I asked this question on twitter today:
I received a lot of great responses.
My question was motivated by this lecture by Dr. Richard Cook about an explosion at a BP petroleum processing plant in Texas in 2005 that killed fifteen plant workers. Here’s a brief excerpt, starting at 16:31 of the video:
Let me make one other observation about this that I think is important, which is that this occurred during startup. That is, once these processes get going, they work in a way that’s different than starting them up. So starting up the process requires a different set of activities than running it continuously. Once you have it running continuously, you can be pouring stuff in one end and getting it out the other, and everything runs smoothly in-between. But startup doesn’t, it doesn’t have things in it, so you have to prime all the pumps by doing a different set of operations.
This is yet another reminder of how similar we are to other fields that control processes.
Surfing Complexity 