I. INTRODUCTION II. THE PERFECT STORM A. Natural Accidents B. Climate Change C. Industrial Terrorism III. DUELING PARADIGMS: MANAGEMENT VS. PREVENTION A. Implementing the Dominant Paradigm B. Inherently Safer Design IV. ADAPTATION: INTEGRATION OF ISD V. CONCLUSION I. INTRODUCTION A Category four hurricane is bearing down upon the Gulf Coast. Managers at the Trident Oil refinery in Pascagoula, Mississippi, invoke shutdown procedures three days prior to expected landfall. All crude oil, sulfuric acid, hydrofluoric acid, and other hazardous materials are drained from the process units and the nearby storage tanks and pumped to a more distant emergency storage area at the facility. Most equipment is shut down, although some steam boilers, power generating units, and cooling systems continue to run in order to maintain temperature and pressure in tanks and to support safety devices. A skeleton crew remains at the facility to deal with emergencies and to restart the facility after the storm passes. The storm arrives, lashing the plant with thick sheets of rain and howling 125 mile per hour winds. Heavy rains have overwhelmed the storm water drains throughout the plant, flooding various buildings. The automatic monitoring system associated with Tank 213, which contains a highly toxic liquid material, is located in one of the flooded buildings. High winds rip Tank 213 from its foundations, causing a massive spill of the contents. The facility operator is unaware of the release due to the failure of the submerged monitoring system, and takes no action until after the released material has reached a nearby channel to the gulf. Just south of downtown Philadelphia, the Atlantic Refining Company's facility is nestled among several working class neighborhoods. A sprawling complex on 25 acres, the Atlantic refinery produces 350,000 barrels per day of gasoline, diesel, and jet fuel each year. In the alkylation process unit, light hydrocarbons react with a catalyst to create alkylate, an important additive used to produce high octane gasoline. At the Atlantic refinery hydrofluoric acid is the catalyst of choice. The hydrofluoric acid is stored in a large green cylindrical tank located adjacent to the alkylation process unit. One July morning the neighborhoods surrounding the Atlantic refinery are slowly rousing. Dogs sniff grass, weeds, and flowers on morning walks or in backyards. Children rush to depart for daycare, or play in the street or in small green patches behind their homes. Distracted parents finish coffee on the run, packing up for a day of work. Unnoticed, a lone figure carrying a large duffle bag emerges from the stairs leading to the roof of a weathered apartment building. He sets it down by the roof's edge facing the refinery, and methodically removes dark machined items from the bag. Once assembled, he lifts the tubular contraption to his shoulder, sighting the dull green cylinder at the refinery some 500 yards away. A projectile erupts from the tube, streaking towards the refinery. A large puff of smoke and flame appear on the face of the cylinder, and an orange-tinted haze slowly oozes out, drifting in silence towards the neighborhood. As the 21st century unfolds, regulators charged with overseeing chemical production and use in the United States face a perfect storm of sorts. Three important phenomena with critical implications for chemical management policy are converging at once. First, production and use of toxic chemicals continue to proliferate. Eighty thousand chemicals are in commerce in the United States, with 1,000 added each year. (1) Although current government and industrial codes are in place to minimize known risks, there are troubling gaps in our understanding of the use and impacts of these chemicals. (2) Despite best efforts, even under normal circumstances chemical releases regularly occur. Normal accident theory posits that unanticipated human and system failures are inevitable at complex facilities like oil refineries and chemical plants. …
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