Hazardex 2019 Conference Presentations - Case study on a failure to understand and manage risks
20 November 2018
This paper presents a case study of an incident that occurred outside the traditional area of process safety, although the circumstances and the learnings are highly relevant to the high hazard process industries. Key areas of failure include leadership, accountability, risk assessment, following established procedures, management of change, consideration of off-site impacts, and emergency procedures.
Organisational issues associated with culture and whistle-blowing also played a key role in the incident.
On 11th July 2011, there was a massive explosion of ordnance that was being stored at a Naval Base in Cyprus resulting in thirteen fatalities, including the Commander of the Cypriot Navy and the Commander of the base. Sixty-two people were injured in the nearby village and some 150 properties were damaged.
The largest power station on the island, located next to the Naval Base, was severely damaged, leading to rolling blackouts around Cyprus for several weeks until alternative power generation capacity could be installed.
The ordnance was part of a cargo that had been intercepted and confiscated by the United Nations in January 2009 as it was being shipped from Iran to Syria. The cargo was offloaded at Limassol Port and transported to the Evangelos Florakis Naval base for interim storage.
Between January 2009 and July 2011, various discussions took place concerning the safety of the material and what to do with it, but nothing substantive was done. A week before the incident, one of the containers was found to have distorted and an inspection took place. The day before the incident was the hottest day of 2011 and during the following night a fire had started around the containers and was being tackled by the local fire brigade when the explosion occurred. Six of the thirteen fatalities were civilian firefighters.
The incident resulted in a large public demonstration and major political fallout including the resignation of the defence and foreign ministers. The findings of an investigation included criticism of the President of the Republic of Cyprus, although he denied any personal responsibility.
The root causes lies with management of the organisation, which, in this case was complicated by the involvement of multiple parties with interests that were not necessarily aligned. This situation can occur in the process industries, particularly when undergoing mergers and acquisitions. The learning from this tragic incident is relevant in our industry and many others.
Roger Stokes is Principal Consultant at BakerRisk Europe and works out of the UK office as part of the Process Safety Group, where his work is currently focused on accident/ incident investigation and insurance risk engineering.
He graduated from UMIST as a Chemical Engineer in 1982 and joined ICI’s Mond Division where he initially worked in a technical capacity on various plants and projects including chlorine/ caustic, chlorinated solvents and chlorinated paraffins. In 1987 he moved into plant management, first on a chlorinated rubber resins plant and then PVC.
In 1992 he joined a firm of Loss Adjusters dealing with commercial insurance claims including fires, explosions and machinery breakdown on chemical, petrochemical, food processing and other manufacturing facilities. This took him to various parts of the globe where he encountered numerous types and sizes of incidents. He joined Baker Risk in 2015.
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