Potential for catastrophe lurks in complex systems
Human failings can subvert well-intentioned efforts to avoid disaster
How's this for a cautionary tale? A small leak in a unit of the US's largest refinery on June 4, 2012, began a chain reaction that resulted in damages that cost more than $300 million dollars to repair.
The incident took place at the Port Arthur, Texas, refinery owned by Motiva Enterprises, a joint venture of oil major Royal Dutch Shell and Saudi Arabia state oil producer Saudi Aramco. A defective valve in the facility's 325,000 barrel per day atmospheric distillation column required a
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