Engineering Disasters: Lessons To Be Learned

Description:
Engineering Disasters - Lessons to be Learned shows that there is always something to be learned from disasters. In this practical and highly relevant text Don Lawson has provided * Thoroughly researched accounts of well-known disasters and failures worldwide * Valuable interpretative sections, drawing out the lessons to be learned in each case * Examples from a wide range of industries * Background information and views of other experts in the field * An excellent source of references for further study * Common threads and conclusions from accident investigations Humans design, build, operate, use, maintain and can wreck engineering products. Humans are fallible. Engineers have to take into account all the potential failures of people, including other engineers, as well as failures of equipment and materials. Design engineering is a structured process using both art and science to create new or improved products - building on experience, bad as well as good. Failure occurs when something or someone fails to perform to expectations.

Table of Contents:
Robert Stephenson's Recommendation xiii; Preamble xv; Acknowledgements xvii; Introduction xix; Part 1 1; 1.1 The Hindenburg Disaster - Hydrogen Myth? 3; 1.1.1 The disaster 3; 1.1.2 Airship history 4; 1.1.3 Why were airships popular? 5; 1.1.4 The impact of world events and the political climate 6; 1.1.5 The key players 7; 1.1.6 The US investigation 8; 1.1.7 The Department of Commerce Report 9; 1.1.8 The role of the FBI 10; 1.1.9 The German investigation 11; 1.1.10 New developments in the 1990s 11; 1.1.11 Is this the end of the story? 13; 1.1.12 Some loose ends 14; 1.1.13 Lessons learned 17; 1.2 UK Railway Woes 21; 1.2.1 What's wrong? 21; 1.2.2 The early history of British railways 21; 1.2.3 Railways in the first half of the twentieth century 22; 1.2.4 Safety, risk, and regulation 22; 1.2.5 Nationalization 1947 23; 1.2.6 Privatization 25; 1.2.7 Lessons learned 40; 1.3 Signals Passed at Danger (SPADs) 43; 1.3.1 Accidents - road versus rail 43; 1.3.2 History 43; 1.3.3 Accidents at Clapham (1988), Southall (1997), and Ladbroke Grove (1999) 44; 1.3.4 What are ATP, ERTMS, ETCS, and GSM-R? 46; 1.3.5 The plan forward 48; 1.3.6 What has to be done? 49; 1.3.7 Some statistical data 49; 1.3.8 The safety case versus commercial costs 50; 1.3.9 Cost/benefit 50; 1.3.10 Experience with TPWS 51; 1.3.11 Lessons learned to date 51; 1.3.12 Lessons learned 57; 1.4 The Wheel/Rail Interface 59; 1.4.1 The rail as a beam 59; 1.4.2 Local contact stresses 59; 1.4.3 Vehicle dynamics 60; 1.4.4 Shakedown theory 61; 1.4.5 Crack propagation 62; 1.4.6 Fracture mechanics 65; 1.4.7 What limits rail life? 65; 1.4.8 Lubrication 65; 1.4.9 Wheel/rail profiles 66; 1.4.10 Metallurgy 66; 1.4.11 Inspection 67; 1.4.12 Experience on rail systems around the world 68; 1.4.13 Lessons learned 78; 1.5 Uskmouth Turbine Failure 83; 1.5.1 The failure 84; 1.5.2 Circumstances surrounding the failure 84; 1.5.3 What should have happened? 84; 1.5.4 The investigation 84; 1.5.5 The technical paper and discussion 86; 1.5.6 Lessons learned 89; 1.6 Dr Richard Feynman and the Challenger Shuttle Inquiry 91; 1.6.1 The Presidential Commission 91; 1.6.2 Dr Richard Feynman (1918-1988) 91; 1.6.3 Culture clash 92; 1.6.4 The working methods of the Commission 92; 1.6.5 The Space Shuttle and its solid booster rockets 92; 1.6.6 The SBR field joints 94; 1.6.7 Putty 95; 1.6.8 Seal test pressure 95; 1.6.9 Anomalies and erosion 96; 1.6.10 Preparation for the launch 96; 1.6.11 Raising concerns about the low temperature 96; 1.6.12 Accident sequence 97; 1.6.13 Dr Feynman at the inquiry 98; 1.6.14 Dr Feynman and Roger Bolsjoly 98; 1.6.15 Figures of fantasy 98; 1.6.16 Dr Feynman and the report writing 99; 1.6.17 The recommendations 99; 1.6.18 Dr Feynman's afterthoughts 100; 1.6.19 Lessons learned 109; 1.7 Lessons from the US Space Program 113; 1.7.1 Preface 113; 1.7.2 Technical and administrative management 113; 1.7.3 The funding trap 114; 1.7.4 Aggregate risk 114; 1.7.5 Achieving adequate safety levels 114; 1.7.6 Some of the small issues that can have a large impact 115; 1.7.7 Software/computers 115; 1.7.8 Summary 116; 1.8 Columbia - Deja Vu? 119; 1.8.1 The investigation board 119; 1.8.2 The physical cause of the disaster 120; 1.8.3 The debris 120; 1.8.4 The bipod and its foam insulation 120; 1.8.5 Shuttle damage 123; 1.8.6 Statistics 125; 1.8.7 Mission Management's role in the disaster 125; 1.8.8 Attitude to foam shedding prior to this mission 125; 1.8.9 The photographic record 126; 1.8.10 The engineers' assessment of the damage 126; 1.8.11 Crater - a tool outside its range 127; 1.8.12 Presentation of engineering analysis to Mission Management 127; 1.8.13 Mission Management's view and review of engineering input 127; 1.8.14 Requests for photographs 128; 1.8.15 Mission Management meetings 128; 1.8.16 Message to the crew 128; 1.8.17 Management view post-disaster 129; 1.8.18 CAIB's summary of management decisions 129; 1.8.19 Organizational flaws 129; 1.8.20 Budget and staff cuts 130; 1.8.21 Management of NASA 131; 1.8.22 Schedule pressure 132; 1.8.23 Previous investigations, reviews, and reports 132; 1.8.24 Safety organization 133; 1.8.25 Safety culture 133; 1.8.26 Can-do culture 134; 1.8.27 Engineering practices 134; 1.8.28 Challenger and Columbia similar disasters? 134; 1.8.29 Insights from organizational theory 135; 1.8.30 Insights from experience in other high-tech, high-risk industries 135; 1.8.31 Discussions with Dr Diane Vaughan 136; 1.8.32 CAIB's summary of organizational issues 137; 1.8.33 Other facts and issues 138; 1.8.34 Lessons learned 144; 1.9 Roll-on/Roll-off Ferries - Are they Safe Enough? 149; 1.9.1 History of ro-ro ships 149; 1.9.2 Accidents 150; 1.9.3 Herald of Free Enterprise 150; 1.9.4 Basic safety principles 151; 1.9.5 How do ro-ro ships meet these safety steps? 152; 1.9.6 Who calls the tune? 154; 1.9.7 Regulations and regulators 155; 1.9.8 Technical developments 158; 1.9.9 Actions by some other countries outside the Stockholm Agreement 160; 1.9.10 Maximum wave 161; 1.9.11 Statistics 162; 1.9.12 Lessons learned 167; 1.10 Bridges Too Far? 169; 1.10.1 Bridge failures 169; 1.10.2 Status of bridges in the United States 169; 1.10.3 The strange case of the bridge at Ynysygwas 170; 1.10.4 A selection of landmark bridge failures 171; The Dee Bridge collapse 171; The Tay Bridge disaster 174; The embarrassment on the bridge at Quebec City 179; Galloping Gertie - the Tacoma Narrows Bridge 187; The Milford Haven Bridge collapse 192; The Millennium Bridge failure 194; 1.10.5 Comments on bridges in general 199; 1.10.6 Lessons learned 202; 1.11 The De Havilland Comet Accidents 207; 1.11.1 Geoffrey de Havilland (1882-1965) 207; 1.11.2 Origins of the Comet airliner 208; 1.11.3 The design of DH106 - Comet 208; 1.11.4 Pressure cabin design 209; 1.11.5 Fatigue testing to confirm the design 209; 1.11.6 Operational experience 210; 1.11.7 The accident investigation 210; 1.11.8 RAE 210; 1.11.9 The fatigue results from service and test 213; 1.11.10 De Havilland versus RAE 214; 1.11.11 Lessons learned 219; 1.12 The Danger of Not Knowing 221; 1.12.1 Example 1. The Gimli glider 221; 1.12.2 Example 2. The day the Azores were in the right place 229; 1.12.3 Lessons learned 234; 1.13 Chernobyl Disaster 237; 1.13.1 Science in Russia 237; 1.13.2 A good fit - nuclear power and Communism 238; 1.13.3 Choosing the reactor for power generation 238; 1.13.4 Competition during the Cold War 238; 1.13.5 Fast expansion of the nuclear programme 239; 1.13.6 The RBMK reactor 239; 1.13.7 The test plan 241; 1.13.8 Events leading up to the test 242; 1.13.9 The accident 243; 1.13.10 Why did the power surge? 243; 1.13.11 Role of Valeri Legasov 244; 1.13.12 Role of Evgeny Velikhov 247; 1.13.13 Aftermath of the accident 248; 1.13.14 Lessons learned 252; 1.14 Radiation Hazards - Are Engineers Failing the Public? 255; 1.14.1 Background 255; 1.14.2 Radiation safety standards and regulation 256; 1.14.3 Data from the atomic bomb survivors 257; 1.14.4 Challenges to the radiation regulations 258; 1.14.5 Sources of radiation from nature and man-made sources 260; 1.14.6 Low-dose radiation models 261; 1.14.7 Epidemiology 261; 1.14.8 DNA damage 262; 1.14.9 Studies of hormesis and other work at low doses 264; 1.14.10 Effects of radiation from Chernobyl 267; 1.14.11 Lessons learned 274; Part 2 277; 2.1 Words of Wisdom 279; 2.1.1 Sir Alfred Pugsley (1903-1998) 279; 2.1.2 Alfred M. Freudenthal (1906-1977) 286; 2.1.3 Henry Petroski 289; 2.1.4 Trevor Kletz 291; 2.1.5 Hyman G. Rickover (1898 or 1900 [uncertainty] - 1986) 295; 2.2 Background - Placing Engineering into Perspective 301; 2.2.1 Science and engineering 301; 2.2.2 What is an engineer? 302; 2.2.3 Cycles in engineering 308; 2.2.4 Does history matter? 310; 2.2.5 Learning from the military 311; 2.2.6 Maintenance holiday - a familiar story 313; 2.3 Organizations Aiming to Reduce Risk - Worth Broader Exposure 315; 2.3.1 Peer reviews - INPO and WANO 315; 2.3.2 Lesson learned 319; 2.3.3 Standing Committee on Structural Safety (SCOSS) 319; 2.3.4 The Hazards Forum 328; 2.4 Technical Aspects of Failure 331; 2.4.1 The problem of probabilities 331; 2.4.2 Robustness 333; 2.4.3 From fatigue to structural integrity 335; 2.5 The Human Approach to Risk, Decisions, and Errors 347; 2.5.1 Dealing with risk 347; 2.5.2 Human decisions and errors 350; 2.5.3 Normal accidents versus High Reliability Theory 363; 2.6 An Engineer's Personal Story Worth Repeating 375; 2.6.1 What does it feel like to be associated with a disaster? 375; Part 3 379; 3.1 Drawing the Threads Together 381; 3.1.1 Is there a pattern to the failures? 381; 3.1.2 The three spheres of failure initiation 382; 3.1.3 The nature of disasters 383; 3.1.4 What are the common reasons for failures? 385; 3.1.5 Why do failures occur? 386; 3.2 The Role of Design 386; 3.3 Organizational Weaknesses 389; 3.4 What Do the Public Want? 390; 3.5 Making Better Decisions 392; 3.6 The Last Words!