Workplace disasters

CEP. GUARDIAN Vol. 11 #1 September, 2001

Human Made Disasters

"Trust Us" - We frequently find ourselves being assured by business leaders and politicians that our health and the environment are being protected, that people wiser than ourselves have assessed the risk and concluded that some product or activity was "safe". Whether it is mad-cow disease, genetically-modified organisms, new chemicals, or drinking water, Canadians are accustomed to being told that our worries are groundless. And in truth, that is what most of us want to believe.

Yet history has shown that humans are not all that good at assessing risks. Time after time the hazards of new technologies and products have been poorly understood at first, underestimated when the knowledge started to become available, and responded to too late. Tobacco, asbestos, vinyl chloride, many pesticides - even technologies such as the automobile or the computer - all were initially proclaimed "safe" and all were strongly defended even after information on their risks became impossible to ignore.

In some of the disasters recounted below, a risk assessment had actually been done, but the wrong conclusions were reached. In other cases, there is no evidence that a risk assessment or an other attempt to judge the danger was made, however they stand as examples of the general insufficiency of information before the fact; and the fallibility of humans in understanding and utilizing even that information which is available.

The Iron Ring and Engineering History -Poor design and careless use of human-made products is the cause of many accidents and quite a few spectacular disasters. In every case, the risk was believed to be low. It is a tradition in Canada for many engineers to wear an iron ring. The iron ring was intended to be a symbol of the engineers' pride in their profession as well as a reminder of their fallibility, and the consequences of their failures. The first iron rings were supposedly handed out in a ceremony at the University of Toronto in 1925. It was rumoured that the rings were made of iron from the remains of the Quebec Bridge, above Quebec City. One of the spans fell into the St. Lawrence river in 1907 killing 75 workers. The span had been lengthened without allowing for the increased strain. Then, in 1916 the centre span fell killing another 13 people. Here are a few other notorious human-made disasters, in alphabetical order:

Bhopal, India, 1984. Over 2,000 deaths and thousands more injured, many permanently, when piping systems failed at a pesticides plant. Methyl isocyanate was released when water was added to a storage tank. Among the safety systems that were under-engineered or out of service at the time were a refrigeration system (shut down for cost reasons), a high temperature alarm (set too high), a scrubber system (undersized and under repair) and the flare system (disconnected). Plant under-staffing was also implicated. The company suggested that the water may have been deliberately added by a disgruntled employee. However, low pay may also have contributed to the scale of the disaster in another way, by encouraging the establishment of a densely populated shanty town adjacent to the plant.

The space shuttle Challenger blew up on January 28, 1986 when 'O'-rings failed. Seven astronauts were killed. Design problems with the 'O'-rings had been identified prior to the disaster but had not been corrected. A risk assessment had concluded that the margin of safety was sufficient.

Chernobyl - in history's worst nuclear accident, the Number 4 reactor in this aging nuclear complex near Kiev, Ukraine, exploded on April 26, 1986 at 1:21 AM. Staff had been conducting tests on the reactor's safety systems at the time of the explosion. The reactor design had been criticized by nuclear experts from around the world. About thirty to forty times the radioactivity of the bombs dropped on Hiroshima and Nagasaki at the end of the second world war was released. The Soviet government did not at first admit to a problem, and local residents first heard of a problem in news broadcast from Sweden. Thirty-one people died immediately, hundreds of thousands of people were relocated, entire cities were abandoned. Ten thousand people still live in Chernobyl and 3 million people still live in zones considered 'contaminated'. Unknown numbers of people will eventually die of cancer as a result of Chernobyl; possibly numbering into the hundreds of thousands. Several reactors of the Chernobyl design are still in operation.

Egypt leptophos disaster -Many farmers and more than a thousand farm animals died of leptophos poisoning in Egypt. This chemical, manufactured in the United States by Velsicol and exported to about 30 countries between 1971 and 1976, had never been registered for domestic use in the U.S.A.

Exxon Valdez - On March 24, 1989 at four minutes past midnight, the Exxon Valdez ran aground in one of the most famous (although not the biggest) oil disasters in history. Almost 11,000,000 gallons of oil was spilled. The U.S. National Transportation Safety Board cited the probable causes of the grounding of the Exxon Valdez as: the failure of the third mate to properly manoeuvre the vessel because of fatigue and excessive workload; the failure of the master to provide a proper navigation watch because of impairment from alcohol; the failure Exxon to provide a fit master and a rested and sufficient crew for the Exxon Valdez; the lack of an effective vessel traffic service because of inadequate equipment and manning levels, inadequate personnel training, and deficient management oversight; and the lack of effective pilotage services. However, many scientists and environmentalists had predicted this disaster since the large-scale shipping of oil in tankers up and down the coast of Alaska and British Columbia began in the 1970s. Because of the very narrow and changeable nature of the shipping channels, frequent severe weather conditions, difficult and often unguided navigation -they had demanded that the large Alaska oil tankers be designed with 'double bottoms' - a design in use in some other parts of the world. Their recommendation was rejected, in part due to risk assessments. Results: financial costs in the billions of dollars; incalculable environmental costs; a captain made scapegoat. Exxon continues to deny liability and fight civil lawsuits totalling billions, but has become fanatically obsessed with drug -and alcohol testing of its employees. Meanwhile, oil continues to be shipped up and down this treacherous coast in an ever-aging fleet of single-bottom tankers.

Hyatt Regency skywalk, Kansas City, Missouri, USA. When this two-level catwalk at the Hyatt Regency hotel collapsed in 1981, 111 fatalities resulted and several engineers lost their professional licenses. The designers intended certain nuts to support the weight of only one floor, but the design was faulty because it turned out to be impossible to install them where specified. The nuts as actually installed bore the weight of both floors. The nuts eventually tore through when there were many people dancing on the catwalk.

Iraq mercury disaster - In 1972, at least 459 people were killed(estimates are over 500) and over 6,500 were hospitalized in Iraq after 8,000 tonnes of wheat and barley, intended as seed for planting only, was instead distributed to villagers and ground for flour. Warning labels on the bags of grain were in English only. Methyl mercury concentrations in the bread baked from the flour were estimated to average approximately 9 milligrams per kilogram(mg/kg) or 9 ppm. The mercury based fungicide which had been used to treat the seed grain, had already been banned in the U.S. at the time of the disaster.

Tacoma Narrows Bridge, Tacoma Washington, USA. Faulty design failed to take into account the effect of wind. The bridge crossed the Puget Sound inlet, which with its mountainous sides, acts as a wind tunnel. The bridge began to oscillate or'gallop' in the wind until it eventually tore itself apart and collapsed, only a few months after it was built, on November 7, 1940.

Thalidomide -This drug, prescribed to pregnant women to combat'morning sickness' was introduced in 1957 and used until it was banned in the early 1960s. It produced "an estimated 10,000 children - but probably many more - born throughout the world as phocomelics, deformed, some with fin-like hands grown directly on the shoulders; with stunted or missing limbs; deformed eyes and ears; ingrown genitals; absence of a lung; a great many of them still-born or dying shortly after birth; parents under shock, mothers gone insane, some driven to infanticide" according to Hans Ruesch, medical historian. Inadequate pre-release safety testing and a tendency to ignore warning signs contributed to the scale of the tragedy. In the 1990s, thalidomide's reputation has undergone something of a rehabilitation and many researchers believe that it may be valuable in the treatment of some disabling diseases. The U.S. Food and Drug Administration (FDA) has recently approved its use for research purposes. The fear of many is that if thalidomide is re- allowed for even these diseases, despite precautions, it is only a matter of time until a pregnant woman is given thalidomide.

According to the Thalidomide Victims Association of Canada, "The thalidomide history is unique and ironic. No longer do we have an assumption of safety regarding new drugs, safety must be proven before licensing. The very reputation of the FDA was built on preventing a thalidomide tragedy in the United States in 1961, and now they have approved this drug ..."

The 'Therac-25', a Canadian designed and manufactured medical device used to deliver radiation for cancer therapy. Poor software design and an absence of safety alarms allowed several people to be overdosed with radiation, some fatally, between 1985 and 1987.

Titanic. At 2.20 am on Monday April the 15th 1912, Titanic disappeared under the Atlantic, just off the Grand Banks, not to be seen again by human eyes for another 73 years. Perhaps the most famous, although not the most deadly, human-made disaster of all time. Excessive pride in the 'unsinkable' design prompted the owners and crew to race the Titanic, on her maiden voyage, at high speeds across the North Atlantic in iceberg season. When the Titanic struck an iceberg, substandard steel rivets shattered and steel plates buckled, breeching more watertight compartments than the designers had ever considered a possibility. Insufficient numbers of lifeboats, (after all, who would need them on an unsinkable ship?) incompletely loaded, resulted in the deaths of about two-thirds of the approximately 2,200 people on board, a total of 1,500 people.

West Gate Bridge, Melbourne Australia, 1970. When construction crews had difficulty connecting two poorly fitted sections, the bolts at the ends of the bridge were loosened in the hopes of allowing enough 'give' for the sections to be joined. It was felt that the risk of this procedure was low. The idea was a bad one: the end bolts failed and one section fell to the ground, killing 35 workers.

Yangtze Dam Bursts -On August 7, 1975, following heavy typhoon rains, a series of 62 dams on the Yangtze River burst in sequence, initiated by the failure of two major dams. Weather conditions (which might have been anticipated), difficult geology, poor engineering (there were insufficient means to release excess water) and poor maintenance (a large dam requires constant care and repair) contributed to the disaster. Within the few hours tens of thousands of people died. Hundreds of thousands more died in the following months due to disease and starvation. Although poorly reported in the West, this may have been the greatest human-made disaster in history. Today, China plans to build a new mega- dam called 'Three Gorges' on the Yangtze river. Besides the environmental disruption it will cause, Three Gorges has been criticized as badly underfunded and situated on a fault line.

Yusho Poisoning - In 1968, more than one thousand people in western Japan became seriously ill after eating food that was cooked in rice oil, contaminated with polychlorinated biphenyls (PCBs). The source of the PCBs had been leaking PCB containing equipment in the factory where the rice oil was produced, so that it mixed with the rice oil during the manufacturing process. Their symptoms included fatigue, headache, cough, numbness in the arms and legs, and unusual skin sores. Pregnant women later delivered babies with birth defects. Another similar incident of massive human exposure to PCBs occurred in Taiwan in 1979.

Thank you for reading. Please send ideas, comments and articles to:

Brian Kohler
National Representative - Health, Safety and Environment Communications, Energy and Paperworkers Union of Canada 350 Albert Street, Suite 1900 OTTAWA, Ontario K1R 1A4

Tel: 613-230-5200
fax: 613-230-5801
email: bkohler@cep.ca