cost grounds. Further, it is alleged that offers from several friendly countries in 2009 to dispose of the materials were ignored as was a nudge from the UN.
Safety risk assessments and decisions based on them should be undertaken by competent persons at site level, with external assistance if necessary. Safety management systems and protocols at site level should take precedence over ‘political’ or other questionable considerations higher up the tree. Civil servants and politicians clearly cannot possess the technical knowledge and competence to know whether explosives are safe or not. They are prone to make naïve, and possibly fatal, assumptions.
Dr Alan Waring is an international risk management consultant with extensive experience in Europe, Asia and the Middle East with industrial, commercial and governmental clients. Contact [email protected] .
©2011 Alan Waring
