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! 393; Index 395