Last Updated S012022

MSR502

Unit Name INCIDENT / ACCIDENT INVESTIGATIONS AND LEARNING FROM DISASTERS
Unit Code
MSR502
Unit Duration 1 Term (online) or 1 Semester (on-campus)
Award
Graduate Diploma of Engineering (Safety, Risk and Reliability)
Duration: 1 year
 
Master of Engineering (Safety, Risk and Reliability)
Duration :2 years

 

Year Level One
Unit Creator / Reviewer Mark Andrew / Arti Siddhpura
Core/Elective: Core
Pre/Co-requisites Nil
Credit Points
3
 
Grad Dip total course credit points = 24(3 credits x 8 (units))
 
Masters total course credit points=48(12 credits (Thesis)+ 3 credits x 12(units))
Mode of Delivery
Online or on-campus.
Combination of modes: Online synchronous lectures; asynchronous discussion groups, videos, remote and cloud-based labs (simulations); web and video conferencing tutorials. High emphasis on personal and group self-study.
Unit Workload
Total student workload including “contact hours” = 10 hours per week
Lecture – 1 hour
Tutorial - 1 hour
Practical / Lab - 1 hour (if applicable)
Personal Study recommended - 7 hours

Unit Description and General Aims

The unit introduces engineers to Incident and Accident Investigations and the benefits of learning from industrial disasters. Students will be encouraged to analyse and learn from classic disasters using a range of investigation techniques. A review of incident / accident investigations performed by different jurisdictions reveals that often the investigations stop as soon as immediate causes leading to the accident are identified. Rarely do the investigations proceed beyond identifying the sharp edge and often miss the underlying root causes.

Learning Outcomes

On successful completion of this unit, students are expected to be able to:

1. Evaluate incident and accident occurrence models and various investigation models

Blooms Level 5

2. Apply individual analytic tools and techniques

Blooms Level 5

3. Evaluate various latent failure methods and analyse Human vs Organization errors

Blooms Level 5

4. Analyse major disaster characteristics

Blooms Level 5

5. Develop an understanding of regulatory roles, legislations and obligations related to accident and incident investigations in different jurisdictions

Blooms Level 5

6. Analyse and Critique various case studies and past investigations

Blooms Level 5

7. Analyse emerging trends for future accidents and incidents

Blooms Level 5

Student assessment

 

Assessment Type

When assessed

Weighting (% of total unit marks) Learning Outcomes Assessed

Assessment 1

Type: Multi-choice test (Proctored)
 
Word length: n/a
 
Topic:All material covered in the syllabus to date. Assessing the accident theory and investigation models.
.
After
Topic 3
15% 1, 2 (Topic 1, 2, 3)

Assessment 2

 

Type: Mid-semester test (Proctored)
 
Example Questions: “What are different types of investigation models? How does energy barrier mapping work? Explain with the help of an example the application of SSAI.”
After
Topic 6
25% 2, 3, 4 (Topic 3, 4, 5, 6)

Assessment 3

Type: Case Study on accident and/or incident investigation and presentation
 
Allocation of weighting:
15% - Report
5% - Presentation (Presentations to take place during Topic 12 tutorial)
 
Word length for Report: 1500
 
Develop, assemble and synthesise appropriate engineering and management elements within a major case study of accident investigation./div>
After
Topic 9
20% 4, 5, 6 (Topic 6, 7, 8, 9)

Assessment 4

Type:Safety and Risk Management Related Report (Final Project)

Word length for Report: 2500
 
Example Topics: Analyse and report on the assessment of accident causation and Latent Failure Modes approaches Accident investigation ‘simulation’ on a current or recent disaster, including data collection, analysis and preliminary findings. Critique of two different accident investigation models with a table showing key differences and similarities (e.g. SSAI versus AcciMap) /
 
After
Topic 12
35% 1 - 7 (All Topics)

 Attendance

Continuous 5% 1 - 7

 

Prescribed and Recommended readings

Required textbook(s)
 
T. K. Butterworth-Heinemann, What Went Wrong? Case Histories of Process Plant Disasters and How They Could Have Been Avoided,6th Edition, IChemE, 2019

 

Reference Materials

  • J. Fortune and G. Peters, Learning from Failure – the systems approach, Wiley, 1995.
  • C. Perrow, Normal Accidents, Princeton University Press, 1999

Also available from Amazon:

  •  Investigating accidents and incidents, HSE Books (HSG245)
  •  Guidelines for Investigating Chemical Process Incidents, 2nd edition, CCPS
  •  C. W. Johnson, A handbook of Accident and Incident reporting
  •  B. Strauch, Investigating Human Error – Incidents, accidents and complex systems, Aldershot Ashgate
  •  S. Dekker, The field guide to understanding human error, Aldershot Ashgate
  •  S. Dekker, Safety Differently – Human factors for a new era, CRC Press
  •  Energy Institute’s top ten Human factors issues https://www.energyinst.org/technical/humanand-organisational-factors/human-factors-top-ten
  •  Australian Transport Safety Bureau http://www.atsb.gov.au/
  •  National Transportation Safety Bureau (includes investigation manuals) www.ntsb.gov
  •  EIT notes and Reference texts as advised.
  •  Other material advised during the lectures

Unit Content

One topic is delivered per contact week, with the exception of part-time 24-week units, where one topic is delivered every two week.

 

Topic 1

Introduction to Accident Theory

  1. Accident and incident definitions
  2. Accident/ Incident investigation definition
  3. The importance of accident investigation
  4. System Characteristic

 

Topic 2

Analysis Models and methods (1)

  1. Accident Investigation Model categories
  2. Sequential Techniques
  3. Epidemiological Techniques
  4. Concepts of intrinsic safety, defence in depth and resilience

 

Topic 3

Analysis Models and methods (2)

1. Systemic Techniques

 

Topic 4

Individual Analytic Tools and Techniques (1)

  1. Events and conditions flowcharting (EG&G Idaho Falls)Events and conditions flowcharting (EG&G Idaho Falls)
  2. Fault / Event Tree Logic mapping

 

Topic 5

Individual Analytic Tools and Techniques (2)

  1. Energy barrier mapping
  2. Failure Modes and Effects Analysis as a post-hoc tool (Key examples: HAZOP and FMECA)
  3. Discrete action analysis: (individual differences, fatigue, information overload)

 

Topic 6

Popular Latent Failure Methods

  1. System Safety Accident Investigation (SSAI, used by BC Hydro)
  2. Incident Causal Analysis Method (ICAM, used by BHPB)
  3. TapRoot, STAMP & SERA (as examples, others can be chosen)
  4. AcciMap

Topic 7

Model and Technique category selection

  1. Model and Technique categories
  2. selection criteria

Topic 8

Learning From Disasters

  1. Learning From Disasters Review of major disasters (Piper Alpha Oil Platform fire, Flixborough (Vapour Cloud Explosion), Bhopal (Industrial gas leakage), Seveso, Longford gas explosion, Fukushima and Deep Water Horizon.)
  2. Detailed case study analysis of three key disasters (e.g. Piper Alpha, Deep Water Horizon, Herald of Free Enterprise, Challenger ‘O’ ring failure or others to suit class backgrounds)
  3. Engineering design factor disasters: Chernobyl, Three Mile Island, Challenger shuttle, Feyzine (LNG storage), Mexico City (BLEVE), Buncefield (Vapour cloud-assisted by tank design), Clapham Junction train collision

 

Topic 9

Stages of Accident Investigation Report

  1. Stages of accident investigation
  2. Post Investigation Reporting and Action
  3. The Accident Investigator

Topic 10

Practical exercises and case study.

 

Topic 11

Future Accidents and Incidents

  1. Emerging threats and technologies (e.g. nanotechnologies)
  2. Emerging social changes (e.g. driverless cars)
  3. The impact of industrial equality (e.g. industrial processes in poorer countries, and the role of international governance)
  4. Learning from allied industries such as medical, air traffic control and climate modelling
  5. When is a disaster industrial? (e.g. industrial conurbations near public dwellings)
  6. Blatant mistakes (LPG tank and apartment block in Alice Springs)
  7. New standards that are compromises

 

Topic 12

Presentation and Unit Review

In the final week, students will prepare and present the main findings of their case study as part of Assessment 3. They will also have an opportunity to review the contents covered so far. Opportunities will be provided for a review of student work and to clarify any outstanding issues. Instructors/facilitators may choose to cover a specialized topic if applicable to that cohort.

Software/Hardware Used

Software

  • Software: N/A

  • Version: N/A

  • Instructions:  N/A

  • Additional resources or files: N/A

Hardware

  • N/A