Foreword |
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xiii | |
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Foreword |
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xv | |
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Foreword |
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xvii | |
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Preface |
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xix | |
Acknowledgement |
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xxi | |
List of Acronyms |
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xxiii | |
1 Introduction |
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1 | (8) |
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1.1 Who Should Read This Book? |
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1 | (1) |
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1.2 Going Beyond the Widget! |
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2 | (3) |
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1.3 Forensic Engineering as a Discipline |
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5 | (2) |
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7 | (1) |
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7 | (2) |
2 Industrial Accidents |
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9 | (70) |
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9 | (30) |
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2.1.1 Principles of Combustion |
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14 | (9) |
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2.1.1.1 Flammable Gases and Vapors |
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17 | (4) |
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2.1.1.2 Flammable Liquids |
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21 | (1) |
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22 | (1) |
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23 | (4) |
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27 | (6) |
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2.1.4 Incidental Scenarios |
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33 | (6) |
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39 | (1) |
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40 | (7) |
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2.3.1 Management of Safety |
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41 | (6) |
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2.4 The Importance of Accidents |
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47 | (21) |
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48 | (3) |
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51 | (4) |
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2.4.3 Flixborough Disaster |
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55 | (3) |
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2.4.4 Deepwater Horizon Drilling Rig Explosion |
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58 | (2) |
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2.4.5 San Juanico Disaster |
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60 | (4) |
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2.4.6 Buncefield Disaster |
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64 | (4) |
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2.5 Performance Indicators |
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68 | (4) |
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2.6 The Role of 'Uncertainty' and 'Risk' |
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72 | (3) |
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75 | (3) |
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78 | (1) |
3 What is Accident Investigation? What is Forensic Engineering? What is Risk Assessment? Who is the Forensic Engineer and what is his Role? |
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79 | (36) |
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79 | (8) |
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87 | (4) |
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91 | (4) |
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95 | (1) |
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96 | (2) |
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3.6 Accident Prevention and Risk Assessment |
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98 | (7) |
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100 | (1) |
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3.6.2 Hazard and Operability Analysis (HAZOP) & Hazard Identification (HAZID) |
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101 | (4) |
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3.6.3 Failure Modes and Effects Analysis (FMEA) |
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105 | (1) |
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105 | (7) |
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112 | (1) |
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113 | (2) |
4 The Forensic Engineering Workflow |
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115 | (68) |
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115 | (3) |
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118 | (6) |
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4.3 Preliminary and Onsite Investigation (Collecting the Evidence) |
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124 | (6) |
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127 | (3) |
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4.3.1.1 Selection of the Sample |
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127 | (1) |
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4.3.1.2 Collection of the Sample |
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128 | (1) |
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4.3.1.3 Packaging of the Sample |
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129 | (1) |
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4.3.1.4 Sealing the Packaging |
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130 | (1) |
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4.4 Sources and Type of Evidence to be Considered |
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130 | (22) |
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133 | (5) |
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4.4.1.1 Conducting the Interview |
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136 | (2) |
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4.4.2 Paper Documentation |
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138 | (2) |
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4.4.3 Digital Documentation and Electronic Data |
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140 | (5) |
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4.4.3.1 An Example About the Value of Digital Evidence |
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141 | (4) |
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145 | (1) |
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146 | (1) |
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147 | (5) |
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4.4.6.1 The Collection of the Photographs |
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148 | (2) |
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4.4.6.2 Photograph Cataloguing |
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150 | (2) |
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4.5 Recognise the Evidence |
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152 | (14) |
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155 | (13) |
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4.5.1.1 Explosion of Flour at the Mill of Cordero in Fossano |
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156 | (1) |
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4.5.1.2 Explosion at the Pettinatura Italiana Plant |
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157 | (3) |
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4.5.1.3 Explosion of the Boiler of the SISAS Plant of Pioltello |
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160 | (3) |
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4.5.1.4 Explosion of the Steam Generator of the Plant Enichem Synthesis at Villadossola |
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163 | (1) |
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4.5.1.5 Aluminium Dust Explosion at Nicomax in Verbania |
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163 | (3) |
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4.6 Organize the Evidence |
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166 | (2) |
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4.7 Conducting the Investigation and the Analysis |
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168 | (7) |
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4.7.1 Method of the Conic Spiral |
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172 | (1) |
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173 | (2) |
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4.8 Reporting and Communication |
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175 | (5) |
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180 | (2) |
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182 | (1) |
5 Investigation Methods |
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183 | (84) |
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5.1 Causes and Causal Mechanism Analysis |
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183 | (9) |
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5.2 Time and Events Sequence |
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192 | (7) |
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196 | (3) |
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199 | (13) |
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204 | (4) |
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5.3.2 Analysis of Operative Instructions and Working Procedures |
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208 | (4) |
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212 | (51) |
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5.4.1 Expert Judgment and Brainstorming |
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213 | (1) |
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5.4.2 Structured Methods and Approaches |
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214 | (60) |
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5.4.2.1 Pre-structured Methods |
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218 | (4) |
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5.4.2.2 Barrier-based Systematic Cause Analysis Technique (BSCAT™) |
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222 | (6) |
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228 | (4) |
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5.4.2.4 Barrier Failure Analysis (BFA) |
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232 | (6) |
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5.4.2.5 Root Cause Analysis (RCA) |
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238 | (15) |
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5.4.2.6 QRA derived tools |
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253 | (10) |
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263 | (3) |
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266 | (1) |
6 Derive Lessons |
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267 | (42) |
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6.1 Pre and Post Accident Management |
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267 | (7) |
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6.2 Develop Recommendations |
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274 | (16) |
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6.2.1 An Application of Risk Analysis to Choose the Best Corrective Measure |
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284 | (6) |
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290 | (6) |
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6.4 Safety (and Risk) Management and Training |
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296 | (2) |
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6.5 Organization Systems and Safety Culture |
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298 | (5) |
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6.6 Behavior-based Safety (BBS) |
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303 | (1) |
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6.7 Understanding Near-misses and Treat Them |
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304 | (3) |
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307 | (1) |
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308 | (1) |
7 Case Studies |
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309 | (168) |
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7.1 Jet Fire at a Steel Plant |
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309 | (20) |
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309 | (1) |
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7.1.2 How it Happened (Incident Dynamics) |
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310 | (4) |
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314 | (7) |
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321 | (1) |
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7.1.5 Lessons Learned and Recommendations |
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322 | (4) |
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7.1.6 Forensic Engineering Highlights |
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326 | (2) |
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7.1.7 References and Further Readings |
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328 | (1) |
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7.2 Fire on Board a Ferryboat |
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329 | (25) |
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329 | (1) |
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7.2.2 How it Happened (Incident Dynamics) |
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330 | (1) |
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330 | (8) |
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338 | (4) |
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7.2.5 Lessons Learned and Recommendations |
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342 | (1) |
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7.2.6 Forensic Engineering Highlights |
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342 | (12) |
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7.2.6.1 The Discharge Activity and the Evidence Collection |
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342 | (3) |
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7.2.6.2 Use of and Issues Regarding Digital Evidences |
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345 | (3) |
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7.2.6.3 Expected Performances of the Installed Digital Memories |
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348 | (1) |
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7.2.6.4 The VDR (Voyage Data Recorder) System |
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348 | (2) |
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7.2.6.5 Data Extraction from the "Black Box" (i.e.: FRM Module) |
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350 | (1) |
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7.2.6.6 Analysis and Use of Extracted Data |
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351 | (1) |
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7.2.6.7 Documentation Analysis of the Fire Detection System |
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352 | (2) |
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7.2.7 References and Further Readings |
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354 | (1) |
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7.3 LOPC of Toxic Substance at a Chemical Plant |
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354 | (12) |
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354 | (1) |
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7.3.2 How it Happened (Incident Dynamics) |
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354 | (1) |
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355 | (3) |
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358 | (5) |
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7.3.5 Lessons Learned and Recommendations |
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363 | (1) |
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7.3.6 Forensic Engineering Highlights |
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364 | (2) |
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7.4 Refinery's Pipeway Fire |
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366 | (15) |
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366 | (1) |
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7.4.2 How it Happened (Incident Dynamics) |
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367 | (4) |
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371 | (2) |
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373 | (2) |
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7.4.5 Lessons Learned and Recommendations |
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375 | (3) |
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7.4.6 Forensic Engineering Highlights |
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378 | (1) |
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7.4.7 References and Further Readings |
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379 | (2) |
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7.5 Flash Fire at a Lime Furnace Fuel Storage Silo |
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381 | (8) |
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381 | (1) |
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7.5.2 How it Happened (Incident Dynamics) |
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382 | (3) |
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385 | (3) |
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388 | (1) |
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7.5.5 Lessons Learned and Recommendations |
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388 | (1) |
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7.5.6 Forensic Engineering Highlights |
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388 | (1) |
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388 | (1) |
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7.6 Explosion of a Rotisserie Van Oven Fueled by an LPG System |
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389 | (18) |
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389 | (1) |
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7.6.2 How it Happened (Incident Dynamics) |
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390 | (4) |
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394 | (4) |
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398 | (1) |
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7.6.5 Lessons Learned and Recommendations |
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399 | (1) |
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7.6.6 Forensic Engineering Highlights |
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399 | (7) |
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406 | (1) |
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7.7 Fragment Projection Inside a Congested Process Area |
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407 | (22) |
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407 | (1) |
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7.7.2 How it Happened (Incident Dynamics) |
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408 | (1) |
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408 | (1) |
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409 | (18) |
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7.7.4.1 Collection of Evidences and Data |
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410 | (1) |
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7.7.4.2 Initial Plate Velocity and Box Deformation |
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410 | (5) |
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7.7.4.3 Development of a Piping Damage Criteria |
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415 | (6) |
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7.7.4.4 Evaluation of Damages |
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421 | (1) |
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7.7.4.5 Results for Impacts for Some Pipes |
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421 | (1) |
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7.7.4.6 FI-BLAST© Adaptation to Perform a Parametric Study |
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422 | (4) |
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7.7.4.7 Results of the Parametric Study |
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426 | (1) |
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7.7.5 Lessons Learned and Recommendations |
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427 | (1) |
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7.7.6 Forensic Engineering Highlights |
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428 | (1) |
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7.7.7 References and Further Readings |
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429 | (1) |
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7.8 Refinery Process Unit Fire |
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429 | (20) |
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429 | (1) |
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7.8.2 How it Happened (Incident Dynamics) |
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429 | (4) |
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433 | (2) |
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435 | (3) |
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7.8.4.1 Examination of the Effects of the Fire |
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437 | (1) |
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7.8.4.2 Water and Foam Consumption |
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438 | (1) |
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438 | (1) |
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7.8.5 Lessons Learned and Recommendations |
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438 | (1) |
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7.8.6 Forensic Engineering Highlights |
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439 | (9) |
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7.8.7 References and Further Readings |
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448 | (1) |
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7.9 Crack in an Oil Pipeline |
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449 | (14) |
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449 | (1) |
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7.9.2 How it Happened (Accident Dynamics) |
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450 | (3) |
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453 | (1) |
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7.9.4 Experimental Campaign on the Pipeline Segment |
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453 | (4) |
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457 | (3) |
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7.9.6 Lessons Learned and Recommendations |
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460 | (2) |
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7.9.7 Forensic Engineering Highlights |
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462 | (1) |
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7.9.8 References and Further Readings |
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463 | (1) |
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7.10 Storage Building on Fire |
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463 | (6) |
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463 | (1) |
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7.10.2 How it Happened (Accident Dynamics) |
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464 | (1) |
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464 | (1) |
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465 | (1) |
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7.10.5 Lessons Learned and Recommendations |
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466 | (1) |
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7.10.6 Forensic Engineering Highlights |
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467 | (1) |
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467 | (2) |
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8 Conclusions and Recommendations |
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469 | (4) |
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471 | (2) |
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473 | (4) |
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476 | (1) |
A Principles on Probability |
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477 | (2) |
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A.1 Basic Notions on Probability |
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477 | (2) |
Index |
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479 | |