Principles of Forensic Engineering Applied to Industrial Accidents

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.

Professor Luca Fiorentini is an internationally recognized expert in the field of industrial, process safety and fire engineering. He is owner and CEO of TECSA S.r.l. international consulting company working in the field of loss prevention and industrial safety, fire engineering and environmental protection. He is senior process safety, HSE, fire engineering and reliability consultant. Professor Fiorentini has experience in QRA (Hazop, LOPA, FTA, ETA, Consequence analysis), CFD and FEM methods, RAM analysis and industrial risk assessment for a number of industries: major hazard industries, refineries, chemical and petrochemical plants, liquid hydrocarbons and LPG storage farms, oil and gas onshore installations and offshore platforms, steelwork plants, food processing facilities, pharmaceutical and fine chemicals production plants, hospitals and health care facilities, ports and piers. He is an expert of fire engineering and fire risk assessment. Fiorentini is a recognized forensic engineer and investigator for fires, explosions and industrial and marine accidents. He is the author of several books, articles and conference papers as well as a reviewer for a number of scientific magazines. He is also a professional member of the Chartered Society of Forensic Sciences (UK) and an editorial board member of "International Journal of Forensic Engineering" and "Fire Protection Engineering Magazine" (SFPE).

Professor Luca Marmo is a researcher at Politecnico di Torino technical university, holder of the chair of "Safety of industrial Processes" on the Chemical Engineering course, and director of the "Experimental Centre for Explosive Atmosphere Safety" at the Politecnico di Torino Scientific Activity. Consultant to the Public prosecutor and to the Court as a forensic engineer, he has investigated more than one hundred industrial and civil accidents, mainly fires and explosions. The skills of his research group are mainly focused on industrial safety and risk analysis, production of microorganisms and biomolecules of industrial interest, valorisation processes of wastes and industrial by-products, and production of microorganisms and enzymes applied in toxic compounds biodegradation processes. Other research fields concern experimental activity on fluidised bed reactors, CFD modelling of gas–solid multiphase reactors, and experimental activity on the valorisation of wastes. Author of more than 60 papers on international journals or presented at conferences, he is also a consultant to many companies and public bodies in the field of industrial safety and accident prevention, including government agencies at national and European level.

Foreword by Giomi xiii

Foreword by Chiaia xv

Foreword by Tee xvii

Preface xix

Acknowledgement xxi

List of Acronyms xxiii

1 Introduction 1

1.1 Who Should ReadThis Book? 1

1.2 Going Beyond theWidget! 2

1.3 Forensic Engineering as a Discipline 5

References 7

Further Reading 7

2 Industrial Accidents 9

2.1 Accidents 9

2.1.1 Principles of Combustion 14

2.1.1.1 Flammable Gases and Vapors 17

2.1.1.2 Flammable Liquids 21

2.1.1.3 The Ignition 22

2.1.2 Fires 23

2.1.3 Explosions 27

2.1.4 Incidental Scenarios 33

2.2 Near Misses 39

2.3 Process Safety 40

2.3.1 Management of Safety 41

2.4 The Importance of Accidents 47

2.4.1 Seveso disaster 48

2.4.2 Bhopal Disaster 51

2.4.3 Flixborough Disaster 55

2.4.4 Deepwater Horizon Drilling Rig Explosion 58

2.4.5 San Juanico Disaster 60

2.4.6 Buncefield Disaster 64

2.5 Performance Indicators 68

2.6 The Role of ‘Uncertainty’ and ‘Risk’ 72

References 75

Further reading 78

3 What is Accident Investigation?What is Forensic Engineering?What is Risk Assessment?Who is the Forensic Engineer and what is his Role? 79

3.1 Investigation 79

3.2 Forensic Engineering 87

3.3 Legal Aspects 91

3.4 Ethic Issues 95

3.5 Insurance Aspects 96

3.6 Accident Prevention and Risk Assessment 98

3.6.1 “What-if ” Analysis 100

3.6.2 Hazard and Operability Analysis (HAZOP) & Hazard Identification (HAZID) 101

3.6.3 Failure Modes and Effects Analysis (FMEA) 105

3.7 Technical Standards 105

References 112

Further Reading 113

4 The Forensic EngineeringWorkflow 115

4.1 TheWorkflow 115

4.2 Team and Planning 118

4.3 Preliminary and Onsite Investigation (Collecting the Evidence) 124

4.3.1 Sampling 127

4.3.1.1 Selection of the Sample 127

4.3.1.2 Collection of the Sample 128

4.3.1.3 Packaging of the Sample 129

4.3.1.4 Sealing the Packaging 130

4.4 Sources and Type of Evidence to be Considered 130

4.4.1 People 133

4.4.1.1 Conducting the Interview 136

4.4.2 Paper Documentation 138

4.4.3 Digital Documentation and Electronic Data 140

4.4.3.1 An Example about the Value of Digital Evidence 141

4.4.4 Physical Evidence 145

4.4.5 Position Data 146

4.4.6 Photographs 147

4.4.6.1 The Collection of the Photographs 148

4.4.6.2 Photograph Cataloguing 150

4.5 Recognise the Evidence 152

4.5.1 Short Case Studies 155

4.5.1.1 Explosion of Flour at the Mill of Cordero in Fossano 156

4.5.1.2 Explosion at the Pettinatura Italiana Plant 157

4.5.1.3 Explosion of the Boiler of the SISAS Plant of Pioltello 160

4.5.1.4 Explosion of the Steam Generator of the Plant Enichem Synthesis at Villadossola 163

4.5.1.5 Aluminium Dust Explosion at Nicomax in Verbania 163

4.6 Organize the Evidence 166

4.7 Conducting the Investigation and the Analysis 168

4.7.1 Method of the Conic Spiral 172

4.7.2 Evidence Analysis 173

4.8 Reporting and Communication 175

References 180

Further Reading 182

5 Investigation Methods 183

5.1 Causes and Causal Mechanism Analysis 183

5.2 Time and Events Sequence 192

5.2.1 STEP Method 196

5.3 Human Factor 199

5.3.1 Human Error 204

5.3.2 Analysis of Operative Instructions andWorking Procedures 208

5.4 Methods 212

5.4.1 Expert Judgment and Brainstorming 213

5.4.2 Structured Methods and Approaches 214

5.4.2.1 Pre-structured Methods 218

5.4.2.2 Barrier-based Systematic Cause Analysis Technique (BSCATTM) 222

5.4.2.3 Tripod Beta 228

5.4.2.4 Barrier Failure Analysis (BFA) 232

5.4.2.5 Root Cause Analysis (RCA) 238

5.4.2.6 QRA derived tools 253

References 263

Further Reading 266

6 Derive Lessons 267

6.1 Pre and Post Accident Management 267

6.2 Develop Recommendations 274

6.2.1 An Application of Risk Analysis to Choose the Best Corrective Measure 284

6.3 Communication 290

6.4 Safety (and Risk) Management and Training 296

6.5 Organization Systems and Safety Culture 298

6.6 Behavior-based Safety (BBS) 303

6.7 Understanding Near-misses and Treat Them 304

References 307

Further Reading 308

7 CaseStudies 309

7.1 Jet Fire at a Steel Plant 309

7.1.1 Introduction 309

7.1.2 How it Happened (Incident Dynamics) 310

7.1.3 Why it Happened 314

7.1.4 Findings 321

7.1.5 Lessons Learned and Recommendations 322

7.1.6 Forensic Engineering Highlights 326

7.1.7 References and Further Readings 328

7.2 Fire on Board a Ferryboat 329

7.2.1 Introduction 329

7.2.2 How it Happened (Incident Dynamics) 330

7.2.3 Why it Happened 330

7.2.4 Findings 338

7.2.5 Lessons Learned and Recommendations 342

7.2.6 Forensic Engineering Highlights 342

7.2.6.1 The Discharge Activity and the Evidence Collection 342

7.2.6.2 Use of and Issues Regarding Digital Evidences 345

7.2.6.3 Expected Performances of the Installed DigitalMemories 348

7.2.6.4 The VDR (Voyage Data Recorder) System 348

7.2.6.5 Data Extraction from the “Black Box” (i.e.: FRM Module) 350

7.2.6.6 Analysis and Use of Extracted Data 351

7.2.6.7 Documentation Analysis of the Fire Detection System 352

7.2.7 References and Further Readings 354

7.3 LOPC of Toxic Substance at a Chemical Plant 354

7.3.1 Introduction 354

7.3.2 How it Happened (Incident Dynamics) 354

7.3.3 Why it Happened 355

7.3.4 Findings 358

7.3.5 Lessons Learned and Recommendations 363

7.3.6 Forensic Engineering Highlights 364

7.4 Refinery’s Pipeway Fire 366

7.4.1 Introduction 366

7.4.2 How it Happened (Incident Dynamics) 367

7.4.3 Why it Happened 371

7.4.4 Findings 373

7.4.5 Lessons Learned and Recommendations 375

7.4.6 Forensic Engineering Highlights 378

7.4.7 References and Further Readings 379

7.5 Flash Fire at a Lime Furnace Fuel Storage Silo 381

7.5.1 Introduction 381

7.5.2 How it Happened (Incident Dynamics) 382

7.5.3 Why it Happened 385

7.5.4 Findings 388

7.5.5 Lessons Learned and Recommendations 388

7.5.6 Forensic Engineering Highlights 388

7.5.7 Further Readings 388

7.6 Explosion of a Rotisserie Van Oven Fueled by an LPG System 389

7.6.1 Introduction 389

7.6.2 How it Happened (Incident Dynamics) 390

7.6.3 Why it Happened 394

7.6.4 Findings 398

7.6.5 Lessons Learned and Recommendations 399

7.6.6 Forensic Engineering Highlights 399

7.6.7 Further Readings 406

7.7 Fragment Projection inside a Congested Process Area 407

7.7.1 Introduction 407

7.7.2 How it Happened (Incident Dynamics) 408

7.7.3 Why it Happened 408

7.7.4 Findings 409

7.7.4.1 Collection of Evidences and Data 410

7.7.4.2 Initial Plate Velocity and Box Deformation 410

7.7.4.3 Development of a Piping Damage Criteria 415

7.7.4.4 Evaluation of Damages 421

7.7.4.5 Results for Impacts for Some Pipes 421

7.7.4.6 FI-BLAST^© Adaptation to Perform a Parametric Study 422

7.7.4.7 Results of the Parametric Study 426

7.7.5 Lessons Learned and Recommendations 427

7.7.6 Forensic Engineering Highlights 428

7.7.7 References and Further Readings 429

7.8 Refinery Process Unit Fire 429

7.8.1 Introduction 429

7.8.2 How it Happened (Incident Dynamics) 429

7.8.3 Why it Happened 433

7.8.4 Findings 435

7.8.4.1 Examination of the Effects of the Fire 437

7.8.4.2 Water and Foam Consumption 438

7.8.4.3 Damages 438

7.8.5 Lessons Learned and Recommendations 438

7.8.6 Forensic Engineering Highlights 439

7.8.7 References and Further Readings 448

7.9 Crack in an Oil Pipeline 449

7.9.1 Introduction 449

7.9.2 How it Happened (Accident Dynamics) 450

7.9.3 Why it Happened 453

7.9.4 Experimental Campaign on the Pipeline Segment 453

7.9.5 Findings 457

7.9.6 Lessons Learned and Recommendations 460

7.9.7 Forensic Engineering Highlights 462

7.9.8 References and Further Readings 463

7.10 Storage Building on Fire 463

7.10.1 Introduction 463

7.10.2 How it Happened (Accident Dynamics) 464

7.10.3 Why it Happened 464

7.10.4 Findings 465

7.10.5 Lessons Learned and Recommendations 466

7.10.6 Forensic Engineering Highlights 467

7.10.7 Further Readings 467

8 Conclusions and Recommendations 469

References 471

9 A Look Into the Future 473

References 476

A Principles on Probability 477

A.1 Basic Notions on Probability 477

Index 479

The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.

The Used, Rental and eBook copies of this book are not guaranteed to include any supplemental materials. Typically, only the book itself is included. This is true even if the title states it includes any access cards, study guides, lab manuals, CDs, etc.