Operational Management -AW-Q135

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Operational Risk

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The idea for this book actually began several years ago. At the time, I was asked to develop a course on risk management based on case studies of actual historical events. The intent was to examine what went wrong and to extract lessons learned from these events that could improve our quality of life today and in the future. Little did I knowwhere it might lead.
Fast forwarding to the present time, this course has evolved into a steady and popular offering on campus. Each year, cases of historical importance are researched, debated, and reconciled. Some focus on natural disasters, others on man-made accidents, and the remainder on terrorist acts. Could the incident have been prevented? Preventable or
not, what could have been done to manage the emergency response more effectively? What actions have we taken since the event occurred to make the world a safer place? Could it happen again?
These are the very same questions that confront and worry families, communities, businesses, and government officials. With media attention devoted to each catastrophe as it occurs around the globe, our anxiety
grows, our perception of various risks can become distorted, and a feeling of uncertainty pervades much of how we think and act. Somehow we must be able to sort out the most important risks we face, determine how
vulnerable we really are, and decide where our risk management resources can be most wisely used. At the same time, we must come to grips with the notion that some risks are simply beyond our control or ix are too small to warrant priority attention. In such circumstances, we must learn to become more tolerant of those risks.
Learning from real-world case studies is important and often overlooked.By examining disasters through a retrospective lens, we have a complete history of the event to review and interpret. Hindsight reveals
much about the cause, impact, and ripple effect, allowing us to judge how likely it is that history could repeat itself. By going ‘‘back to the future,’’this process enables us to prepare for a better tomorrow.
This book contains many of my favorite case studies. Undoubtedly,you will be familiar with some of them, although perhaps not the important details. They have been carefully selected to cover all three hazard types (man-made accidents, terrorist acts, and natural disasters),in a variety of scenarios across many different industries and environments,both in the United States and abroad.
When you have finished reading, it is my hope that you no longer feel hostage to the anxiety and uncertainty that is limiting our quality of life. My aim is to show that risks can be successfully managed—it is just a matter of dealing with risks in the right way. And you can do your part.As in any endeavor of this scale, this work would not have been possible without the assistance of many others. I am particularly appreciative of the students at Vanderbilt University who have participated in the riskmanagement class and the encouragement of my colleagues for recognizing
the importance of this topic. Special thanks, however, goes to Dr.Derek Bryant, whose dedicated and tireless research formed the basis of the case study narratives. I am also appreciative of his assistance in formalizing the book manuscript. In addition, I would like to acknowledge the support and encouragement of Sheck Cho at John Wiley&Sons, Inc. Finally, the importance of family in motivating an author to dedicate the time and energy it takes to write a book cannot be understated. For me, the daily interactions with Susan, Alyssa, Kendra, and Jason kept me
on an even keel throughout the project. Mom, your confidence in me has been a constant from as far back as I can remember. And Dad, thanks for inspiring me to become a teacher and for instilling in me such important
life values. I can only hope that I am living up to them.

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It seems like every time we turn on the news, a disaster has occurred.A tornado has touched down creating a swath of destruction, a chemical explosion is spewing toxic fumes into the air, an earthquake has crippled a populated area, wildfires are burning out of control, terrorists have attacked a major public transportation system, a hurricane is
ravaging the coastline, buildings are collapsing, ships are sinking. And the list goes on.
Why do these disasters happen? With all of our knowledge, skill,and technology, why can’t we do something to prevent them or at least keep them from causing such devastation? The more that we ask this question without a good explanation, the more frustrated and fearful we become of the world we live in. This situation has generated so
much uncertainty and anxiety in today’s society that our concern for these events seriously affects the way we think and act. It is truly unfortunate . . . and unnecessary.
Disasters come in many different forms, which can be conveniently organized into three groups. Man-made accidents are the result of human action or inaction that starts a chain of events leading to a catastrophic outcome. These errors in judgment are not considered intentional or malicious. However, terrorist acts are conscious actions
made by people with purposeful and destructive intent. These acts are typically well planned, with a specific target in mind, directed at causing 1.
heavy casualties and creating mass hysteria. Natural disasters, which make up the third category, are considered acts of God, the cause of which is beyond human control. Most natural disasters ultimately can be attributed to weather patterns or movements of the earth’s crust.Although humans are not responsible for the occurrence of natural
disasters, we can have a profound impact on the severity of the consequences.
While these disaster groups may seem quite different, when one takes a closer look at how these events evolve, there is remarkable similarity. That is to say, there emerges a pattern or ‘‘recipe’’ for disaster. The question that then arises is: What are the ingredients to this recipe, and how do they mix together to form such a lethal outcome?
Each ingredient can be thought of as an underlying risk factor that,when present, alone or in combination with other risk factors, erodes into a margin of safety that we normally try to build into our lives. Once that margin of safety is compromised, however, the situation is free to unravel to epic proportions.
I consider there to be 10 basic risk factors
1. Design and construction flaws. Major facilities, such as power plant , skyscrapers, refineries, and ships, are built according to detailed blueprints, otherwise known as design specifications.These specifications are based on engineering analyses that focus on designing the structure to withstand the forces that will be imposed on it, such as load, wind, vibration, puncture, or blast. If there is a flaw in the design process and it is not discovered in
time, when those forces are applied to the structure, it will be prone to failure. This failure can lead to a partial or complete collapse of the facility.
Even when the design specification is valid, problems still can arise if the materials used to fabricate the building components are faulty or the components are not assembled properly. In either case, the integrity of the structure is compromised, making it susceptible to failure, with outcomes similar to those that occur.
2 Operational Risk Management
when a design flaw is present. Because of the close relationship between design and construction, it is not uncommon in a structural failure for opposing sides to argue whether the fault rests with a flaw in the design or in the construction.

2. Deferred maintenance. In the helter-skelter of trying to keep an operation up and running, discovery of a mechanical problem spurs a debate on whether to shut down the operation and fix the problem immediately, or to keep going and make the repair at a more convenient time. This is a judgment call, where the risk of deferring maintenance is weighed against the benefit of maintaining continuous operations. In these instances, it is human nature
to choose to deal with problems at a later time, especially if the system is not actually malfunctioning.
Unfortunately, decisions to defer maintenance often lead to the failure of a key system component before the repair can be made, causing a serious accident to occur. Moreover, within a culture where maintenance problems are customarily deferred, the situation is ripe for multiple component failures, allowing the consequences of the ensuing
accident to propagate and intensify.
3. Economic pressures. As might be expected, one of the more common risk factors involves money. Whether exploring space,building a major facility, moving large quantities of cargo, or protecting a community from natural disasters, one is always dealing with a limited amount of available funding. Therefore,resources must be invested wisely. When a budget is too tight or spending is not controlled adequately, pressure intensifies to implement strict cost-cutting measures. This can translate into shoddy workmanship, purchasing lower-quality materials, eliminating the use of backup operating and safety equipment, or ignoring problems that arise. While economic pressures alone are
rarely considered a root cause, they often serve as a catalyst for causing human errors that initiate a disastrous event.
4. Schedule constraints. Economic pressures and schedule constraints often go hand in hand as risk factors, as evidenced by the Why Do Disasters Happen? 3 phrase ‘‘Time is money.’’ When a deadline has been imposed, and the project or operation has fallen behind, pressure to make up ground can cause the responsible party to cast a blind eye toward important details. Often this situation leads to the elimination of critical tasks, trying to accomplish tasks in parallel that should be done in sequence, or not pursuing certain considerations in sufficient depth to fully understand their impact on safety. As in the case of economic pressure, schedule constraints are considered a catalyst for committing errors in judgment that can lead to a destructive outcome.
5. Inadequate training. Most tasks in today’s world have been made more complicated by the complexity of the technology being used and the highly integrated nature of various systems.Consequently, the performance of many important functions requires an individual to be highly trained. At the same time,some organizations view training as a burden because it can be costly to perform and because employees are not being productive while participating in a training program. This shortsighted perspective can place in positions of responsibility individuals whose lack of training causes them to make a mistake that either initiates an accident or allows a crisis situation to intensify.
Problems with inadequate training go beyond the time when an individual first joins an organization. When there are personnel shortages, individuals may be thrown into an important decisionmaking role while covering for others, performing a function for which they were not properly trained. Because individuals tend to forget what they were originally taught and because processes change over time and require new learning, lack of retraining can
also be a problem.
6. Not following procedures. Most organizations have well-defined procedures for how employees should perform a task or function.These procedures are often documented and made available during training and for reference purposes when individuals are on the job. Moreover, job supervisors have as one of their duties to ensure that each employee is following standard procedures. Surprisingly,procedural errors are a frequent root cause of failure.When engaged in a repetitive activity, complacency can set in, and individuals tend to drift away from following a strict protocol.
Consequently, they either neglect to perform certain steps or invent other ways to accomplish the same task, often not considering the ramifications of their actions on safety. Failing to follow procedure can create a hazardous situation, one that is exacerbated by coworkers whose actions are based on assuming that those procedures are being followed.
7. Lack of planning and preparedness. Planning and preparedness make up a proactive effort focused on applying resources in advance of an undesirable event to improve understanding and response to the threats with the greatest potential to cause serious harm. Depending on the nature of the threat, attention can be directed at preventing an undesirable event from occurring, mitigating the consequences of an event once it has occurred, or both.
Planning and preparedness activities include the gathering of knowledge (intelligence), assessment of the likelihood and consequence of various disaster scenarios, evaluation of alternative risk reduction strategies, and conduct of exercises and drills to determine the effectiveness of ongoing efforts and maintain a
state of readiness.
Unfortunately, lack of planning and preparedness is evident in virtually every catastrophe recorded in history. Because of the luxury of time and the fact that a disastrous event may not have been experienced in recent memory, people tend to place a low priority on making the effort and spending the resources to be adequately prepared for a crisis situation. All too often, little forethought is given to the variety of disaster scenarios that could
occur, the magnitude and impact of these events are underestimated if the scenario is considered, or the ability of the response community to handle mass casualty situations is overestimated.
Why Do Disasters Happen?

Even in circumstances where significant effort has been devoted to planning and preparedness, the product of this effort can be a written plan that is not practiced or updated, rendering it of little value when a calamity arises.
8. Communication failure. This risk factor also is present in nearly every historical disaster, contributing to either the cause or the consequence of the event. Communication failures can occur at various stages, altering an outcome in different ways. One common form of communication failure occurs between members of the same organization. In this instance, critical information is not shared, such as when one group decides to shut down a critical
protection system for maintenance while another group is carrying out a dangerous experiment. Poor communication between organizations is also problematic. A typical scenario is two agencies engaged in a response effort, each of which is unaware of what the other is doing. Finally, lack of communication with the public or the provision of inaccurate information can place people at risk either because they do not know the hazards they are facing or because they are not properly advised on how to protect themselves.



We live in a society in which technology has provided significant lifestyle improvements that consumers have come to demand as necessities. Our dependence on electric power, advanced telecommunications,household goods, transportation, and other amenities has put considerable pressure on the economy to manufacture large quantities of product in a timely and economical fashion. Beyond this, the human race is not easily satisfied with the status quo, preferring instead to push the technology envelope toward bigger and better things, and doing it sooner rather than later. Whether putting men and women in space,erecting the tallest building, or constructing the largest vessel, we often
forgo our common sense in pursuit of these endeavors.

It should therefore come as no surprise that history is filled with disasters of an accidental nature caused by human error. Some of these mistakes were specific in nature, attributed to a single individual who ‘‘fell asleep at the wheel.’’ In other cases, the fault rests more with an entire organization, where a sloppy culture fostered a breeding ground for poor decisions. Sometimes the problem began by neglecting to examine a minute detail, which became a catalyst in unleashing a chain of destructive events. In other circumstances, the opportunity for tragedy
was painstakingly clear and evident to many.

The five cases you will read about in this part involve accidental disasters that have occurred in a variety of disciplines, covering the construction,nuclear, chemical, transportation, and space industries. In one instance, separate tragedies occurred several years apart, due to similar causes. All of these events were considered preventable, and some were met with such public scrutiny that the perception of safety in certain industries continues to suffer to this day, even though the events took place decades ago.

Atea dance hosted in the atrium of the Hyatt Regency Hotel in Kansas City on July 17, 1981, ended in tragedy when the secondand fourth-floor skywalks collapsed onto a crowded dance floor, leaving 114 people dead and another 216 injured. Flaws in a simple design change made to a support mechanism went unnoticed, allowing the
skywalk to buckle at the worst possible moment. The Hyatt Regency hotel opened its doors in Kansas City in July of
1980. A facility over four years and $50 million in the making, the building stood 45 stories and 500 feet tall, occupying a prominent position on the city skyline. The most notable of its eye-catching design elements
was a 60-foot, four-story glass atrium lobby, crossed by three skywalks, one each on the second, third, and fourth floors. On a summer night in 1981, the beauty of these features would be all but forgotten, as two of the skywalks crashed to the floor in one of the worst structural failures in U.S. history.

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