(#22) All the Dominoes Fall

This article was originally published in the October 2020 edition of The Chemical Engineer magazine.

As part of Marc’s work at Pre-Site Safety, the article also appears in episode 5 of the Pre-Site Podcast. You can listen along with the YouTube version below.

In the autumn of 2011, a light wind carried my father’s ashes from my fingertips into the sea. It was the cold, bitter end to a long battle waged against his post-traumatic stress. Long before alcohol claimed him, my late father had survived one of the worst process safety disasters the world has ever known. On 6 July 1988, over 20 years before his death, he was working aboard the Piper Alpha oil rig when it exploded in the North Sea. The accident killed 167 men and left just 61 survivors. Aged 25, Mark Archibald Reid jumped from a burning helipad, and succumbed to the horrors aged 48.

But it wasn’t until 30 years after the accident, when I got the chance to speak to an audience about this story, that I noticed something profound. Something beyond Piper Alpha, beyond my father, beyond me. Through the kind and captured gaze of the crowd to whom I spoke, I saw that I was filling their heads with a missing piece of the safety puzzle. My painfully personal connection to one survivor of a process safety failure has, in turn, inspired a new perspective on how we might improve safety culture in chemistry, on both small and large scales. While media and incident reports provide a focus on consequences of accidents in the short-term, we do not tend to consider the consequences in the long-term. And, in my view,the rarity of looking at the long-term moral implications of an accident might be related to what happens when you tell a young child to sacrifice one marshmallow now for the promise of two marshmallows later.

Short-term thinking is a long-term challenge

A now infamous psychology experiment at Stanford University in the 1970s asked what would become of children who could resist the urge for the instant gratification of one marshmallow immediately, and instead be rewarded with two marshmallows later. Increasingly sophisticated versions of this experiment have shown that individuals and companies who are able to think of longer-term rewards over short-term immediate gains are more successful.

In a related line of thought, consider the following options.

You can have $50 right after reading this article, or $60 next month. Which would you prefer?

You can have $50 12 months from now, or $60 13 months from now. What’s your choice?

Whatever the case, you probably found your first decision was harder than the second. Many people prefer the instantaneous reward of $50 now versus $60 in a month’s time. In the short-term, right now versus one month from now seems comparatively distant and not worth the pain of waiting. But when it comes to $50 in 12 months, or $60 in 13 months, well, you’ve waited a whole 12 months already. One more month won’t hurt, right?

Such psychological studies have revealed that longer-term thinking patterns lead to more investment in the future and reduced risk taking. On the basis of Construal-Level Theory,[1] the more distant an event is in time, the more likely it is to be viewed vaguely and abstractly. When it comes to envisaging vivid details, it’s harder for our minds to do this for distant events than for near-future events. As behavioural psychologist Dan Gilbert said about the future of humanity:

“If we are not here in 10,000 years…it is because we underestimated the odds of our future pains, and overestimated the value of our present pleasures.”

In the practice of process safety, we plan to maintain the pleasures of our work by preventing future pains. But how far in time does this gaze actually extend?

Safety tools capturing short-term effects

There are several conceptual risk-based frameworks used to understand the additive nature of events before and after a major accident. However, there is no clear framework that encourages people to look past the immediacy of the events before and after an accident. Before we get to that, let’s look at two complementary tools that, together, capture the causes and consequences surrounding the short-term timeline of a major accident.

The Swiss cheese model

Perhaps the most famous risk-based safety model for conceptualising pre-accident events is James Reason’s Swiss Cheese Model. Here, the preventative “barriers” in place to prevent an accident are represented by thin slices of cheese. The more slices of cheese, the more layers of protection we have, and the lower the risk of a major accident taking place. The holes in each layer of this conceptual cheese represent the unlikely cases in which an event could penetrate the first layer of protection and increase the risk of an accident occurring. With several slices of cheese stacked together, it should be highly unlikely for holes across all slices of cheese to align and present a clear path towards disaster (see Figure 1). It is, nonetheless, these very unlikely alignments of holes in cheese that lead to disasters like Piper Alpha, and myriad reported process safety failures that fill chemical engineering textbooks.

The Swiss Cheese Model does not necessarily assume that, if one barrier fails, all other protective barriers will fail, too. Having said this, protective barriers can fail in succession. The Swiss Cheese Model is also flexible. It is not particular to large-scale accidents and can also apply in small-scale chemical research laboratories, or in the practice of medicine. So, if holes in cheese help our understanding of events occurring before an accident, how is it we grasp what can happen after an accident? We go from layers of cheese to stacks of dominoes.

The Domino effect

The Domino Effect is used to describe cascade-style action at risk of occurring immediately after an accident. It focusses on the impact and quantifiable likelihood of secondary asset (or equipment) damage being caused by the initial accident. If the accident itself is the flick of your finger as it crashes into the first domino, the secondary damage lies in all the dominoes that fall, each colliding with the one behind itself. It’s a concept that is directly applicable to the events occurring in series after the first explosion aboard Piper Alpha. All told, four consecutive blasts engulfed the platform in under two hours. Far more recently, on 4 August 2020, the colossal ammonium nitrate explosion at a port facility in Beirut destroyed a nearby grain store and surrounding infrastructure over a 10 km radius. These examples show very clearly what can happen beyond the epicenter of a major accident.

For an example of what the aftermath looked like, see here.

Whilst the Domino Effect is a well-established theory that does an extraordinary job of assessing the risks to assets on densely-packed manufacturing sites, it does not consider the long-term moral costs of accidents, nor (in balance) was the concept designed for this purpose. Alongside shorter-term considerations framed by the Swiss Cheese Model and the Domino Effect, there is the opportunity to introduce a complementary domino-style concept that serves to stimulate a longer-term view of accidents. From the dust of my father’s remains, there is a way to provide motivation for people to make all possible protective safety arrangements, keeping the dim and distant long-term risks in the front of our minds.

The Domino Fallacy: Looking beyond the first to see the others that fall behind

The effects of an accident like Piper Alpha can carry on through time, long after the initial accident, and long after the mainstream media has moved on. The aches, the pains, the mental struggles, all fall like dominoes, one after the other, all after the first domino falls on the day of the disaster. When an accident is reported, it can be compared to looking at a domino square in the face. We can stand face-to-face with a domino and analyse the details, defects, and numbers engraved on its surface. Only by looking sideways, by peering forward beyond the immediacy of the most obvious view, can we see what happens after the first domino falls. This is what I am calling The Domino Fallacy: the tendency to forget or fail to account for the long-term moral costs of an accident whose short-term impact is clearly documented. In the case of my father, his escape from Piper Alpha was simply the first domino to fall.

Behind the newspaper-worthy details of the event lay the unheard trauma of a family life forever changed by an inferno. The educational details would only become clear over decades, not days. In an accident scenario, the other dominoes falling after the first might be the struggles of recovering from physical injury, the mental anguish of reliving the horrors, the strain placed on family and friends. Every process safety disaster has such untold stories tied to it. Accidents outside the realm of oil and gas, or large-scale chemical manufacturing are no different. In any accident, after the first domino tips over, all the dominoes fall. But are we using this point to its full potential, or are we still choosing to eat one marshmallow now rather than waiting on the reward of two later? Where can we find the substance behind the Domino Fallacy?

A broader look at chemical manufacturing disasters

The preventable disaster of Piper Alpha does not stand alone. One process safety review[2] collated 70 major accidents across 30 countries in the period 1998–2015. A broader perspective is given by the Centre for Research on the Epidemiology of Disasters (CRED).[3] Since 1901, the database has captured over 1,200 disasters involving chemical spills, fires, gas leaks, or explosions recorded worldwide. In the last decade alone, over 180 chemical-related disasters have led to the deaths of nearly 6,000 people; the number of injuries is nearly three times the fatalities. The conservative estimate of the number of people affected by those accidents stands at over 120,000. Moreover, CRED only includes disasters above a minimum threshold of people involved in a particular accident. The full picture is likely much bigger, and darker. Inside the “number affected” statistics,lie the dominoes that have fallen behind the first. These are the stories we have not read and cannot yet use in the improvement of process safety.

Lab-level safety concerns

The large-scale safety concerns in chemical manufacturing also manifest on the small scale. Whilst industrial chemistry suffers many safety challenges, these sites are generally held to a higher standard of safety practice than academic laboratories. A series of university chemistry lab incidents has highlighted challenges in lab safety culture the world over.

• In 2016, Thea Ekins Coward, a visiting student at Hawaii University lost an arm as a result of a compressed gas cylinder explosion. She had not been appropriately trained for working with such units.[2] Whilst the likely cause was thought to be static electrical ignition, an independent report cited a deep lack of safety culture as a core issue at the institution.

• In China, a hydrogen leak led to an explosion which seriously injured and subsequently killed researcher Meng Xiangjian at Tsinghua University. He was working alone. In this case, the struggle to balance research budgets with funding for adequately up-to-date and safe equipment was highlighted.[4]

• Perhaps one of the best-known cases of chemistry lab safety failure occurred in 2008, when Sheri Sanji died in a lab fire in UCLA, US. Sanji, just 23 years old, used a highly pyrophoric chemical in an unsafe manner and with insufficient protective equipment. She died in hospital from her burn injuries. Her lab supervisor was never charged, but the ten-year legal saga cost approximately US$9m in fees.[2]

But if these lab accidents each represent just the first domino to fall, what of the other dominoes now falling over the longer-term? What of Thea, whose career has been stunted by the loss of her arm? And what of Sheri and Meng’s families, who now mourn for the loss of their talented children? 20 years from now, on the same timeline as my father’s demise, what will be the last domino to fall for them?

A call to arms

Beyond the melancholy of my father’s story and the demise of Piper Alpha, there is the opportunity to show that a safety failure is far more than a single point in time. The moral impact of an accident extends over many months and years, and far beyond the reported fallout of the original event. To make use of this fact, we are challenged to overcome the temptations of short-term thinking. It’s easier to remember the past than to imagine the possible details of a grim future.

How can you bring a long-term perspective to process safety?

Further reading

1. Trope, Y and Liberman, N, Psychol. Rev., 2010, 117, 440–463, DOI: 10.1037/a0018963.

2. Reid, M, ACS Chem. Heal. Saf., 2020, 27, 88–95, DOI: 10.1021/acs.chas.9b00022 [Open Access].

3. EM-DAT, The international disasters database, https://emdat.be, (accessed 8 September 2020).

4. D. Cyranoski, Nature, 2015, DOI:10.1038/nature.2015.19066.

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