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Principles of Forensic Engineering Applied to Industrial Accidents

Principles of Forensic Engineering Applied to Industrial Accidents

Luca Fiorentini, Luca Marmo

ISBN: 978-1-118-96281-7

Jan 2019

536 pages

Pre-order

$140.00

Description

An introductory text on the investigation of industrial accidents

Forensic engineering should be seen as a rigorous approach to the discovery of root causes that lead to an accident or near-miss. The approach should be suitable to identify both the immediate causes as well as the underlying factors that affected, amplified, or modified the events in terms of consequences, evolution, dynamics, etc., as well as the contribution of an eventual "human error".

This book is a concise and introductory volume to the forensic engineering discipline which helps the reader to recognize the link among those important, very specialized aspects of the same problem in the global strategy of learning from accidents (or near-misses). The reader will benefit from a single point of access to this very large, technical literature that can be only correctly understood with the right terms, definitions, and links in mind.

Keywords:

  • Presents simple (real) cases, as well as giving an overview of more complex ones, each of them investigated within the same framework;
  • Gives the readers the bibliography to access more in-depth specific aspects;
  • Offers an overview of the most commonly used methodologies and techniques to investigate accidents, including the evidence that should be collected to define the cause, dynamics and responsibilities of an industrial accident, as well as the most appropriate methods to collect and preserve the evidence through an appropriate chain of security.

Principles of Forensic Engineering Applied to Industrial Accidents is essential reading for researchers and practitioners in forensic engineering, as well as graduate students in forensic engineering departments and other professionals.

Table of contents

 

ACKNOWLEDGEMENT 2

PREFACE 3

PREFACE 4

PREFACE 5

PREFACE 6

LIST OF ACRONYMS 7

1.1 WHO SHOULD READ THIS BOOK? 10

1.2 GOING BEYOND THE WIDGET! 11

1.3 FORENSIC ENGINEERING AS A DISCIPLINE 13

REFERENCES 15

FURTHER READING 15

INDUSTRIAL ACCIDENTS 16

2.1 ACCIDENTS 16

2.1.1 Principles of combustion 19

2.1.2 Fires 28

2.1.3 Explosions 31

2.1.4 Incidental scenarios 35

2.2 NEAR MISSES 41

2.3 PROCESS SAFETY 42

2.4 THE IMPORTANCE OF ACCIDENTS 46

2.4.1 Seveso disaster 48

2.4.2 Bhopal disaster 51

2.4.3 Flixborough disaster 53

2.4.4 Deepwater Horizon drilling rig explosion 55

2.4.5 San Juanico disaster 60

2.4.6 Buncefield disaster 61

2.5 PERFORMANCE INDICATORS 65

2.6 THE ROLE OF ‘UNCERTAINTY’ AND ‘RISK’ 67

REFERENCES 70

FURTHER READING 72

WHAT IS ACCIDENT INVESTIGATION? WHAT IS FORENSIC ENGINEERING? WHAT IS RISK ASSESSMENT? WHO IS THE FORENSIC ENGINEER AND WHICH IS HIS ROLE? 73

3.1 INVESTIGATION 73

3.2 FORENSIC ENGINEERING 79

3.3 LEGAL ASPECTS 81

3.4 ETHIC ISSUES 85

3.5 INSURANCE ASPECTS 86

3.6 ACCIDENT PREVENTION & RISK ASSESSMENT 87

3.6.1 “What-if” analysis 88

3.6.2 Hazard and Operability Analysis (HAZOP) & Hazard Identification (HAZID) 89

3.6.3 Failure Modes and Effects Analysis (FMEA) 93

3.7 TECHNICAL STANDARDS 93

REFERENCES 98

FURTHER READING 99

THE FORENSIC ENGINEERING WORKFLOW 100

4.1 THE WORKFLOW 100

4.2 TEAM AND PLANNING 103

4.3 PRELIMINARY AND ONSITE INVESTIGATION (COLLECTING THE EVIDENCE) 106

4.3.1 Sampling 108

4.4 SOURCES AND TYPE OF EVIDENCE TO BE CONSIDERED 112

4.4.1 People 114

4.4.2 Paper documentation 117

4.4.3 Digital documentation and electronic data 118

4.4.4 Physical evidence 123

4.4.5 Position data 124

4.4.6 Photographs 124

4.5 RECOGNIZE THE EVIDENCE 129

4.5.1 Short case studies 130

4.6 ORGANIZE THE EVIDENCE 142

4.7 CONDUCTING THE INVESTIGATION AND THE ANALYSIS 143

4.7.1 Method of the conic spiral 145

4.7.2 Evidence analysis 146

4.8 REPORTING AND COMMUNICATION 148

REFERENCES 152

FURTHER READING 153

INVESTIGATION METHODS 154

5.1 CAUSES AND CAUSAL MECHANISM ANALYSIS 154

5.2 TIME AND EVENTS SEQUENCE 162

5.2.1 STEP Method 165

5.3 HUMAN FACTOR 168

5.3.1 Human error 174

5.3.2 Analysis of operative instructions and working procedures 177

5.4 METHODS 180

5.4.1 Expert judgment and brainstorming 181

5.4.2 Structured methods and approaches 182

REFERENCES 227

FURTHER READING 229

DERIVE LESSONS 230

6.1 PRE AND POST ACCIDENT MANAGEMENT 230

6.2 DEVELOP RECOMMENDATIONS 235

6.2.1 An application of risk analysis to choose the best corrective measure 242

6.3 COMMUNICATION 250

6.4 SAFETY (AND RISK) MANAGEMENT AND TRAINING 251

6.5 ORGANIZATION SYSTEMS AND SAFETY CULTURE 252

6.6 BEHAVIOR-BASED SAFETY (BBS) 256

6.7 UNDERSTANDING NEAR-MISSES AND TREAT THEM 257

REFERENCES 260

FURTHER READING 261

CASE STUDIES 262

7.1 JET FIRE AT A STEEL PLANT 262

7.1.1 Introduction 262

7.1.2 How it happened (incident dynamics) 263

7.1.3 Why it happened 267

7.1.4 Findings 273

7.1.5 Lessons learned and recommendations 274

7.1.6 Forensic engineering highlights 276

7.1.7 References & further readings 278

7.2 FIRE ON BOARD OF A FERRYBOAT 280

7.2.1 Introduction 280

7.2.2 How it happened (incident dynamics) 280

7.2.3 Why it happened 281

7.2.4 Findings 287

7.2.5 Lessons learned and recommendations 288

7.2.6 Forensic engineering highlights 289

7.2.7 References & further readings 296

7.3 LOPC OF TOXIC SUBSTANCE AT A CHEMICAL PLANT 297

7.3.1 Introduction 297

7.3.2 How it happened (incident dynamics) 297

7.3.3 Why it happened 297

7.3.4 Findings 298

7.3.5 Lessons learned and recommendations 303

7.3.6 Forensic engineering highlights 304

7.3.7 References & further readings 305

7.4 REFINERY’S PIPEWAY FIRE 306

7.4.1 Introduction 306

7.4.2 How it happened (incident dynamics) 306

7.4.3 Why it happened 309

7.4.4 Findings 311

7.4.5 Lessons learned and recommendations 313

7.4.6 Forensic engineering highlights 315

7.4.7 References & further readings 316

7.5 FLASH FIRE AT A LIME FURNACE FUEL STORAGE SILO 318

7.5.1 Introduction 318

7.5.2 How it happened (incident dynamics) 319

7.5.3 Why it happened 323

7.5.4 Findings 324

7.5.5 Lessons learned and recommendations 324

7.5.6 Forensic engineering highlights 325

7.5.7 References & further readings 325

7.6 EXPLOSION OF A ROTISSERIE VAN OVEN FUELLED BY AN LPG SYSTEM 327

7.6.1 Introduction 327

7.6.2 How it happened (incident dynamics) 327

7.6.3 Why it happened 330

7.6.4 Findings 334

7.6.5 Lessons learned and recommendations 334

7.6.6 Forensic engineering highlights 335

7.6.7 References & further readings 341

7.7 FRAGMENT PROJECTION INSIDE A CONGESTED PROCESS AREA 342

7.7.1 Introduction 342

7.7.2 How it happened (incident dynamics) 342

7.7.3 Why it happened 343

7.7.4 Findings 343

7.7.5 Lessons learned and recommendations 363

7.7.6 Forensic engineering highlights 364

7.7.7 Credits & references 364

7.8 REFINERY PROCESS UNIT FIRE 365

7.8.1 Introduction 365

7.8.2 How it happened (incident dynamics) 365

7.8.3 Why it happened 369

7.8.4 Findings 370

7.8.5 Lessons learned and recommendations 372

7.8.6 Forensic engineering highlights 378

7.8.7 References & further readings 379

7.9 CRACK IN AN OIL PIPELINE 381

7.9.1 Introduction 381

7.9.2 How it happened (accident dynamics) 382

7.9.3 Why it happened 384

7.9.4 Findings 389

7.9.5 Lessons learned and recommendations 392

7.9.6 Forensic engineering highlights 392

7.9.7 References & further readings 393

7.10 STORAGE BUILDING ON FIRE 394

7.10.1 Introduction 394

7.10.2 How it happened (accident dynamics) 394

7.10.3 Why it happened 395

7.10.4 Findings 396

7.10.5 Lessons learned and recommendations 397

7.10.6 Forensic engineering highlights 397

7.10.7 References & further readings 397

CONCLUSIONS AND RECOMMENDATIONS 399

REFERENCES 401

A LOOK INTO THE FUTURE 402

REFERENCES 405

TABLE OF CONTENTS 406

APPENDIX 411

A.1 BASIC NOTIONS ON PROBABILITY 411