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