Vikram, AVP [Business Analysis]

Author Archives: Vikram, AVP [Business Analysis]

Molasses Disaster: Natural or Standard Operating Procedure Neglect


Purity Distilling Company which was into the business of manufacturing alcohol was based out in Boston, Massachusetts, USA. The company made use of huge volumes of molasses which is the key ingredient in this industrial process of alcohol manufacturing and by nature it was syrupy. When this syrupy by-product of sugar was processed it could be served as a domestic sweetener and used in rum or industrial ethyl alcohol production post fermentation. On the 19th of January 1919 business was going as usual with the day being slightly warmer than usual. Purity’s had its vast reserves of crude molasses stored at 529 Commercial Street. The storage capacity on that particular day was about 8.7 million litres of molasses.

The unfolding of the events that could not be dealt in the standard operating procedures manual:

Around 12:40 p.m. the 50 ft tall tank fractured loudly with a roar along with a machine-gun popping of the rivets that exploded. As a result of this event the ground shook violently spewing out a huge wave of molasses that raised about 15 ft high leading to engulfing of the surrounding area. The wave of molasses that rose higher spread out like a sticky tsunami at a speed of 35 mph and engulfed the surrounding buildings, invaded a fire station, tossed a train off the tracks, demolishing the bridges and at the end of this calamity most parts of the city witnessed blocks of flooding to a depth of 3ft.

So what could have gone wrong here-was the SOP document not really precise?

Though there were various arguments to put forth this accident in various aspects a few factors seem to have been the root cause for this mishap. First was that the weather on that particular day was unusually hot encouraging internal fermentation to have happened more vigorously and then the other aspect suspected to be the culprit it seems was that the maintenance of the cast-iron tank was not properly done which on the prima face seems certain that the SOP document had not really made an impact. Also the SOP document shall have clearly stressed the importance of repairing the stress cracks available at the base rather than loosely addressing it leading to the misinterpretation that may be painting was an option available rather than fixing.

The rescue efforts were recorded to have been a nightmare as the clinging molasses were solidly coated on the bodies that were retrieved from the area of disaster by the rescue teams. The death toll was recorded at 21 with more than around 150 seriously injured. It was recorded that the subsequent clean-up took about 3,600 laborious man-days with Purity eventually paying out $600,000 in compensation.

Flight 191 Crash-Case of SOP Format & SOP Meaning unclearly formulated


This incident shall go into being one of the worst airline disasters to have ever occurred in American lands and it took place on the 25th of May 1979 at Chicago’s O’Hare International Airport. On that fateful day this particular aircraft “Flight 191”, a 3-engined Mc Donnell Douglas DC-10 bund for Los Angeles took off around 3:05 p.m. with over 270 people on board. On that particular day the weather was clear with a gently breeze blowing. All seemed to be going fine when the aircraft was hurtling down the runway when to the horror of the air traffic controller something seem to be going terribly wrong.

So what went wrong?

The traffic controller saw the left hand engine detach from the aircraft, flip back over the wing and crash onto the runway. The 2 experienced pilots on board; Captain Walter Lux & First Officer James Dillard had by now understood that they were championing a lost cause to bring the aircraft to halt using the other 2 engines. But what happened is that at the time of the severing of the 1st engine the hydraulic lines that controls the wing’s stalling speed also ripped the front section of the wing that would have otherwise informed Captain Walter Lux precisely of the situation. As a result of this the hydraulic fluid drained and the wing slats retracted leading to the cart wheeling of the aircraft onto the hangar which was on the old Ravenswood Airport site. All this happened within 31 seconds of trying to take-off. The impact of this resulted in death of all on-board passengers and 2 other workers on the ground.

Were things not in lines with the standard operating procedure?

To answer this question at the hind sight it definitely seems that the vital aspects from the standard operating procedure were really missing. So what is that was missed, the preventive maintenance perhaps not done in a specific method that actually led to the damaging of the mounting pylon during an engine change. Though minor it might seems when one hears it, it was imperative to have checked and corrected the problem at first point itself. It seems that such deviations could have occurred because the SOP format was not very specific or did not have the necessary points to provide the right guidance to the technical team that carried out such repairs regularly.

The above accident actually resulted in about 273 passengers losing their lives in no time. In fact it seems like only after 2 more such fatal accidents was the SOP meaning better understood, tuned to tighten up the minor design faults and maintenance procedures refined.

This can go as one of those SOP examples that could have better been formulated first hand.

Sant Carles De La Rapita – Example of SOP Guidelines Non-adherence


The resort of Sant Carles de la Rapita in Southern part of Catalonia, Spain happens to be buzzing tourist destination and also has a history of having witnessed a very horrific accident in the year 1978 on the 27th of July. The location is and the time was such that it was the prime holiday season in Spain at that point of time as result of which there were also foreign tourists present. At the same time when these carefree vacationers were partying that the campsite of Los Alfaques, a tanker truck with flammable liquid polypropylene was on the highway closer to this location where the campers were enjoying their holiday. Little did they realise that this tanker carrying this flammable liquid would change their lives for ever.

So what happened here?

At the ENPETROL refinery at the loading point the employee’s in charge had loaded about 23 tonnes of this flammable onto the trucker where the official permitted value was about 19 tonnes only. Also the driver who had been clearly instructed to take the old N-340 coast road to avoid heavy toll at A-7 motor way which was located on the other parallel way did not adhere to it.

SOP guidelines non-adhere resulted in:

This combined non-adherence of illegal loading and penny pinching route paved for a fatal consequence to take place. Some first-hand account says that the tyre of the tanker burst causing the vehicle to swerve and hit a wall rupturing the tank. Another version is that tanker sprung out a pressure leak with an audible bang opposite the camp site.

As a strong breeze blew a white cloud of gaseous propylene gathered around the camp. Seeing all these developments there were curious onlookers who began to assemble around this area. At this point when a deadly cloud got over there it found an ignition source that caused the flames to be flashed back to the tanker. This resulted in a devastating Boiling Liquid Expanding Vapour Explosion like a huge fireball and a large crater. The temperature at that point of time was over 10000F. The non-adherence of SOP guidelines and instruction sent out resulted now in the fire lighting up and covering an approximate radius of 985 ft burning everything on its way like the vehicles, tent laid, caravans, people, the disco, the tank driver resulting in about 220 causalities. Of those numbers about 150 people lost their lives instantly.

Result of standard operating procedure not –conformance

For this fatal accident four employees of ENPETROL refinery who loaded the flammable liquid beyond the tanker’s capacity were convicted for criminal negligence which was later over turned. The company paid huge compensation to all those who were affected by this negligence again reminding us of the severe repercussions of sometimes ignoring certain simple aspects quoted in our ever to be followed standard operating procedure.

Double-Decker Horror- Example of Standard Operating Procedure laxity


On a cold and dark winter evening of 4th of December in 1951 particular incident that happened in Gillingham, Kent, UK would send out chills down your spine! On the account of having plans to witness a boxing tournament about 52-strong company of the Royal Marines Volunteer Cadet Corps set out marching from Gillingham’s Melville Barracks to the Royal Naval Barracks located in Chatham. For this contingent to be led to the tournament Lt. Clarence Carter was given the charge assisted by cadet of non-commissioned officers. These youth marchers formed a column of about 15 m in length and arranged themselves into 3 such contingents.

Outside the gates of Chatham Road Naval Dockyard in Dock Road, when the cadets had reached a dark section of the road where one of the street lights had failed a bus belonging to Chatham & District Traction Company approached these cadets from behind. Lt. Clarence Carter who had noticed this bus coming towards them immediately told the boys to get as close to the edge of the road as possible. The double-decker bus at that time was travelling at a 40 mph and it did not move aside to pass them but found it ploughing through the cadet marcher’s line before ultimately stopping. The driver on the wheel was John Samson a 57 year old who had about 40 years of experience.

So when the driver with so many years of experience was on the wheel why and how did things go awfully wrong? The answer once again lies with the absence of a sound standard operating procedure not in place at the first instance. SOP guidelines here should have clearly spelt out clearly to the driver that not only the sidelights but also the main head lamp should have been on when driving during the evenings at the time of winter along with a recommended speed to be driving. Also the local administration should have had SOP guidelines to have street lights checked on a daily basis and also a scheduled and preventive maintenance in place. As the colour of the uniforms worn by the cadet was in dark-blue colour the driver claimed that he did not realise the presence of the marchers. Samson also claimed that he had not driven the bus at 40 mph as mentioned by Lt. Clarence and was only driving at 20 mph. Lt. Clarence emerged unscathed though dazed. The resultant of this gory road accident resulted in about 24 young cadets lesser than 10 years lose their lives though the driver escaped with a fine of £20. The Chatham & District Traction Company paid out £10,000 in compensation to the parents of the dead boys which was shared among them and this led to British military marchers now showing red-light at night while marching leading to a new establishment of a safety measure like a standard operating procedure to follow while marching at night on public roads.

Hell Gate Tragedy – Did Standard Operating Procedure take a Back Seat?


On the 15th day of June 1904, about 1,358 members mostly consisting of women and children set out on an annual trip conducted by St. Mark’s Lutheran Church on a chartered ferry named “SS General Slocum” from the East River located in the city of New York, USA. These women and children were one among the many immigrant population who inhabited the slummy and dingy areas of New York’s Lower East Side. The spot for the picnic was to be on the North Shore of Long Island.

This steam ferry was a bit different as it was a side wheeler which was a more common sight those days in the waters of New York harbour. The picnic crowd boarded at the 3rd street. During the course of this journey the ferry was passing through a narrow tidal strait known as “Hell Gate” when a fire broke out suddenly spreading quickly causing panic amongst the passengers. The captain hoping to contain the fire maintained his course towards the sound but due to a stiff wind that blew directly against the course in which the moving object was moving a resistance was created resulting in further fanning of the flames. Through the captain’s laborious efforts the ship was eventually beached to North Brother Island. The hospital was already a location for infectious diseases. By this time there was complete chaos prevailing in the ferry as a result of which the passengers started to leap into the water to protect themselves from the flames.

Was there a standard operating procedure in place?

Here if one were to go and see what really went wrong then certain aspects in terms of adherence to safety measures were missed or not taken carefully which could be due to the absence of what we call the standard operating procedure. If someone here were to ask this what is SOP got to do here to do, then the obvious answer would be that the safety measures would have been addressed in the standard operating procedures manual. The presence of the standard operating procedures manual may have indicated about the life-jackets, how to address for defects in the life jackets, how and when to have done a preventive or scheduled maintenance, how these life jackets should have been placed so that it were made accessible during an emergency, how the crew members should have been properly trained to access these life jackets and thus averted this tragedy that resulted in about 1000 people mostly women and children losing their lives.

Incidents like these time and again remind us of the importance of SOP writing to be adopted by entities while in existence.

Show Buttons
Hide Buttons