Chapter
1.2 Why Learning from Failures?
1.3 The Background of This Book
1.4 Who Should Use This Book
1.5 Introduction to the Concept of Learning from Failures
1.6.1 Learning from Case Studies Versus the Narrative Fallacy Concept
1.6.2 Learning from Hindsight Rewards Versus Risk Aversion
1.6.3 Specific Versus Generic Lessons
1.6.4 High Reliability Theory Versus Normal Accidents Theory
1.6.5 Reliability Versus Safety
1.6.6 Concluding Remarks on Theories Related to Learning from Failures
1.7.1 Choice of Case Studies and Research Methodology
1.7.2 Types of Recommendations
1.8 Critical Commentary Section
2 Introduction to Failure Analysis Techniques in Reliability Modeling
2.3 Example: A Storage Tank
2.4 A Simple Illustrative Application Case (A Car Accident)
3 Introduction to the Analytic Hierarchy Process
3.2 An Overview of the Analytical Hierarchy Process
3.2.2 Pair-wise Comparisons
3.2.4 Priorities Derivation
3.2.6 Sensitivity Analysis
3.3 Conclusion and Future Developments
2 A–Z of Disastrous Case Studies
4 Bhopal Disaster—Learning from Failures and Evaluating Risk
4.2 Bhopal Narrative and the Incorporation of FTA and RBD
4.2.1.3 Precursors Leading to the Disaster
4.2.2 Direct Causes of the Accident
4.6 Critical Commentary Section
5.1 Case Study Deepwater Horizon
5.1.1 Background to the Disaster
5.1.2 Technical Cause of the Failure
5.1.2.1 Poor Design of Cement Barrier
5.1.2.2 Mechanical Failure of the BOP
5.1.2.3 Damage of Control Cables
5.1.2.4 Fire and Gas System
5.1.3 Consequences and Severity
5.1.3.1 Fatalities and Injuries
5.1.3.2 Environmental Impact
5.2 Analysis of First Group of Students
5.2.1 The Technical Reasons
5.2.2 The Design and Safety Reasons
5.2.3 Financial and Organizational Factors
5.2.4 Fault Tree Analysis
5.2.5 Reliability Block Diagram
5.2.6 Recommendations and Reliability Improvement
5.2.6.1 Technical Recommendations
5.2.6.2 Management and Financial Recommendations
5.3 Analysis of Second Group of Students
5.3.1 Summary of the Technical Cause of the Disaster
5.4 Analysis of Third Group of Students
5.4.1 Technical Cause of the Disaster
5.5 Feedback and Generic Lessons
5.6 Critical Commentary Section
6.3 Sequence of Events and Incident
6.5 Fault Tree Analysis and Reliability Block Diagram for the Texas City Disaster
6.7 Critical Commentary Section
7.3 The Technical and Logic of the Failure
7.4 Causes of the Incident
7.5 Fault Tree Analysis and Reliability Block Diagram for the Disaster
7.6 Generic Lessons and Proposed Improvements
7.7 Critical Commentary Section
8.2.1 A History of Problems
8.2.2 Options for Improvement
8.3 Theory and Use of γ Analysis (Modified FMEA)
8.4 Application of the AHP to the Concorde Accident
8.4.2 Step 2: Construction of the Hierarchy
8.4.3 Step 3: Making Judgments
8.4.4 Step 4: Synthesis of Results with Respect to the Goal
8.7 Critical Commentary Section
9 Fukushima Nuclear Disaster
9.1.1 The Evolutionary of the Disaster
9.1.2 The Consequences of the Failure
9.1.3 The Japanese Nuclear Industry
9.1.4 Some Basic Information About Risk Assessment in Nuclear Industry
9.2 Analysis of First Group of Delegates
9.2.1 Technical Background
9.2.2 The Cooling Water System
9.2.3 Overview of the Disaster
9.2.4 Analysis of Contributory Factors
9.2.4.1 The Basis of the Design
9.2.4.2 The Cooling Water System
9.2.4.3 The Emergency Response
9.2.6 Discussion of First Group of Delegates
9.2.7 Conclusion of First Group of Delegates
9.3 Analysis of Second Group of Delegates
9.3.1 The Analytic Hierarchy Process
9.3.2 Design Evaluation of the Fukushima Nuclear Plant
9.3.3 BWR Design for Mitigation of Abnormal Conditions
9.3.4 The Cooling System Design
9.3.4.2 Pump Redundancy and Diversity
9.3.4.3 Redundant Water Sources
9.3.5 Design Against Earthquakes and Tsunamis
9.3.6 Exploring the Incident
9.3.7 The Nuclear Safety Debate
9.3.8 The Nuclear Power Decision for Japan
9.3.8.1 Replace All Nuclear Power with Alternative Sources
9.3.8.2 Continue Using NPP with Improved Barriers to External Influences and Better Legislation
9.3.8.3 Continue with the Status Quo
9.3.9 Application of MCDM
9.3.11 Conclusion of the Second Group of Delegates
9.4 Feedback and Generic Lessons
9.4.1 Overall Criticism of the Two Groups
9.4.2 Wider Generic Lessons for the Nuclear Power Industry
9.5 Critical Commentary Section
10 Hurricane Katrina Disaster
10.2 Background to the Disaster
10.2.2 Hurricane Protection System
10.2.4 Consequences of Failure
10.3 Technical Causes of Failure
10.3.2 Contributing Factors
10.4 Hybrid Modeling Approach
10.6 Reliability Block Diagram
10.7 Failure Modes, Effects, and Criticality Analysis
10.8 An AHP Model for the Hurricane Katrina Disaster
10.9 Results of Sensitivity Analysis
10.10 Discussion and Lessons Learned
11 NASA’s Space Shuttle Columbia Accident
11.2 Logic of the Technical Causes of the Failure
11.3 Consequences and Severity
11.4 Proposed Improvements and Generic Lessons
11.6.1 Generic Lessons That Are Mainly Related to Setting Priorities
11.6.1.1 Too Much Belief in Previous Successes
11.6.1.2 Coping with Growth
11.6.1.3 Misconception of Fashionable Paradigms
11.6.2 Generic Lessons That Are Mainly Related to Responsibility and Skills
11.6.2.1 The “I Operate, You Fix” Attitude
11.6.2.2 Skill Levels Dilemma
11.6.3 Generic Lessons That Are Mainly Related to Communication
11.6.3.1 No News Is Good News
11.6.3.2 Bad News Bad Person
11.8 Critical Commentary Section
12 Titanic, the Unsinkable Ship That Sank
12.3 Logic of the Technical Cause of the Disaster
12.4 Consequences and Severity
12.5 FTA and RBD for the Disaster
12.6 Proposed Improvements and Generic Lessons
3 Generic Lessons, Other Models of Learning from Failures and Research Directions
13 Introduction to the Concept of the Generic Lesson as an Outcome of Learning from Failures
13.1 Why Failure Can Be the Best Thing to Happen
13.1.1 Lesson 1: Too Much Belief in Previous Successes
13.1.2 Lesson 2: Coping with Growth
13.1.3 Lesson 3: Misunderstanding Fashionable Paradigms
13.1.4 Lesson 4: Legislation
13.1.5 Lesson 5: The “I Operate, You Fix” Attitude
13.1.6 Lesson 6: No News Is Good News
13.1.7 Lesson 7: Bad News, Bad Person
13.1.8 Lesson 8: Everyone’s Highest Priority Is Their Own Machine
13.1.9 Lesson 9: Solving a Crisis Is a Forgotten Experience
13.1.10 Lesson 10: Skill Levels Dilemma
13.2 Attributes of the Generic Lessons
13.3 Best Practice of Learning from Failures from Different Industries
13.4 Best Practice Can Be Learned from Worst Practice
14 A Model of Learning and Unlearning from Failures
14.2 Research Methodology
14.3 Routine Dynamics in Learning and Unlearning from Failures
14.3.1 Literature on Organizational Dynamic Routines
14.3.2 Literature Related to Learning from Disasters
14.3.3 Learning and Unlearning from Disasters—The Case of NASA
14.4 A New Theory of Routines for Adaptive Organizational Learning from Failures
14.4.1 Lessons Learnt from the Maintenance and Reliability Field
14.4.1.1 Human-Oriented Approach Based on the TPM Concept
14.4.1.2 Systems-Oriented Approach Based on the RCM Concept
14.4.2.1 Suggested Strategies
14.5 Case Study of Applying the Proposed Model to a Disaster Analysis
14.6 Theoretical Framework and Discussion
14.6.1 Near-Misses and Failures
14.6.2 High Severity with Low Frequency Versus High Severity with High Frequency
14.6.4 Adaptive Ostensive and Performative Routines
Not Just Rearranging the Deckchairs on the Titanic: Learning from Failures Through Risk and Reliability Analysis
Learning from Failures as a Process Study
Choice of Case studies and research methodology
Case Study 1: Titanic the Unsinkable Ship That Sank
Fault Tree Analysis and Reliability Block Diagram for the Titanic Disaster
Proposed Improvements and Generic lessons
Case Study 2: The BP Texas City Incident
Sequence of events and Incident
Fault Tree Analysis and Reliability Block Diagram for the BP Texas City Disaster
Case Study 3: The Chernobyl Disaster
Fault Tree Analysis and Reliability Block Diagram for the Chernobyl Disaster
Proposed Improvements and Generic lessons
Case Study 4: NASA’s Space Shuttle Columbia Accident
Technical and Logic Cause of the Failure
Fault Tree Analysis and Reliability Block Diagram for the Columbia Disaster
Generic Lesson 1 – Too Much Belief in Previous Successes
Generic Lesson 2 – Coping with Growth
Generic Lesson 3 – Misconception of Fashionable Paradigms
Generic Lesson 4 – Legislations
Generic Lesson 5 – The “I operate, You fix” attitude
Generic Lesson 6 – No News is Good news
Generic Lesson 7 – Bad News Bad Person
Generic Lesson 8 – Everyone’s Own Machine is the Highest Priority to Him
Generic Lesson 9 – Solving a Crisis is a Forgotten Experience
Generic Lesson 10 – Skill Levels Dilemma
Attributes of the Generic Lessons
Appendix A: Fault Tree Analysis (FTA)
Reliability Block Diagrams (RBD)
Learning from Failures
：Decision Analysis of Major Disasters
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