Table Of ContentPrinciplesofForensicEngineeringAppliedto
IndustrialAccidents
Principles of Forensic Engineering Applied to
Industrial Accidents
LucaFiorentini
TECSAS.r.l.
Italy
LucaMarmo
PolitecnicodiTorino
Italy
Thiseditionfirstpublished2019
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LibraryofCongressCataloging-in-PublicationData
Names:Fiorentini,Luca,1976-author.|Marmo,Luca,1967-author.
Title:Principlesofforensicengineeringappliedtoindustrialaccidents/
LucaFiorentini,Prof.LucaFiorentini,TECSAS.r.l.,IT,LucaMarmo,
Prof.LucaMarmo,PolitecnicodiTorino,IT.
Description:Firstedition.|Hoboken,NJ,USA:Wiley,2019.|Includes
bibliographicalreferencesandindex.|
Identifiers:LCCN2018034915(print)|LCCN2018037469(ebook)|ISBN
9781118962787(AdobePDF)|ISBN9781118962794(ePub)|ISBN9781118962817
(hardcover)
Subjects:LCSH:Forensicengineering.|Industrialaccidents.|Accident
investigation–Casestudies.
Classification:LCCTA219(ebook)|LCCTA219.F572018(print)|DDC
363.11/65–dc23
LCrecordavailableathttps://lccn.loc.gov/2018034915
CoverDesign:Wiley
CoverImage:©Phonix_a/GettyImages
Setin10/12ptWarnockProbySPiGlobal,Chennai,India
10 9 8 7 6 5 4 3 2 1
Tomywonderfulfamily:tomybelovedwifeSoniaandtomyincrediblechildren
Riccardo,LodovicoandEttore.
Toallthosewho,thankstothisbook,willtaketheirfirststepsintheworldofforensic
engineeringorincreasetheirinterestinthisfascinatingdiscipline.
LucaFiorentini
ToBaba,Beat,Bibi,Chicco.
Toallthoseguysthatbelieveinscience,evidencesandknowledge.
LucaMarmo
vii
Contents
ForewordbyGiomi xiii
ForewordbyChiaia xv
ForewordbyTee xvii
Preface xix
Acknowledgement xxi
ListofAcronyms xxiii
1 Introduction 1
1.1 WhoShouldReadThisBook? 1
1.2 GoingBeyondtheWidget! 2
1.3 ForensicEngineeringasaDiscipline 5
References 7
FurtherReading 7
2 IndustrialAccidents 9
2.1 Accidents 9
2.1.1 PrinciplesofCombustion 14
2.1.1.1 FlammableGasesandVapors 17
2.1.1.2 FlammableLiquids 21
2.1.1.3 TheIgnition 22
2.1.2 Fires 23
2.1.3 Explosions 27
2.1.4 IncidentalScenarios 33
2.2 NearMisses 39
2.3 ProcessSafety 40
2.3.1 ManagementofSafety 41
2.4 TheImportanceofAccidents 47
2.4.1 Sevesodisaster 48
2.4.2 BhopalDisaster 51
2.4.3 FlixboroughDisaster 55
2.4.4 DeepwaterHorizonDrillingRigExplosion 58
2.4.5 SanJuanicoDisaster 60
2.4.6 BuncefieldDisaster 64
2.5 PerformanceIndicators 68
viii Contents
2.6 TheRoleof‘Uncertainty’and‘Risk’ 72
References 75
Furtherreading 78
3 WhatisAccidentInvestigation?WhatisForensicEngineering?Whatis
RiskAssessment?WhoistheForensicEngineerandwhatishis
Role? 79
3.1 Investigation 79
3.2 ForensicEngineering 87
3.3 LegalAspects 91
3.4 EthicIssues 95
3.5 InsuranceAspects 96
3.6 AccidentPreventionandRiskAssessment 98
3.6.1 “What-if”Analysis 100
3.6.2 HazardandOperabilityAnalysis(HAZOP)&HazardIdentification
(HAZID) 101
3.6.3 FailureModesandEffectsAnalysis(FMEA) 105
3.7 TechnicalStandards 105
References 112
FurtherReading 113
4 TheForensicEngineeringWorkflow 115
4.1 TheWorkflow 115
4.2 TeamandPlanning 118
4.3 PreliminaryandOnsiteInvestigation(CollectingtheEvidence) 124
4.3.1 Sampling 127
4.3.1.1 SelectionoftheSample 127
4.3.1.2 CollectionoftheSample 128
4.3.1.3 PackagingoftheSample 129
4.3.1.4 SealingthePackaging 130
4.4 SourcesandTypeofEvidencetobeConsidered 130
4.4.1 People 133
4.4.1.1 ConductingtheInterview 136
4.4.2 PaperDocumentation 138
4.4.3 DigitalDocumentationandElectronicData 140
4.4.3.1 AnExampleAbouttheValueofDigitalEvidence 141
4.4.4 PhysicalEvidence 145
4.4.5 PositionData 146
4.4.6 Photographs 147
4.4.6.1 TheCollectionofthePhotographs 148
4.4.6.2 PhotographCataloguing 150
4.5 RecognisetheEvidence 152
4.5.1 ShortCaseStudies 155
4.5.1.1 ExplosionofFlourattheMillofCorderoinFossano 156
4.5.1.2 ExplosionatthePettinaturaItalianaPlant 157
4.5.1.3 ExplosionoftheBoileroftheSISASPlantofPioltello 160
Contents ix
4.5.1.4 ExplosionoftheSteamGeneratorofthePlantEnichemSynthesisat
Villadossola 163
4.5.1.5 AluminiumDustExplosionatNicomaxinVerbania 163
4.6 OrganizetheEvidence 166
4.7 ConductingtheInvestigationandtheAnalysis 168
4.7.1 MethodoftheConicSpiral 172
4.7.2 EvidenceAnalysis 173
4.8 ReportingandCommunication 175
References 180
FurtherReading 182
5 InvestigationMethods 183
5.1 CausesandCausalMechanismAnalysis 183
5.2 TimeandEventsSequence 192
5.2.1 STEPMethod 196
5.3 HumanFactor 199
5.3.1 HumanError 204
5.3.2 AnalysisofOperativeInstructionsandWorkingProcedures 208
5.4 Methods 212
5.4.1 ExpertJudgmentandBrainstorming 213
5.4.2 StructuredMethodsandApproaches 214
5.4.2.1 Pre-structuredMethods 218
5.4.2.2 Barrier-basedSystematicCauseAnalysisTechnique(BSCATTM) 222
5.4.2.3 TripodBeta 228
5.4.2.4 BarrierFailureAnalysis(BFA) 232
5.4.2.5 RootCauseAnalysis(RCA) 238
5.4.2.6 QRAderivedtools 253
References 263
FurtherReading 266
6 DeriveLessons 267
6.1 PreandPostAccidentManagement 267
6.2 DevelopRecommendations 274
6.2.1 AnApplicationofRiskAnalysistoChoosetheBestCorrective
Measure 284
6.3 Communication 290
6.4 Safety(andRisk)ManagementandTraining 296
6.5 OrganizationSystemsandSafetyCulture 298
6.6 Behavior-basedSafety(BBS) 303
6.7 UnderstandingNear-missesandTreatThem 304
References 307
FurtherReading 308
7 CaseStudies 309
7.1 JetFireataSteelPlant 309
7.1.1 Introduction 309
7.1.2 HowitHappened(IncidentDynamics) 310
x Contents
7.1.3 WhyitHappened 314
7.1.4 Findings 321
7.1.5 LessonsLearnedandRecommendations 322
7.1.6 ForensicEngineeringHighlights 326
7.1.7 ReferencesandFurtherReadings 328
7.2 FireonBoardaFerryboat 329
7.2.1 Introduction 329
7.2.2 HowitHappened(IncidentDynamics) 330
7.2.3 WhyitHappened 330
7.2.4 Findings 338
7.2.5 LessonsLearnedandRecommendations 342
7.2.6 ForensicEngineeringHighlights 342
7.2.6.1 TheDischargeActivityandtheEvidenceCollection 342
7.2.6.2 UseofandIssuesRegardingDigitalEvidences 345
7.2.6.3 ExpectedPerformancesoftheInstalledDigitalMemories 348
7.2.6.4 TheVDR(VoyageDataRecorder)System 348
7.2.6.5 DataExtractionfromthe“BlackBox”(i.e.:FRMModule) 350
7.2.6.6 AnalysisandUseofExtractedData 351
7.2.6.7 DocumentationAnalysisoftheFireDetectionSystem 352
7.2.7 ReferencesandFurtherReadings 354
7.3 LOPCofToxicSubstanceataChemicalPlant 354
7.3.1 Introduction 354
7.3.2 HowitHappened(IncidentDynamics) 354
7.3.3 WhyitHappened 355
7.3.4 Findings 358
7.3.5 LessonsLearnedandRecommendations 363
7.3.6 ForensicEngineeringHighlights 364
7.4 Refinery’sPipewayFire 366
7.4.1 Introduction 366
7.4.2 HowitHappened(IncidentDynamics) 367
7.4.3 WhyitHappened 371
7.4.4 Findings 373
7.4.5 LessonsLearnedandRecommendations 375
7.4.6 ForensicEngineeringHighlights 378
7.4.7 ReferencesandFurtherReadings 379
7.5 FlashFireataLimeFurnaceFuelStorageSilo 381
7.5.1 Introduction 381
7.5.2 HowitHappened(IncidentDynamics) 382
7.5.3 WhyitHappened 385
7.5.4 Findings 388
7.5.5 LessonsLearnedandRecommendations 388
7.5.6 ForensicEngineeringHighlights 388
7.5.7 FurtherReadings 388
7.6 ExplosionofaRotisserieVanOvenFueledbyanLPGSystem 389
7.6.1 Introduction 389
7.6.2 HowitHappened(IncidentDynamics) 390
7.6.3 WhyitHappened 394
Contents xi
7.6.4 Findings 398
7.6.5 LessonsLearnedandRecommendations 399
7.6.6 ForensicEngineeringHighlights 399
7.6.7 FurtherReadings 406
7.7 FragmentProjectionInsideaCongestedProcessArea 407
7.7.1 Introduction 407
7.7.2 HowitHappened(IncidentDynamics) 408
7.7.3 WhyitHappened 408
7.7.4 Findings 409
7.7.4.1 CollectionofEvidencesandData 410
7.7.4.2 InitialPlateVelocityandBoxDeformation 410
7.7.4.3 DevelopmentofaPipingDamageCriteria 415
7.7.4.4 EvaluationofDamages 421
7.7.4.5 ResultsforImpactsforSomePipes 421
7.7.4.6 FI-BLAST©AdaptationtoPerformaParametricStudy 422
7.7.4.7 ResultsoftheParametricStudy 426
7.7.5 LessonsLearnedandRecommendations 427
7.7.6 ForensicEngineeringHighlights 428
7.7.7 ReferencesandFurtherReadings 429
7.8 RefineryProcessUnitFire 429
7.8.1 Introduction 429
7.8.2 HowitHappened(IncidentDynamics) 429
7.8.3 WhyitHappened 433
7.8.4 Findings 435
7.8.4.1 ExaminationoftheEffectsoftheFire 437
7.8.4.2 WaterandFoamConsumption 438
7.8.4.3 Damages 438
7.8.5 LessonsLearnedandRecommendations 438
7.8.6 ForensicEngineeringHighlights 439
7.8.7 ReferencesandFurtherReadings 448
7.9 CrackinanOilPipeline 449
7.9.1 Introduction 449
7.9.2 HowitHappened(AccidentDynamics) 450
7.9.3 WhyitHappened 453
7.9.4 ExperimentalCampaignonthePipelineSegment 453
7.9.5 Findings 457
7.9.6 LessonsLearnedandRecommendations 460
7.9.7 ForensicEngineeringHighlights 462
7.9.8 ReferencesandFurtherReadings 463
7.10 StorageBuildingonFire 463
7.10.1 Introduction 463
7.10.2 HowitHappened(AccidentDynamics) 464
7.10.3 WhyitHappened 464
7.10.4 Findings 465
7.10.5 LessonsLearnedandRecommendations 466
7.10.6 ForensicEngineeringHighlights 467
7.10.7 FurtherReadings 467
xii Contents
8 ConclusionsandRecommendations 469
References 471
9 ALookIntotheFuture 473
References 476
A PrinciplesonProbability 477
A.1 BasicNotionsonProbability 477
Index 479
