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Assignment Requirement -

For the Assignment you need to choose a well-known disaster (apart from the Texas City refinery disaster, as this is covered in another course) with publicly available information. Table 5.1 lists some possible choices but you can choose another so long as there is sufficient publicly available information that is detailed and impartial. More recent disasters have often had public inquiries that have a great deal of information available online. Ideally you need to choose one that is not too recent as it is best when the dust has settled and the public inquiry and most of the legal discussions are complete. This can be several years after the event. Give some thought to your chosen case study and feel abundantly free to discuss your ideas on the Discussion Board.

Remember there is a lot of useful information to be obtained from many of the online journals which can be searched using a number of databases accessed from the library website. You may find many sources of information from different viewpoints. This can be helpful to get a balanced picture of your chosen accident. You should be cautious about only using information provided by pressure groups such as trade unions or victim support groups as these are liable to represent a particular view to the possible exclusion of others. You should be critical of the sources you choose and evaluate them fairly. In many cases there are reports from public inquiries that in general provide not just a thorough but also a fair and impartial account of a disaster.

We are looking for a comprehensive analysis that should not be affected by your personal opinion prior to investigation. Part of the test in this course is to use the methods approach your chosen analysis from first principles and with an open mind. You may well be surprised how the 'obvious' cause is, in fact, not so obvious. In previous versions of the course we used to recommend avoiding cases with which you have personal involvement. This year I am willing to be flexible, especially if by employing the methods/insights on this course you challenge your own preconceptions and discover something new. If in doubt, please do discuss your potential choice on the Discussion Board before proceeding. The methods require a case study for which there is sufficient information and detail, and one that is impartial.

We have given some summaries on the web of the public inquiry reports for some of the learning from disaster 'classics', e.g. Piper Alpha, Clapham Junction and Bhopal. In these, as in other cases there is certainly a lot more information you could find that would help you check that the information contained within them is reasonable. I should mention that although Piper Alpha is a good example there are many other interesting oil and gas industry disasters to choose from (sadly!) and you may learn more by picking something from a different industry than you normally work in. For example, those of you working in the oil and gas sector I am sure will learn a lot by studying an aviation or nuclear case study.

Your coursework should include the following sections.

1) A short description of the important details of the disaster containing all the details that are subsequently referred to in your analysis. Provide full references to all the sources you have used. These should all be easy to access for the course leader to check if required.

2) Use at least Events and Causal Factors Analysis, Barrier Analysis and the Management Oversight and Risk Tree to analyse the root causes of your disaster. Depending on the nature of the disaster you may find it appropriate to use MORT only on one part as it is a lengthy and time consuming procedure. As the analyst, you are free (indeed encouraged) to use your judgement in order to 'scale' your analysis appropriately - in other words, we do not expect an analysis so large that it exceeds the time and resources you have available. Explain the reasoning behind your analysis approach. As you try all three methods you should modify them as your understanding of the accident improves. Like most methods, you will likely iterate your analysis forward over a few versions until you arrive at the finished version. We would expect these three techniques to link together logically (again, explain those linkages and your analysis strategy) but also bear in mind it is perfectly acceptable to have areas in your analysis which require further exploration. As you do not have full access to all the information available we expect you will not be able to fully explore 'all' possibilities. In these cases you need to highlight where further investigation may be required. This is itself an important outcome of applying the methods.

3) Most major accidents result in changes in legislation. In the case of the disaster you have analysed, how did it contravene existing national and international regulations? In the aftermath of the accident and inquiry were there any major changes in legislation that might improve safety? How did it affect the operating procedures for similar organisations? What were the long term lessons learnt from the disaster? Are there any problems that still remain and may have even caused similar accidents subsequently? Include explicit answers to these, and any other issues you feel pertinent, within your coursework.

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