THERE IS NO SUCH THING

AS A BLACK SWAN
PROCESS INCIDENT
Paul Amyotte, Alyssa Margeson & Amelie Chiasson
Dalhousie University, Halifax, NS, Canada

Faisal Khan & Salim Ahmed

Memorial University, St. Johns, NL, Canada

Hazards 24, Edinburgh, UK (May 7-9, 2014)

Introduction
Scope
Low probability/high consequence process
incidents
Motivation
These incidents have received considerable
attention recently in the popular and technical
literature
Objective
An examination of warning signs (or signals)
that a low probability/high consequence
process incident could occur

Hurricane Juan: once-in-a-hundred-year storm

Halifax, Nova Scotia (September 2003)

Five months later (February 2004) another

once-in-a-hundred-year storm
White Juan: 1 m of snow in 24 h

Paltrinieri et al. (2012) & Gowland (2013)

Known knowns

events we know about and for which we can plan

Known unknowns

events we can predict even if they have not

occurred yet

Unknown knowns

events that have occurred but are not

remembered (re. loss of corporate memory)

Unknown unknowns

events not yet predicted or which have been

dismissed as unrealistic

Taleb (2010)
Black swan is an event that
is not expected (an outlier)
has an extreme impact
is explainable and predictable after the fact
CPI and other examples from Mascone (2013)

terrorist attacks of Sept 11, 2001, Hurricane

Katrina, credit crisis and great recession, Gulf
of Mexico oil spill, Fukushima Daiichi nuclear
reactor meltdowns, Superstorm Sandy,

A confusing landscape!

Black swan (or unknown unknown)?

Incident
Flixborough (1974)
Bhopal (1984)

Buncefield (2005)
BP Texas City (2005)
Macondo (2010)
Fukushima (2011)

Yes
Murphy &
Conner (2012)
Murphy &
Conner(2012)

No

Gowland (2013)
Gowland (2013)
Murphy &
Murphy &
Conner (2012) Conner (2013)
Murphy &
Gowland (2013)
Conner (2012) Mannan (2013)

Buncefield
Hertfordshire, UK
Kletz (2010)

UNKNOWN KNOWN
The underlying cause of the explosion at
Buncefield was that all the people and
organizations involved in design, operations and
maintenance believed that cold petrol vapour had
never exploded in the open air. They were
unaware that such explosions had occurred in
Newark, New Jersey in 1983, Naples, Italy in
1995, St Herblain, France in 1991 and elsewhere.

Aven (2013)
Black swan an extreme event that is a

surprise relative to the present

knowledge/beliefs of person(s) to be specified
Black swan from an (A,C&U) risk perspective,
an extreme event that is a surprise relative to
the knowledge defined by the A events of the
risk assessment (an unknown unknown)

atypical accident scenario a scenario deviating

from normal expectations of unwanted events or
worst case reference scenarios, and thus not
deemed credible by common risk assessment
processes (Paltrinieri et al., 2012)

How can warning signs be detected?

Many tools available to broadly identify

hazards and accident scenarios, assess

likelihood and estimate consequences over
design life cycle

PHA, QRA, PRA, LOPA, DRA

CCPS (2012): Recognizing Catastrophic

Incident Warning Signs in the Process

Industries

integration of warning sign detection and

prevention methods into PSM system

How can we prevent low probability/

high consequence incidents?
Risk Awareness
Impediment

Improvement
Means

CCPS PSM
Concept

Cognitive
dissonance

Consistency of
behaviours & values

Commitment to
process safety

Lack of
perception of
vulnerability

Workplace appeals
Storytelling

Understanding
hazards & risks

Lack of selfefficacy

Training
Managing risks
Individual performance
standards

Conjunction
fallacy

Storytelling
Learning from
Assurance of corporate experience
memory

How can we prevent low probability/

high consequence incidents?
Inherently

safer design

Knowledge management

Information becomes knowledge when it is

interpreted by individuals and given a context
and anchored in the beliefs and commitments
of individuals. (Piirto, 2012)

Evolution of Safety Performance in the Process

Industries (Updated from Pasman & Suter, 2004;
De Rademaeker et al., 2013)
Knowledge Management/Communication

Process Safety

Safety Culture
Safety Management Systems
Management Focus on HSE
Human Error/Human Factors

Technical Safety Improvements

1960 1970 1980 1990 2000 2010

Year

Not a black swan process incident

INTERIM INVESTIGATION REPORT
CHEVRON RICHMOND REFINERY FIRE

www.csb.gov
CHEVRON RICHMOND
REFINERY
RICHMOND,
CALIFORNIA
AUGUST 6, 2012

CSB public meeting (April 19, 2013)

Poster handed out by concerned public

Far too many warning signs that are in

fact accident precursors

SAFETY
CULTURE
DAMAGE
MECHANISM
HAZARD REVIEW
Imperative to act on lessons learned from site

operations, company operations, and more broadly

from what is happening within the industry itself

results from previous corrosion inspections at Chevron

Richmond refinery
sulfidation corrosion incidents at other Chevron
refineries including El Segundo refinery
sulfidation corrosion incident and ensuing fire at BPs
Cherry Point refinery
2006 CSB Safety Bulletin on Positive Material
Verification providing further information on specific
matter of corrosion of carbon steel

A possible black swan process

incident?
14th International Symposium on Loss

Prevention and Safety Promotion in the Process

Industries, Florence, Italy (May 12-15, 2013)
Can dusts
detonate?
West
Pharmaceuticals
Kinston, NC
2003; 6 dead
(www.csb.gov)

A dust deflagration (subsonic

speed of reaction front) can occur

But a dust detonation (sonic or

supersonic speed of reaction front)?
Black swan an extreme event that is a

surprise relative to the present

knowledge/beliefs of person(s) to be
specified (Aven, 2013)
Dust detonations are not common in
industry, and the vast majority of
industrial dust explosions occur as
deflagrations (James, 2001; Exponent,
2012)

Should a dust detonation be

considered a black swan event?
Black swan from an (A,C&U) risk

perspective, an extreme event that is a

surprise relative to the knowledge
defined by the A events of the risk
assessment (an unknown unknown)
(Aven, 2013)
Detonations of combustible dust have
been shown to occur under laboratory
conditions that optimize fuel, geometry
and flow criteria for DDT

Should a dust detonation be

considered a black swan event?
Material (fuel) conditions
high reactivity
fine particle size distribution
low moisture content
ease of dispersion/entrainment
Boundary (geometry and flow) conditions
sufficient run-up distance
wide flow channel
turbulence generated by wall surface roughness
or obstacles on flow path

A practical, industrial warning sign of

post-ignition turbulence generation

A dust detonation should not always

be a surprise
These material and boundary conditions

form the basis for dust detonation warning

signs related to, for example
process safety information
risk analysis and management of change

A dust detonation is therefore a credible

scenario in, for example

long coal mine galleries (Amyotte et al., 1988)
long, wide lines as may be found in pulverized
fuel power plants (James, 2001)

Concluding Remarks
Beware of the black swan as some have warned
Move beyond the black swan excuse as others

have advised
Adopt a belief that there should be no black swan
process incidents if knowledge acquisition and
dissemination are well-managed
Continue to learn from Trevor Kletz What Went
Wrong?: Only that shall happen which has
happened, only that occur which has occurred;
There is nothing new beneath the sun [Book of
Ecclesiastes]