Learning from Failures book cover

Learning from Failures

Decision Analysis of Major Disasters

Learning from Failures provides techniques to explore the root causes of specific disasters and how we can learn from them. It focuses on a number of well-known case studies, including: the sinking of the Titanic; the BP Texas City incident; the Chernobyl disaster; the NASA Space Shuttle Columbia accident; the Bhopal disaster; and the Concorde accident. This title is an ideal teaching aid, informed by the author’s extensive teaching and practical experience and including a list of learning outcomes at the beginning of each chapter, detailed derivation, and many solved examples for modeling and decision analysis.

This book discusses the value in applying different models as mental maps to analyze disasters. The analysis of these case studies helps to demonstrate how subjectivity that relies on opinions of experts can be turned into modeling approaches that can ensure repeatability and consistency of results. The book explains how the lessons learned by studying these individual cases can be applied to a wide range of industries.

This work is an ideal resource for undergraduate and postgraduate students, and will also be useful for industry professionals who wish to avoid repeating mistakes that resulted in devastating consequences.


Primarily post graduate and under graduate students. Secondary usage by Process Engineers, Safety Engineers, Chemical Engineers, Mechanical Engineers in the Process Industries, Managers in the Process Industries, Safety Consultants.

Hardbound, 336 Pages

Published: June 2014

Imprint: Butterworth Heinemann

ISBN: 978-0-12-416727-8


  • Part One: Background of Analytical methods used in investigation of disasters

    Chapter 1: Introduction to the concept of Learning from Failures


    Why Learning from Failures

    The Background of this Book

    Introduction to the Concept of Learning from Failures

    Taxonomy of Theories

    Learning from Case Studies versus the Narrative Fallacy Concept

    Learning from Hindsight Rewards versus Risk Aversion

    Specific versus Generic Lessons

    High Reliability Theory versus Normal Accidents Theory

    Reliability versus Safety

    Concluding Remarks on Theories related to Learning from Failures

    Case Studies

    Choice of Case studies and research methodology

    Types of Recommendations

    Chapter 2: Introduction to Failure Analysis Techniques in Reliability Modelling


    FTA and RBD

    Example: Storage Tank

    A Simple Illustrative Application Case (Car Accident)

    Chapter 3: Introduction to the Analytic Hierarchy Process


    An Overview of the Analytical Hierarchy Process (AHP) method.

    Problem modelling.

    Pair-wise comparisons.

    Judgement scales.

    Priorities derivation.


    Sensitivity analysis.

    Conclusion and future developments.

    Part Two: A-Z of Disastrous Case Studies

    Chapter 4: The Bhopal Disaster - Learning From Failures & Evaluating Risk


    Bhopal Narrative and the incorporation of FTA and RBD


    Direct Causes of the Accident



    Concluding Remarks for Part One


    Chapter 5: BP Deepwater Horizon 

    Case Study: Deepwater Horizon

    Analysis of 1st Group of Students

    Analysis of 2nd Group of Students

    Analysis of 3rd Group of Students

    Feedback and Generic Lessons


    Chapter 6: Case Study: BP Texas City Disaster

    What Happened?

    Technical and Logic of the Failure

    Sequence of events and Incident


    Fault Tree Analysis and Reliability Block Diagram for the BP Texas City Disaster

    Generic Lessons


    Chapter 7: Chernobyl Disaster


    What Happened?

    Technical and Logic of the Failure

    Causes of the Incidence

    Fault Tree Analysis and Reliability Block Diagram for the Chernobyl Disaster

    Generic lessons and Proposed Improvements

    Chapter 8: The Concorde Crash


    The Accident

    Application of The AHP To The Concorde Accident

    Analysis Of Results


    Chapter 9: Fukushima Nuclear Disaster

    Brief Introduction About The Accident

    Analysis of 1st Group of Delegates

    Analysis of 2nd Group of Delegates

    Feedback and Generic Lessons



    Chapter 10: Hurricane Katrina Disaster


    Background about the Hurricane Katrina Disaster

    Technical Causes of Failure

    Fault Tree Analysis (FTA)

    Reliability Block Diagram (RBD)

    Failure Modes, Effects And Criticality Analysis

    A Brief Overview of the Analytic Hierarchy Process (AHP)

    The Development of the AHP Model For Hurricane Katrina Disaster

    Discussion and Lessons Learned

    Concluding Remarks


    Chapter 11: NASA’s Space Shuttle Columbia Accident

    What Happened?

    Technical and Logic Cause of the Failure

    Proposed Improvements and Generic lessons

    Fault Tree Analysis and Reliability Block Diagram for the Columbia Disaster

    Generic Lessons

    Chapter 12: The Titanic

    Introduction to Cruising

    The Titanic Case Study - What Happened

    Technical and Logic of the Failure

    Consequences and Severity

    Fault Tree Analysis and Reliability Block Diagram for the Titanic Disaster

    Proposed Improvements and Generic lessons


    Part Three: Generic Lessons, other models of learning from failures and research directions

    Chapter 13: Introduction to the concept of Generic Lesson as an outcome of Learning from Failures

    Why failure can be the best thing to happen?

    Lesson 1: Too Much Belief in Previous Successes

    Lesson 2: Coping with Growth

    Lesson 3: Misunderstanding fashionable paradigms

    Lesson 4: Legislation

    Lesson 5: The "I operate, You fix" attitude

    Lesson 6: Bad News, Bad Person

    Lesson 7: Everyone’s Own Machine is the Highest Priority to Him/Her

    Lesson 8: Solving a Crisis is a Forgotten Experience

    Lesson 9: Skill Levels Dilemma

    Attributes of the Generic Lessons

    Best Practice of Learning from Failures from Different Industries

    Best Practice can be learned from Worst Practice

    Chapter 14: A Model of Learning and Unlearning from Failures


    Research Methodology

    Routine Dynamics In Learning And Unlearning From Failures

    The Learning And Unlearning From Accidents

    A New Theory Of Adaptive Organizational Learning From Failures Routines

    Lessons Learnt From The Maintenance & Reliability Field

    Case Study Of Applying The Proposed Model To A Disaster Analysis

    Theoretical Framework And Discussion


    List of References



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