Table of Contents Cover Foreword by Giomi Foreword by Chiaia Foreword by Tee Preface Acknowledgement List of Acronyms Introduction Who Should Read This Book? 1.2 Going Beyond the Widget! 1.3 Forensic Engineering as a Discipline References Further Reading 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 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 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 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 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 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 Conclusions and Recommendations References 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 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 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 and of the Norman Atlantic, suggesting two different typologies of fire The oxygen controlled fire at deck (on the right) and fuel controlled fire at deck (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 Figure 3.2 The Conclusion Pyramid Source: Adapted from [10] Figure 3.3 A damaged item under investigation Figure 3.4 Handling of an item under investigation Figure 3.5 Explosion of flour at the mill of Cordero di Fossano (CN) The damages caused involved many insurance related consequences Figure 3.6 Feed line propane butane separation column Source: Adapted from [23] Reproduced with permission Figure 3.7 Top Gates of the Fire Safety Concepts Tree Figure 3.8 Use of the Scientific Method according to NFPA 921 Source: Adapted from [25] Reproduced with permission Chapter 04 Figure 4.1 The forensic engineering workflow Figure 4.2 A detailed investigative workflow Figure 4.3 During the preliminary and onsite investigation, remember to wear the PPE Figure 4.4 Collection of some portions of metal sheet from the processing tape and their subsequent enumeration, ThyssenKrupp investigation Figure 4.5 Samples in glass cans and in plastic bags with zipping closure Figure 4.6Figure 4.6 The collection process of digital data Figure 4.7 The sequence of smoke sensors activation In grey the first group, in dark grey the following 60 seconds, in dashed circle the first open loop and in dashed circle and dashed rectangles the residual activation, all in less than 180 seconds Figure 4.8 The wall collapse a few minutes after the arrival of the fire brigade unit Figure 4.9 Rolls of expanded LDPE with flame retardant included invested from heat Figure 4.10 Identification of fire extinguishers by tags (on the left) and acknowledgement by photography (on the right), ThyssenKrupp investigation Figure 4.11 Detail of a small imperfection on the edge of a metal sheet, ThyssenKrupp investigation Figure 4.12 Straight graduated ruler, Norman Atlantic fire investigation Figure 4.13 Example of metadata related to a photo taken during the ThyssenKrupp investigation Figure 4.14 Example of keywords for filtering the picture of a collection Figure 4.15 Example of visualised information when finding a photograph by keywords Figure 4.16 Example of Pareto Chart Figure 4.17 Evidence: overpressure damage to a flours repump duct flange Figure 4.18 Building (south side) with noticeable damage from excess pressure Figure 4.19 Building (north side) with widespread collapse primarily from static collapse Figure 4.20 Explosion of wool burrs, state of places Figure 4.21 Explosion of wool burrs, state of the places, card rooms Figure 4.22 Explosion of wool burrs, burrs storage boxes Figure 4.23 Explosion of wool burrs, state of places, burrs collection boxes corridor logic diagrams  171 logic tree approach  214, 215 morphological process  217, 218 MTO investigation  210–211 near misses incidents incidents vs nonincidents  304–305 investigative methods  306–307 management system  306 purpose of  306 organization systems and safety culture features of  302 incident investigation  300 investigation management system manual  299 investigation skill levels  298 magnitude of incident's severity  299 proactive and reactive system safety enhancement  301 pre and post (see also emergency management) evaluation  274 incident investigation policy  273 initial reporting  274 investigation  274 management of change (MOC)  268 preventive measures  274 prioritization of action  273 process knowledge  267–268 quality criteria  273 results dissemination  274 selection methodology  274 pre structured methods  218–222 purpose of  80 Quantitative Risk Assessment (QRA) methodologies  253–263 recommendations ALARP study  284 application  275 cost/benefit ratios  278 draft report, management approval  280 evaluation of  277 fault tree  290–293 flowchart  279 front line personnel  277 GIGO principle  281 goals  274–275 hazard control strategies  281 industry wide  276 intermediate  276 levels of  282 long range  276 modified/rejected  280 performance influencing factor  288–290 plant modifications  284–290 proactive sharing  279 review type  284 risk analysis, application of  284–290 safer designs  277 short term  276 SMART action plan  283 steps  283 strategies for drafting  275 technical contents  282 types of  281 workflow  283 root cause analysis (RCA)  238–253 root causes  171–172 safety (and risk) management and training  296–298 STEP method  196–199 task analysis  171 timeline tool  192–195 Tripod Beta  228, 230–232 indirect sampling process  129 individual failure  10 individual protection layers (IPLs)  75 induction period  19 inductive method  informal interviews  183 initiating event (IE)  47 intentional human errors  204 investigation tools  183 investigative checklists  183 j jet fire  35, 36 jet fire at steel plant consequences of  314–321 findings  321–322 forensic engineering highlights  326–328 incident dynamics  310–314 information about  309–310 lessons learned and recommendations  322–326 pickling and annealing (P&A) lines  310 l layer of protection analysis (LOPA) aim of  261 critical administrative control (CAC)  262 vs event tree analysis  262 and HAZOP  263 risk assessment tool  260 safeguards  261 safety integrity level (SIL)  263 learning from experience (LFE) process  47 limiting oxygen concentration (LOC)  18 logic trees  183 creation  190–191 multiple levels  189, 190 AND and OR combinations in  189, 190 risk assessment  189–190 LOPA see layer of protection analysis (LOPA) LOPC of toxic substance, at chemical plant cause of incident  355–357 findings  358–363 forensic engineering highlights  364–366 incident dynamics  354–355 information about  354, 355 lessons learned and recommendations  363–364 loss causation model  187, 188 Loss Of Primary Containment (LOPC)  11 lower explosive limit (LEL)  17 lower flammability limit (LFL)  17, 18 m Major Accident Reporting System (MARS)  271 refinery's pipeway fire  367 management and human errors  208 management of organizational change (MOOC)  269 Management Oversight Risk Tree (MORT) technique  219–222 Man, Technology and Organisation (MTO) investigation  210–211 material safety data sheets (MSDSs)  267–268 mechanical tests  175 minimum ignition energy (MIE)  23 minimum oxygen concentration (MOC)  18, 19 mistakes definition  209 making  208 n near hit  39–40 near miss  39–40see also accidents near misses incidents incident investigation incidents vs nonincidents  304–305 investigative methods  306–307 management system  306 purpose of  306 non destructive tests acoustic emission test  175 with current  175 leakage test  174 magnetoscopy  174 with penetrating liquid  174 ultrasounds test  175 visual exam  174 Norman Atlantic Fire, numerical simulations  253, 255 Norman Atlantic investigation, timeline tool developed for  193, 194 not confined fires  25 o operational excellence (OE) of company  40 organisational network  organisational safety culture  71 organizational change management (OCM)  269 organizational incident  84 organizational recurrent factor  71, 72 organizational/system failure  10 organization systems and safety culture incident investigation features of  302 incident investigation  300 investigation management system manual  299 investigation skill levels  298 magnitude of incident's severity  299 proactive and reactive system safety enhancement  301 oxygen controlled fires  16–17, 25, 26 p paper documentation  138–140 Pareto analysis  152, 154 partially confined explosions  38 people related data evidence  133–138 performance indicators  471 development of  71 examples of  70 lagging process safety  68, 70 leading process safety  68, 70 organizational recurrent factor  71, 72 performance influencing factor (PIF)  288–290 photographs, as evidence  147 cataloguing  150–152 collection of  148–150 physical evidence  145–146 piloted ignition  23 piping and instrumentation diagram (P&ID), for benzene production  44, 46 pool fire  35, 36 potential incident  11 pre and post incident investigation see also emergency management evaluation  274 incident investigation policy  273 initial reporting  274 investigation  274 management of change (MOC)  268 preventive measures  274 prioritization of action  273 process knowledge  267–268 quality criteria  273 results dissemination  274 selection methodology  274 pre defined trees  183 preliminary and onsite investigation evidence (see evidence) personal protection equipment  124 proper documentation  125 sampling process  127–130 security chain of custody  125 time factor  126 premixed flames  28 primary dust explosion  31, 33 probability principles  477–478 process flow sheet (PFS), for benzene production  44, 45 process hazard analysis (PHA)  47 process safety  471 commitment  42 culture  42 definition  40 management of  41–47 process safety information (PSI)  267–268 production and design documents  139 programmatic cause  85 project management attitude  pyrolysis  17 q qualitative risk analysis  75 Quantitative Risk Assessment (QRA) methodologies event tree analysis (ETA)  257, 259–260 fault tree analysis (FTA)  254–258 layer of protection analysis (LOPA)  260–263 r radiation  15 RealityCharting® software  246, 248 REASON© RCA  249, 251–254 Reason's classification of human error  206, 207 recommendations, incident investigation ALARP study  284 application  275 cost/benefit ratios  278 draft report, management approval  280 evaluation of  277 fault tree  290–293 flowchart  279 front line personnel  277 GIGO principle  281 goals  274–275 hazard control strategies  281 industry wide  276 intermediate  276 levels of  282 long range  276 modified/rejected  280 performance influencing factor  288–290 plant modifications  284–290 proactive sharing  279 review type  284 risk analysis, application of  284–290 safer designs  277 short term  276 SMART action plan  283 steps  283 strategies for drafting  275 technical contents  282 types of  281 workflow  283 refinery process unit fire findings  435–438 forensic engineering highlights  439–448 incident dynamics  429–433 information about  429, 430 investigation results  433–435 lessons learned and recommendations  438–439 refinery's pipeway fire causes of incident  371–373 findings  373–375 forensic engineering highlights  378–380 incident dynamics  367–371 information about  366, 367 lessons learned and recommendations  375–378 MARS database  367 reporting during incident investigation  177–180 resilience test  175 risk acceptability  74 assessments  47, 470 definition  72, 74 matrix  74–75 mitigation  75 risk based process safety management  41, 42 Risk Priority Number (RPN)  105 root cause analysis (RCA)  84, 238–253 Apollo RCA™ methodology  246–251 Corrective Action Helper Module  246, 247 definition  238, 239 ferryboat, fire on board  332 levels of analysis  240 RealityCharting® software  246, 248 reasoning by analogy  241 REASON© RCA  249, 251–254 Root Cause Map™  242–243 TapRooT®  243–246 TIER diagrams  242 Root Cause Map™  242–243 root cause, of an incident  83, 85 rotisserie van oven fueled by LPG system causes of incident  394–398 findings  398–399 forensic engineering highlights  399–406 incident dynamics  390–394 information about  389, 390 lessons learned and recommendations  399 s safeguard  47 safety documentation  139 safety instrumented function (SIF)  44 safety instrumented system (SIS)  44 safety integrity level (SIL)  43–44 safety (and risk) management and training  296–298 safety management system (SMS)  79 safety related incidents  11 sampling process, preliminary and onsite investigation sample collection  128–129 sample packaging  129–130 sample selection  127–128 sealing the packaging  130 San Juanico disaster  60, 61, 63, 64 scientific investigation, goal of  82 secondary dust explosion  31, 33 self correcting process step  209, 210 semi quantitative risk analysis  75 sequence diagram  183 sequence errors  207 sequentially timed events plotting (STEP) method assumptions  196 BackSTEP analysis  197 for car accident  197 row and column tests for  197, 198 worksheet  196, 198, 199 Seveso disaster  48–51 smoldering  28 smouldering fires  17 SnapCharT®  243, 244, 246 spontaneous ignition  23 spreadsheet event timeline  193 STEP method see sequentially timed events plotting (STEP) method storage building on fire accident dynamics  464 causes for  464–465 findings  465–466 forensic engineering highlights  467 information about  463 lessons learned and recommendations  466–467 Swiss cheese model  212–213 t TapRooT®  243–246 technical standards creation of  106 definition  105 EN/IEC 61508, 107 EN/IEC 61511, 107–109 individual protection layer (IPL)  108–109 NFPA 550Standard 109 NFPA 921Standard 110–111 purpose of  111 thermal degradation  155 timeline tool  183 for complex incidents  194 construction  194–195 developed for Norman Atlantic investigation  193, 194 for single event  194 timing errors  207 traction test  175 Tripod Beta  228 analysis  230 appearances  230, 231 basic risk factors  231, 232 u uncertainty  74 unconfined vapor cloud explosion (UVCE)  37–38 underlying cause, of an incident  83 undesired circumstance  39, 40 unintentional human errors  204 upper explosive limit (UEL)  17 upper flammability limit (UFL)  17, 18 v Venn diagrams  477, 478 virtual reality, during onsite inspection  475, 476 voyage data recorder (VDR) data ferryboat, fire on board 330 w “what if” analysis  100–101 WILEY END USER LICENSE AGREEMENT Go to www.wiley.com/go/eula to access Wiley’s ebook EULA ... incidenti industriali” (Principles of forensic engineering applied to industrial accidents) by Prof Luca Fiorentini and Prof Luca Marmo constitutes an essential text for researchers and professionals... Forensic Engineering Applied to Industrial Accidents I was invited to so by one author of this book, Luca Fiorentini, who is the editorial board member of the International Journal of Forensic Engineering. .. author Title: Principles of forensic engineering applied to industrial accidents /  Luca Fiorentini, Prof Luca Fiorentini, TECSA S.r.l., IT, Luca Marmo,  Prof Luca Marmo, Politecnico di Torino, IT