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What should be in a reading list on failures, disasters and their prevention 12

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MartinLe

MartinLe

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Oct 12, 2012
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Beyond the specific codes etc. I work with in my field, what are essential readings on the above?

I'm interested in the social aspects as well as in how to systematically think about the technical aspects. Reports of investigations into specific accidents may also be interesting.

My own field is supervision of construction sites and design of wastewater treatment plants but I'm also interested in safety thinking for other fields.

Onn one hand, I sometimes encounter codes or standards that don't feel entirely logical, but then I'm not sure what would actually be logical. On the other hand, there's often a drive to not follow all regulations etc. when they get into the way of the work.

What would I do on such a reading list?
I'm thinking of getting "Normal Accidents" unless a more recent work on similar themes is better in some way.

A few years back I read a longish report on the sinking of the Merchant Vessel Faro that went into the technical details but also contained lots of transcripts of what was said on the bridge, alowing one at least to guess what went through the minds of the sailors in their last hours (don'tfind the link to the report now, shorter article without technical details:
This subforum!
 
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The NTSB wesite will have quite a few, plus other incident investigating organisations such as the CAA, MAIB,(UK based) plus OSHA and many others. They publish reports and recommendations.

The HSE in the UK publish many guidance documents and research reports - You need to go digging for those a bit but search for RR or "research reports HSE"

I'm sure there is an equivalent in the US.

Also try the specialist magazines and also the engineering industry body responsible for civil design or waste water. They will have a good list somewhere.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.
 
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megaprojects_bwslox.jpg



Brad Waybright

It's all okay as long as it's okay.
 
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Here lately, most of my intake of that kind of stuff has been via Youtube videoos rather than reading. On the historic stuff, a visit to a good library should turn up material.
The Chemical Safety Board issues reports (and videos) of accidents that are fairly informative.
 
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"I'm interested in the social aspects as well as in how to systematically think about the technical aspects."

The Mayday TV series (various names in different markets) is exactly that, but focused on air accidents. Many such investigations focus on the human / social factors that surround such accidents, making the TV series a useful resource.

 
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I'm interested in the social aspects as well as in how to systematically think about the technical aspects. Reports of investigations into specific accidents may also be interesting.
Click to expand...

I would start with a thorough review of the usual lean/agile process, DFMEA, and failure analysis training then consider a few case studies. Usually the first question to consider with case studies is - Did the process fail or did the people? Usually its the later as people shortcut the process by not considering every failure mode, which is why standard process and standard templates are our friend.
 
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CWB1, in talking about people failing, do you mean in the design process or during manufacture / operation / maintenance?

Upon first glance, I'm not sure a DFMEA goes much beyond a risk assesment according to the EU machinery directive (apparently there's no equivalent in the US & no equivalent to a CE marking).
 
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CWB1, in talking about people failing, do you mean in the design process or during manufacture / operation / maintenance?

Upon first glance, I'm not sure a DFMEA goes much beyond a risk assesment according to the EU machinery directive (apparently there's no equivalent in the US & no equivalent to a CE marking).
Click to expand...

The technical aspects of a particular design should be driven by a DFMEA. Every aspect of the construction, maintenance, and usage, along with your overall design process are driven by a PFMEA. I understood the OP to be mostly interested in the design aspects but realistically, there should be a FMEA covering every detail and driving subprocess like safety plans and quality inspections by explicitly listing out specific mitigations for every risk. When I question whether the process failed or did the people, I'm effectively asking if a complete process was followed or shortcuts taken. If a FMEA wasn't created or followed then shortcuts were taken.

Consumer safety laws are a bit of a pet peeve of mine. Stateside ours have been whittled away over the years by a combination of lobbying on the part of foreign importers and the legal societies whose lifeblood is lawsuits. Our equivalent of your CE mark is a stamp from one of our nationally recognized testing labs, the most common being "Underwriter's Laboratories" and their "UL-certification." Years ago it was rare stateside to find anything electrical without one, today its common.
 
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Away from engineering, but still dealing with defective thinking that can lead to disaster, are the following books about injury and death in three of the most visited national parks in the United States. I have read all three.
[ul]
[li]Death in Yellowstone: Accidents and Foolhardiness in the First National Park
[/li]
[li]Off the Wall: Death in Yosemite
[/li]
[li]Over The Edge: Death in Grand Canyon, Newly Expanded 10th Anniversary Edition
[/li]
[/ul]

I have visited each of these national parks: Yellowstone three times, Yosemite about 200 times (seriously, it's a day trip for me), and Grand Canyon twice. I hike a lot in Yosemite and by nature am pretty cautious. These books have re-emphasized to me the importance of good decision making while on the trail.

(A Google search for [books about death in the national parks] turned up several more similar books about other national parks, including Zion and Glacier.)

============
"Is it the only lesson of history that mankind is unteachable?"
--Winston S. Churchill
 
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I'm not sure what is the definitive history on the Comet I, but for sure they eventually figured out forensically what went wrong/was missed during the design & validation phases.
Another less catastrophic fiasco was the parent metal aluminum cylinder concept in the GM 2300cc Vega engine introduced in 1971 or so.
Unsafe at any Speed by Ralph Nader makes interesting reading, and while controversial technically, might make a good starting point for deeper investigation of questionable designs that were offered to the public.

"Schiefgehen wird, was schiefgehen kann" - das Murphygesetz
 
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The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA
by Diane Vaughan

The hardback edition which I have is thick. A slow reading book that drives home the phrase "Normalization of Deviance". But for me, made me re-think the decision processes and internal culture of the companies at which I have worked.
 
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Speaking of the Challenger disaster...

On this day in history (January 28, 1986): Challenger explosion kills 7 astronauts


I had just been promoted and subsequently transferred from SoCal to Detroit (I was working for the commercial software division of McDonnell Douglas). We heard about the accident a few minutes after I had walked into our sales office in Southfield for my first day on the job in my new role as the Midwest Regional Sales Support Manager. I only knew a few of the people in the office and had to start from scratch since this was a new position with people reporting to me who had previously been part of other organizations. Needless to say, my plans for my first day on the new job went totally out the window.


John R. Baker, P.E. (ret)
EX-Product 'Evangelist'
Irvine, CA
Siemens PLM:
UG/NX Museum:

The secret of life is not finding someone to live with
It's finding someone you can't live without
 
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