Principles of Forensic Engineering Applied to Industrial Accidents

727 Pages·2019·25.92 MB·English

by  Luca Fiorentini

Table of Contents
Cover
Foreword by Giomi
Foreword by Chiaia
Foreword by Tee
Preface
Acknowledgement
List of Acronyms
1 Introduction
Who Should Read This Book?
1.2 Going Beyond the Widget!
1.3 Forensic Engineering as a Discipline
References
Further Reading
2 Industrial Accidents
2.1 Accidents
2.2 Near Misses
2.3 Process Safety
2.4 The Importance of Accidents
2.5 Performance Indicators
2.6 The Role of ‘Uncertainty’ and ‘Risk’
References
Further reading
3 What is Accident Investigation? What is Forensic Engineering? What is
Risk Assessment? Who is the Forensic Engineer and what is his Role?
3.1 Investigation
3.2 Forensic Engineering
3.3 Legal Aspects
3.4 Ethic Issues
3.5 Insurance Aspects
3.6 Accident Prevention and Risk Assessment
3.7 Technical Standards
References
Further Reading
4 The Forensic Engineering Workflow
4.1 The Workflow
4.2 Team and Planning
4.3 Preliminary and Onsite Investigation (Collecting the Evidence)
4.4 Sources and Type of Evidence to be Considered
4.5 Recognise the Evidence
4.6 Organize the Evidence
4.7 Conducting the Investigation and the Analysis
4.8 Reporting and Communication
References
Further Reading
5 Investigation Methods
5.1 Causes and Causal Mechanism Analysis
5.2 Time and Events Sequence
5.3 Human Factor
5.4 Methods
References
Further Reading
6 Derive Lessons
6.1 Pre and Post Accident Management
6.2 Develop Recommendations
6.3 Communication
6.4 Safety (and Risk) Management and Training
6.5 Organization Systems and Safety Culture
6.6 Behavior-based Safety (BBS)
6.7 Understanding Near-misses and Treat Them
References
Further Reading
7 Case Studies
7.1 Jet Fire at a Steel Plant
References
Further readings
7.2 Fire on Board a Ferryboat
References
Further Readings
7.3 LOPC of Toxic Substance at a Chemical Plant
7.4 Refinery's Pipeway Fire
References
Further Readings
7.5 Flash Fire at a Lime Furnace Fuel Storage Silo
Further readings
7.6 Explosion of a Rotisserie Van Oven Fueled by an LPG System
Further Readings
7.7 Fragment Projection Inside a Congested Process Area
Reference
Further Readings
7.8 Refinery Process Unit Fire
Reference
Further readings
7.9 Crack in an Oil Pipeline
References
Further Reading
7.10 Storage Building on Fire
Further Readings
8 Conclusions and Recommendations
References
9 A Look Into the Future
References
Appendix A: Principles on Probability
A.1 Basic Notions on Probability
Index
End User License Agreement
List of Tables
Chapter 02
Table 2.1 Incident typologies and correlated potentiality and magnitude.
Table 2.2 Flammability limits of some gas and vapors.
Table 2.3 MOC values (volume percent oxygen concentration above
which combustion can occur).
Table 2.4 Approximate values of the Auto Ignition Temperature for some
substances.
Table 2.5 Storage pressure of some compressed gasses.
Table 2.6 Classification of flammable liquids according to CLP Rule (EU
Directive 1272/08).
Table 2.7 Classification and FPT of some common flammable liquids.
Table 2.8 Extinguishers and their actions.
Table 2.9 Categories of growth velocity of fire.
Table 2.10 Values of t for some materials commonly used.
1
Table 2.11 Characteristic explosion indexes for gasses and vapors.
Table 2.12 Characteristic explosion indexes for powders.
Chapter 03
Table 3.1 Example of “what-if” analysis [23].
Table 3.2 Guide words for HAZOP analysis.
Table 3.3 Extract of example of HAZOP analysis.
Table 3.4 Subdivision of the analysed system into areas.
Table 3.5 Subdivision of the analysed system into areas.
Table 3.6 List of typical consequences.
Table 3.7 HAZID worksheet.
Table 3.8 Relations between discrete values of SIL and continuous range
of PFD and PFH.
Chapter 04
Table 4.1 Possible checklist for developing an investigation plan.
Table 4.2 Investigation team members should and should not.
Table 4.3 Some containers for sampling, their main features, pros, and
cons.
Table 4.4 Checklists to evidence examination.
Table 4.5 Forms of data fragility.
Table 4.6 Digital evidence and their volatility.
Table 4.7 Example of form to use for the collection of pictures.
Table 4.8 Summary of the evidence and deductions.
Table 4.9 Summary of technical assessments, explosion of wool burrs at
Pettinatura Italiana.
Table 4.10 Sequence of events that led to the explosion.
Table 4.11 Summary of the evidence and deductions.
Table 4.12 Summary of the evidence and deductions
Table 4.13 Summary of the evidence and deductions.
Chapter 05
Table 5.1 Examples of unsafe acts and conditions.
Table 5.2 Example of spreadsheet event timeline.
Table 5.3 Example of Gantt chart investigation timeline.
Table 5.4 Example of human factors in process operations.
Table 5.5 Human and management errors.
Table 5.6 Definition of BRFs in Tripod.
Table 5.7 Causal factor types and problem categories.
Chapter 06
Table 6.1 PIF (current configuration).
Table 6.2 PIF (A configuration).
Table 6.3 PIF (POST configuration).
Table 6.4 Frequency of the considered incidental hypotheses
Table 6.5 Comparative table for teaching differences between incidents
and nonincidents.
Chapter 07
Table 7.1.1 General information about the case study.
Table 7.1.2 Record of the supervisor systems (adapted from Italian).
Table 7.1.3 Threshold values according to Italian regulations.
Table 7.1.4 Summary of the investigation.
Table 7.2.1 General information about the case study.
Table 7.2.2 Some lessons learned from the incident, written so that they
can also be used in other business sectors, such as the process industry.
Table 7.3.1 General information about the case study.
Table 7.4.1 General information about the case study.
Table 7.5.1 General information about the case study.
Table 7.5.2 Chemical substances involved.
Table 7.6.1 General information about the case study.
Table 7.6.2 Reference parameters for scenario b).
Table 7.6.3 Scenario a), release characteristics.
Table 7.6.4 Identification of simulations related to scenario a) indicating
the breaking point and of the released phase.
Table 7.6.5 Results of simulations with C-Phast code.
Table 7.7.1 General information about the case study.
Table 7.7.2 Simulation results for steam pressure and temperature
variation.
Table 7.7.3 Simulations characterised by a Dynamic Increase Factor.
Table 7.7.4 Results for impacts.
Table 7.8.1 General information about the case study
Table 7.8.2 Tabular timeline of the main events.
Table 7.9.1 General information about the case study.
Table 7.10.1 General information about the case study.
List of Illustrations
Chapter 01
Visual explanation of the addition rule of probability, through Venn
diagrams.
Visual explanation of the conditional probability, through Venn
diagrams.
Chapter 01
Figure 1.1 The onion-like structure between immediate causes and root
causes.
Figure 1.2 Galileo Galilei (left) and Roger Bacon (right): two of the
brightest scientists of the world who supported the scientific method.
Chapter 02
Figure 2.1 Causes of industrial accidents in chemical and petrochemical
plants in the United States in 1998.
Figure 2.2 Components related to the industrial accidents in chemical and
petrochemical plants in the United States in 1998.
Figure 2.3 The Fire Triangle.
Figure 2.4 The different mechanisms of heat transfer.
Figure 2.5 The involvement of deck no. 3 of the Norman Atlantic into the
fire, due to radiation: simulation and evidence (plastic boxes, melted at
the top).
Figure 2.6 The chromatic scale of the temperatures in a gas fuel.
Figure 2.7 Graphical representation of the concepts of LFL and UFL.
Figure 2.8 Relations among the flammability properties of gas and
vapors.
Figure 2.9 Comparison among the MIE of gases and vapors and the
energy of electrostatic sparks. Adapted from [11].
Figure 2.10 Different colors at the access of deck 3 and 4 of the Norman
Atlantic, suggesting two different typologies of fire. The oxygen-
controlled fire at deck 3 (on the right) and fuel-controlled fire at deck 4
(on the left).
Figure 2.11 Evolution of a fire.
Figure 2.12 Shock front and pressure front in detonations and
deflagrations.
Figure 2.13 Primary and secondary dust explosion.
Figure 2.14 Incidental scenarios and their genesis.
Figure 2.15 An example of Flash Fire.
Figure 2.16 On the left, a modelled jet fire for a fire investigation
Figure 2.17 Example of Pool Fire.
Figure 2.18 Schematic representation of a fireball in the stationary stage.
Figure 2.19 A Vapor Cloud Explosion test.
Figure 2.20 Sequence events to BLEVE.
Figure 2.21 Example of BLEVE.
Figure 2.22 Differences between accident (a), near miss (b), and
undesired circumstance (c).
Figure 2.23 Contributing factors in improving loss prevention
performance in the process industry.
Figure 2.24 The evolution of safety culture.
Figure 2.25 Example of BFD for the production of benzene by the
HydroDeAlkylation of toluene (HDA).
Figure 2.26 Example of PFS for the manufacture of benzene by Had.
Figure 2.27 Example of P&ID for the production of benzene by Had.
Figure 2.28 Principles of incident analysis.
Figure 2.29 The importance of incident investigation.
Figure 2.30 Steps of incident analysis.
Figure 2.31 Temperatures at the Seveso reactor.
Figure 2.32 A photograph of the signs used to forbid access into the
infected areas in Seveso.
Figure 2.33 Simplified conceptual Bow-Tie of Seveso incident.
Figure 2.34 The chemical plant in Bhopal after the incident.
Figure 2.35 Arrangement of reactors and temporary bypass.
Figure 2.36 The chemical plant in Flixborough after the incident.
Figure 2.37 The Deepwater Horizon drilling rig on fire.
Figure 2.38 Application of the Apollo RCA™ Method using
RealityCharting® to the Deepwater Horizon incident.
Figure 2.39 Application of the Apollo RCA™ Method using
RealityCharting® to the Deepwater Horizon incident. Used by
permission. Taken from [43].
Figure 2.40 Application of the Apollo RCA™ Method using
RealityCharting® to the Deepwater Horizon incident.
Figure 2.41 Some LPG spherical tanks during the San Juanico disaster.
Figure 2.42 The IHLS.
Figure 2.43 The site after the incident.
Figure 2.44 Pipe penetrations for the loss of seal between pipes and
walls.
Figure 2.45 RCA of the Bouncefield explosion developed by company
Governors BV (NL).
Figure 2.46 Example of a risk matrix.
Chapter 03
Figure 3.1 Phases in accident investigation.