Last Updated S022021

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. Identify incident and accident occurrence models
2. Apply root cause and contributory factor analysis techniques
3. Apply tools such as System Safety Accident Investigation, Accimap, STAMP, ICAM, SERA and other Latent Failure Mode approaches
4. Identify organisational factors behind industrial disasters
5. Identify engineering design factors behind industrial disasters
6. Identify regulatory factors behind industrial disasters
7. Apply accident investigation model and techniques to a current disaster, and using best - available evidence to date, develop analysis and preliminary findings as to contributory factors.

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. Engineered systems, dynamic complexity and the illusion of perfect control

3. Concepts of intrinsic safety, defences in depth and resilience

 

Topic 2

Investigation Models

  1. Accident proneness model
  2. Fault and blame models (police and legal directives)
  3. Natural causes models
  4.  Latent Failure models (e.g. James Reason, Jens Rasmussen).

 

Topic 3

Individual Analytic Tools and Techniques

1. Events and conditions flowcharting (EG&G Idaho Falls)

2. Energy barrier mapping 3. Fault / Event Tree Logic mapping

4. Failure Modes and Effects Analysis as a post-hoc tool (Key examples: HAZOP and FMECA)

5. Discrete action analysis: (individual differences, fatigue, information overload)

 

Topic 4

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 5

Human versus Organisation Error

1. Human error within operational domains

2. Human error within engineering design domains

3. Human error within management domains

4. Human error within government domains (policy driven error)

 

Topic 6

Major Disaster Characteristics

1. 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 7

Regulatory Roles

1. Legislation and obligations in different jurisdictions

2. Enquiries, Coronial processes and the role of expert witnesses (e.g. NSW Waterfall Rail Fatalities)

3. Example: Royal Commission into the 2009 Victorian Bushfires, and the role of Utility firms and the Energy Regulator Victoria ESV, including the impact of state asset privatisations that occurred in the 1990s

4. Regulatory factors behind industrial disasters: Basle, Pasadena, Baia Mare, BP Texas City, Buncefield, Pike River Coal, Hungary Tailings Dam failure, Chevron Richmond refinery fire, West Fertilizer explosion, Illinois crystal facility explosion.

 

Topic 8 and 9

Case Study Analysis

1. Detailed application of flowcharting and logic trees to disasters

2. Mapping of findings to conclusions

3. The differences between ‘judgements of need’ (JONs) and recommendations.

 

Topic 10

Retrospective review of Past Investigations

  1. Sources of conflict between findings and industry leaders
  2. Compromises between findings and potential improvements
  3. Learning from disasters – changes to design rules, standards, regulations and industry resourcing policies (such as maintenance planning & scheduling of energy assets, and crew fatigue management for shift workers)
  4. Unwillingness to learn from other industries (such as the use of gas blows to clean gas pipes, which caused deaths in the Slim Jim food processing facility (Tennessee?) and the Clean Energy power plant (Connecticut)
  5. Government failures (Crystal failure – Illinois) - Political decision-making in investigation and regulation agencies – examples of successes and compromises

 

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