Potential for catastrophe lurks in complex systems

Human failings can subvert well-intentioned efforts to avoid disaster

Vincent Kaminski

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 temporar