Learning from Failures

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.

• Explores the root cause of disasters and various preventative measures
• Links theory with practice in regard to risk, safety, and reliability analyses
• Uses analytical techniques originating from reliability analysis of equipment failures, multiple criteria decision making, and artificial intelligence domains

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

• Acknowledgments
• Part 1: Background of Analytical Methods Used in Investigation of Disasters
  • Chapter 1. Introduction to the Concept of Learning from Failures
    • 1.1 Introduction
    • 1.2 Why Learning from Failures?
    • 1.3 The Background of This Book
    • 1.4 Who Should Use This Book
    • 1.5 Introduction to the Concept of Learning from Failures
    • 1.6 Taxonomy of Theories
    • 1.7 Case Studies
    • 1.8 Critical Commentary Section
  • Chapter 2. Introduction to Failure Analysis Techniques in Reliability Modeling
    • 2.1 Introduction
    • 2.2 FTA and RBD
    • 2.3 Example: A Storage Tank
    • 2.4 A Simple Illustrative Application Case (A Car Accident)
  • Chapter 3. Introduction to the Analytic Hierarchy Process
    • 3.1 Introduction
    • 3.2 An Overview of the Analytical Hierarchy Process
    • 3.3 Conclusion and Future Developments
• Part 2: A–Z of Disastrous Case Studies
  • Chapter 4. Bhopal Disaster—Learning from Failures and Evaluating Risk
    • 4.1 Introduction
    • 4.2 Bhopal Narrative and the Incorporation of FTA and RBD
    • 4.3 Theory/Calculation
    • 4.4 Discussion
    • 4.5 Concluding Remarks
    • 4.6 Critical Commentary Section
  • Chapter 5. BP Deepwater Horizon
    • 5.1 Case Study Deepwater Horizon
    • 5.2 Analysis of First Group of Students
    • 5.3 Analysis of Second Group of Students
    • 5.4 Analysis of Third Group of Students
    • 5.5 Feedback and Generic Lessons
    • 5.6 Critical Commentary Section
  • Chapter 6. BP Texas City Disaster
    • 6.1 What Happened
    • 6.2 The Process
    • 6.3 Sequence of Events and Incident
    • 6.4 Investigation
    • 6.5 Fault Tree Analysis and Reliability Block Diagram for the Texas City Disaster
    • 6.6 Generic Lessons
    • 6.7 Critical Commentary Section
  • Chapter 7. Chernobyl Disaster
    • 7.1 Introduction
    • 7.2 What Happened
    • 7.3 The Technical and Logic of the Failure
    • 7.4 Causes of the Incident
    • 7.5 Fault Tree Analysis and Reliability Block Diagram for the Disaster
    • 7.6 Generic Lessons and Proposed Improvements
    • 7.7 Critical Commentary Section
  • Chapter 8. The Concorde Crash
    • Notation
    • 8.1 Introduction
    • 8.2 The Accident
    • 8.3 Theory and Use of γ Analysis (Modified FMEA)
    • 8.4 Application of the AHP to the Concorde Accident
    • 8.5 Analysis of Results
    • 8.6 Conclusion
    • 8.7 Critical Commentary Section
  • Chapter 9. Fukushima Nuclear Disaster
    • 9.1 Brief Introduction
    • 9.2 Analysis of First Group of Delegates
    • 9.3 Analysis of Second Group of Delegates
    • 9.4 Feedback and Generic Lessons
    • 9.5 Critical Commentary Section
  • Chapter 10. Hurricane Katrina Disaster
    • 10.1 Introduction
    • 10.2 Background to the Disaster
    • 10.3 Technical Causes of Failure
    • 10.4 Hybrid Modeling Approach
    • 10.5 Fault Tree Analysis
    • 10.6 Reliability Block Diagram
    • 10.7 Failure Modes, Effects, and Criticality Analysis
    • 10.8 An AHP Model for the Hurricane Katrina Disaster
    • 10.9 Results of Sensitivity Analysis
    • 10.10 Discussion and Lessons Learned
    • 10.11 Concluding Remarks
  • Chapter 11. NASA’s Space Shuttle Columbia Accident
    • 11.1 What Happened?
    • 11.2 Logic of the Technical Causes of the Failure
    • 11.3 Consequences and Severity
    • 11.4 Proposed Improvements and Generic Lessons
    • 11.5 FTA and RBD
    • 11.6 Generic Lessons
    • 11.7 Concluding Remarks
    • 11.8 Critical Commentary Section
  • Chapter 12. Titanic, the Unsinkable Ship That Sank
    • 12.1 Cruising
    • 12.2 What Happened
    • 12.3 Logic of the Technical Cause of the Disaster
    • 12.4 Consequences and Severity
    • 12.5 FTA and RBD for the Disaster
    • 12.6 Proposed Improvements and Generic Lessons
• Part 3: Generic Lessons, Other Models of Learning from Failures and Research Directions
  • Chapter 13. Introduction to the Concept of the Generic Lesson as an Outcome of Learning from Failures
    • 13.1 Why Failure Can Be the Best Thing to Happen
    • 13.2 Attributes of the Generic Lessons
    • 13.3 Best Practice of Learning from Failures from Different Industries
    • 13.4 Best Practice Can Be Learned from Worst Practice
  • Chapter 14. A Model of Learning and Unlearning from Failures
    • 14.1 Introduction
    • 14.2 Research Methodology
    • 14.3 Routine Dynamics in Learning and Unlearning from Failures
    • 14.4 A New Theory of Routines for Adaptive Organizational Learning from Failures
    • 14.5 Case Study of Applying the Proposed Model to a Disaster Analysis
    • 14.6 Theoretical Framework and Discussion
    • 14.7 Conclusion
• Not Just Rearranging the Deckchairs on the Titanic: Learning from Failures Through Risk and Reliability Analysis
  • Abstract:
  • Introduction:
  • Learning from Failures as a Process Study
  • Case Studies:
  • Case Study 4: NASA’s Space Shuttle Columbia Accident
  • Technical and Logic Cause of the Failure:
  • Concluding Remarks
  • Appendix A: Fault Tree Analysis (FTA):
  • Reliability Block Diagrams (RBD)
  • Acknowledgement:
  • References
• References
  • Other Related Literature
• Glossary of Terms
• Index