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Principles of Forensic Engineering Applied to Industrial Accidents

Luca Fiorentini

TECSA S.r.l.



Politecnico di Torino


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To my wonderful family: to my beloved wife Sonia and to my incredible children Riccardo, Lodovico and Ettore.

To all those who, thanks to this book, will take their first steps in the world of forensic engineering or increase their interest in this fascinating discipline.

Luca Fiorentini

To Baba, Beat, Bibi, Chicco.

To all those guys that believe in science, evidences and knowledge.

Luca Marmo

Foreword by Giomi

Fires and explosions, by their very nature, tend to delete any evidence of their causes, destroying it or making it unrecognizable. Establishing the origins and causes of fire, as well as the related responsibilities, therefore requires significantly complex investigations.

Simple considerations illustrate these difficulties. In the case of arson retarding devices may be used to delay the phenomenon, or accelerating substances, such as petroleum derivatives, alcohols and solvents, by pouring them on combustible materials present on site. The use of flammable and/or combustible liquids determines a higher propagation velocity, the possible presence of several outbreaks of diffuse type – which do not occur in accidental fires that usually start from single points, in addition temperatures are higher than those that would result from just solid fuels, such as paper, wood or textiles.

Generally, in accidental fires, burning develops slowly with a rate that varies according to the type and quantity of combustible materials present, as well as to the ventilation conditions of involved buildings. In addition, temperatures are, on the average, lower than those reached in malicious acts.

Obviously, these considerations must be applied to the context: the discovery of a container of flammable liquid is not in itself a proof of arson, on the other hand, the absence of traces of ignition at the place of the fire is not evidence that the fire is of an accidental nature!

Forensic Engineering, science and technology at the same time, interprets critically the results of an experiment in order to explain the phenomena involved, borrowing from science the method of investigation, replacing the experimental results with the evidence collected in the investigation, to understand how a given phenomenon took place and what were its causes, and also any related responsibility.

The reconstruction takes place through reverse engineering to establish the possible causes of the event.

The same scientific and engineering methodologies are used for the analysis of failures of particular elements (failure analysis) as well as the procedures for the review of what happened, researching the primary causes (root causes analysis).

The accident is seen as the unwanted final event of a path that starts from organizational and contextual conditions with shortcomings, due to inefficiencies and errors of design and actual conditions in which individuals find themselves working, and continues by examining the unsafe actions, human errors and violations that lead to the occurrence of the accident itself.

The assessment of the scientific skills and abilities of the forensic engineer should not be limited, as often happens, to just ascertaining the existence of the specialization, but should also include the verification of an actual qualified competence, deducting it from previous experiences of a professional, didactic, judicial, etc. nature.

In this context, the book “Principi di ingegneria forense applicati ad incidenti industriali” (Principles of forensic engineering applied to industrial accidents) by Prof. Luca Fiorentini and Prof. Luca Marmo constitutes an essential text for researchers and professionals in forensic engineering, as well as for all those, including technical consultants, who are preparing to systematically approach the discipline of the so‐called “industrial forensic engineering”.

The authors, industrial process safety experts and recognised “investigators” on fires and explosions, starting from the analysis of accidents or quasi‐accidents that actually occurred in the industrial field, offer, among other things, an overview of the methodologies to be adopted for collecting evidence and storing it by means of an appropriate measurement chain, illustrate some analysis methodologies for the identification of causes and dynamics of accidents and provide guidance for the identification of the responsibilities in an industrial accident.

The illustration of some highly complex cases requiring the use of specialist knowledge ensures that this text can also be a useful reference for the Investigative Police, that, as is well known, in order to validate the sources of evidence must be able to understand the progress of the events.

Gioacchino Giomi

Head, National Fire Brigade, Italy

Foreword by Chiaia

The number and the magnitude of industrial accidents worldwide has risen since the 70s and continues to grow in both frequency and impact on human wellbeing and economic costs. Several major accidents (see, e.g. the Seveso disaster in 1976, the Bhopal gas tragedy in 1984, the Chernobyl accident in 1986, and Deepwater Horizon oil spill in 2010) and the increased number of hazardous substances and materials have been under the lens of the United Nations Office for Disaster Risk Reduction (UNISDR), which puts great effort in developing safety guidelines within the Sendai Framework for Disaster Risk Reduction 2015–2030.

On the other hand, man‐made and technological accidents still represent a major concern in both the advanced countries and in under‐developed ones. In the first case, risk is related not only to possible human losses but also to the domino effects, in terms of fires, explosions and possible biological effects in highly populated areas. Indeed, as pointed out by a great number of forensic engineering cases, the safety regulations for industries in developed countries are usually very strict and demanding. On the contrary, in underdeveloped countries, there is clear evidence that industrial regulations are less strict and that a general lack of the “culture of safety” which generally results in a looser application of the rules, thus providing higher frequency of industrial accidents.

Quite often, the default of a plant component or a human error are individuated as the principal causes of an accident. However, in most cases the picture is not so simple. For instance, the intrinsic probability of experiencing a human error within a certain industrial process is a crucial factor that should be kept in mind when designing the process ex‐ante and, inversely, during a forensic investigation ex‐post, to highlight correctly responsibilities and mistakes. Another source of complexity is represented by the so‐called black swans, i.e. the negative events which were not considered before their occurrence (i.e. neither during the plant design, nor during functioning of the plant) simply because no one had never encountered such events (black swans are also called the unknown unknowns).

In this complex framework, Forensic Engineering, as applied in the realm of industrial accidents, plays the critical and fundamental role of knowledge booster. As pointed out by Fiorentini and Marmo in this excellent and comprehensive book, application of the structured methods of reverse engineering coupled with the specific intuition of the smart, experienced consultant, permits the reader to reconstruct the fault event tree, to individuate the causes of defaults and even to identify, a posteriori, possible black swan events. In this way, a well‐conducted Forensic Engineering activity not only aims at solving the specific investigation problem but, in many cases, provides significant advancements for science, technology, and industrial engineering.

Bernardino Chiaia

Vice Rector, Politecnico di Torino, Italy

Foreword by Tee

It is my pleasure and privilege to write the foreword for this book, titled Principles of Forensic Engineering Applied to Industrial Accidents. I was invited to do so by one author of this book, Luca Fiorentini, who is the editorial board member of the International Journal of Forensic Engineering published by Inderscience Publishers.

Kong Fah Tee

Editor-in-Chief: International

Journal of Forensic Engineering;

Reader in Infrastructure Engineering,

Department of Engineering Science,

University of Greenwich,

Kent, United Kingdom