×
INTELLIGENT WORK FORUMS
FOR ENGINEERING PROFESSIONALS

Log In

Come Join Us!

Are you an
Engineering professional?
Join Eng-Tips Forums!
  • Talk With Other Members
  • Be Notified Of Responses
    To Your Posts
  • Keyword Search
  • One-Click Access To Your
    Favorite Forums
  • Automated Signatures
    On Your Posts
  • Best Of All, It's Free!
  • Students Click Here

*Eng-Tips's functionality depends on members receiving e-mail. By joining you are opting in to receive e-mail.

Posting Guidelines

Promoting, selling, recruiting, coursework and thesis posting is forbidden.

Students Click Here

Jobs

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

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

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

(OP)
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: https://www.vanityfair.com/news/2018/04/inside-el-...)

This subforum!

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

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.

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

More bulletins than reports, but also check SCOSS/CROSS Safety Reports.

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


Brad Waybright

It's all okay as long as it's okay.

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

A good article that I copied from someone else's post in the 737MAX thread which is one man's take on that debacle. It's maybe over-political and maybe not exacting in detail, but I see similarities with other failed projects past.
https://newrepublic.com/article/154944/boeing-737-...

Brad Waybright

It's all okay as long as it's okay.

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

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.

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

"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.

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

Quote:

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.

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.

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


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

(OP)
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).

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

2
I would start with the books written by Dr. Henry Petroski:

https://en.wikipedia.org/wiki/Henry_Petroski

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

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



Also interesting in general on materials and failure mechanisms:


And if you wanted to know more about the whole El Faro disaster:

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

Quote:

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).

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.

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

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.
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

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

Three authoritative deep dives into institutional failings that may or may not have had a lasting effect on the industries concerned:

The Hidden Report (Clapham Junction rail accident)

The Culham Report (Piper Alpha oil production platform fire)

The Haddon-Cave Report (loss on operations of Nimrod XV230)

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

For structural engineers, the Levy and Salvadori book which JAE proposed is a must read.

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

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

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

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.

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

Speaking of the Challenger disaster...

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

https://www.wnem.com/news/us_world_news/on-this-da...;;

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

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

Speaking of space shuttles, the Columbia Accident Investigation Board report is voluminous and extremely interesting. Lots of parallels to the Challenger accident but different in it's own way. As with a lot of accidents, hubris is a significant contributor.
https://www.nasa.gov/columbia/home/CAIB_Vol1.html

Brad Waybright

It's all okay as long as it's okay.

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

The challenger disaster, with the O-ring issue, the management rush to meet the launch date, despite engineers knowing there was an issue without a solution implemented, was frequently raised throughout my university education in ethics, law, and management courses.

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

Hi MartinLe. Your view point is very interesting and similar to my own safety concerns.

I take it that in "codes" you are sort of referring to the technical prudence that is part of practicing professional engineering. And in "social" you are sort of referring to the construction site attitudes that are part of being a "professional" journeyman. For the former I think the others have made good suggestions. For the latter two sources have influenced me, both are from my nonprofessional interest in railroads.

-The Historical Interstate Commerce Commission reports available online have perhaps a thousand railroad accident investigations over more than half a century. A very persistent thread in them is how many times two to four minor oversights of the rules added up to a serious accident. Gross violations were far from being the most common factor.

-TrainOrders.com is a hobbyist/staff/executive railroad discussion board. Although their "Nostalgia" forum threads that hit me are much dispersed there, the essence seemed to be the staff jesting about past cutting of petty corners and the executives retrospectively criticizing them strongly for it. In the end I felt that the staff got away safely 99% of the time and so thought it was okay but the executives saw the 1%'s cumulative loss in dollars, sick time, permanent disability and most sadly, death. The difficulty seemed to be in convincing the staff that any cutting of corners would eventually backfire and the executives just didn't want to be part of that.

Bill

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

Great podcast by Sean Brady on all kinds of failures and disasters. He explores how human factors are critical in most of these events.

Sean Brady Podcast

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

(OP)
How complex systems fail is IMO a good read and it's interesting to go through the bullet points and see if and how they are baked into different codes and design processes. And what it would mean if we take "There's no root cause" seriously.

So far no one commented on "Normal Accidents" too sociological and so no one here read it?

Bent Flyvbjerg has lots of papers online - is the Megaprojects book a good starting point, or rather some of the papers?


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

2
One thing I'm trying to do is refer to anything that happens as an "Incident".

As soon as you use the term "accident" it implies that the cause was "accidental" and hence somehow not in our control or ability to influence things. It might only be a subtle difference, but in the same way I ban the use of the word "Temporary" from any description of work.

The inherent implication is that a "temporary" design or item or connection doesn't have the same level of design, construction, quality and scrutiny as the "permanent" design.

If it contains pressurised fluids or bears a load then it doesn't matter if it's in operation for one second or one decade. It can still kill you.

Thus are subtle changes in how people think about risks and incidents.

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

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

A lot of "user error" is actually caused by poor design. For a decent primer on human factors in design, I suggest The Design of Everyday Things.

My glass has a v/c ratio of 0.5

Maybe the tyranny of Murphy is the penalty for hubris. - http://xkcd.com/319/

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

If we're going to talk about 'product design', then I would suggest watching the documentary, 'Objectified', produced by Gary Hustwit:

https://www.imdb.com/title/tt1241325/

And while you're at it, despite them not fitting this thread, try watching Hustwit's other documentaries, including 'Helvetica' and 'Urbanized':

https://www.imdb.com/title/tt0847817/

https://www.imdb.com/title/tt1701976/

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

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

The Hyatt Regency Walkway failure.

Mike McCann, PE, SE (WA, HI)


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

The book 'Fatal Defect' by Ivars Peterson explores buggy software.


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

As for other fields and safe thinking, the Nuclear industry has a lot on human performance, which could apply to operating any plant, including WWTP.

On example would be: http://nuclearsafety.info/wp-content/uploads/2010/...

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

3
This very forum.

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

OSHA
OSHA produces 20-50 page documents with site photos of all construction accidents.
The target audience is semi technical.
Example: "Investigation of the December 6, 2017 Fatal Parking Garage Collapse at Berkman Plaza 2, Jacksonville, FL"

Unlike many politically correct government documents, these documents identify negligence and the guilty parties by name (usually the contractor and engineer share culpability).

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

NASA does safety messages on various incidents, always with an edge towards everyday's engineering works.
This one is special to me:
Link
as it conveys, how human decisions influence the course of acion.
I remember that time, the incredulous facts that the maintenance workers didn't heed the checking systems red light for that wheel, .. "because the reading could not possibly be right" and that the passenges and staff did not pull the emergency brake even with a heavy metal spike having pierced the compartment floor.

Roland Heilmann

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

Sorry Roland, but I find the wording of that memo a bit weak.

3 km at 200 kmh leaves about a minute for the passengers to instinctively get out of the way, realize the situation, go back 2 cars to find the manager, tell him, let him get back to the scene to gauge the info and call the driver. This unfortunately falls on the "insufficient time" side of the analysis rather than anyboy's inaction.

Yes the "heritage" wheel was designed about 1935 for an extremely successful, 40mph 17 ton car. But heritage is not the word that is wrong in the thought, a successful 5 year old 40mph 17 ton design would have also been a question. It's the checking of the application that should have been the emphasized phrase.

There are varying degrees of completeness and objectivity in accident reports. Three drivers in an engine cab missed a signal in Ontario a few years back. They were lined for a different track than they had expected and were killed in the ensuing accident. The official report goes over all sorts of issues but nowhere does it come out and say the fellows just sadly missed the signal.

Bill

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

The link is really a lessons learned briefing from 9 years after the accident, and is structured like an elevator briefing.

https://en.wikipedia.org/wiki/Eschede_derailment suggests that the root cause was anticipated well before the accident, in 1992, but no one did anything about it.

TTFN (ta ta for now)
I can do absolutely anything. I'm an expert! https://www.youtube.com/watch?v=BKorP55Aqvg
FAQ731-376: Eng-Tips.com Forum Policies forum1529: Translation Assistance for Engineers Entire Forum list http://www.eng-tips.com/forumlist.cfm

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

Yes, there's much more detailed investigation to be found.
Actual distance from rim-pierces-compartment event to derailment was ~6 km, almost 2 minutes time (wiki)
And yes, the manager was obliged by regulations to first assess the situation.
However, what would one decide to do if a really big bang makes bulge up the floor in a train compartment?
However, how would one decide if the readings on a train wheel checking machine could not possible be real?
I find technical and social aspects intertwined, "internal" logical argument going against conformity, belief in regulation, pressure felt from schedule...

Roland Heilmann

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

among the other listings, the book "What Went Wrong" by Trevor Klatz.

https://www.elsevier.com/books/what-went-wrong/kle...

i read an edition back in the early 90's. a worthy read.

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

Not just reading:
https://www.ted.com/talks/kathryn_schulz_on_being_...
https://www.ted.com/speakers/kathryn_schulz?langua...

because one cannot avoid mistakes if one doesn't know what it feels like to make them. I won't spoil the punchline on that, but if you think you know what it feels like to be wrong, you are probably wrong.

Kathryn Schulz
Wrongologist

Also author of Being Wrong: Adventures in the Margin of Error

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

(OP)
@ TheBard3:
Thinking about the Megaprojects book, from what I've read Flyvbjerg writes mostly about financial risks, not not physical safety? Can someone comment?

Red Flag This Post

Please let us know here why this post is inappropriate. Reasons such as off-topic, duplicates, flames, illegal, vulgar, or students posting their homework.

Red Flag Submitted

Thank you for helping keep Eng-Tips Forums free from inappropriate posts.
The Eng-Tips staff will check this out and take appropriate action.

Reply To This Thread

Posting in the Eng-Tips forums is a member-only feature.

Click Here to join Eng-Tips and talk with other members! Already a Member? Login


Resources

White Paper - How to Capitalize on HVAC/R Trends to Drive Business Growth
According to Steve Yurek, CEO of the Air Conditioning, Heating and Refrigeration Institute, the HVAC/R industry is facing change on all fronts. This includes challenging trends on contractors and distributors like new refrigerants, growing automation, complex sensors and monitoring, green initiatives and a technician shortage. We look at these trends and outline actionable insights on how it all can be turned into a competitive advantage and business opportunity. Download Now
eBook - Manufacturing the Cars of Tomorrow
In this ebook, we'll explore how additive manufacturing is going to transform the way cars are made. This includes commentary from thought leaders such as Ford's CTO, Ken Washington, Customer case studies of ways 3D printing is being used today, and a variety of part examples where 3D printing is already impacting how automobiles are made. Download Now
White Paper - Smart Manufacturing for Semiconductor
New technologies and approaches present great opportunities for semiconductor manufacturers to achieve high levels of innovation, yield and improvement. This white paper explores some of these cutting-edge technologies and how they can be applied effectively in the semiconductor industry. Read about how Smart Manufacturing is transforming the semiconductor industry. Download Now

Close Box

Join Eng-Tips® Today!

Join your peers on the Internet's largest technical engineering professional community.
It's easy to join and it's free.

Here's Why Members Love Eng-Tips Forums:

Register now while it's still free!

Already a member? Close this window and log in.

Join Us             Close