ASTM G145-08(2016)
(Guide)Standard Guide for Studying Fire Incidents in Oxygen Systems
Standard Guide for Studying Fire Incidents in Oxygen Systems
SIGNIFICANCE AND USE
5.1 This guide helps those studying oxygen system incidents to select a direct cause hypothesis and to avoid conclusions based on hypotheses, however plausible, that have proven faulty in the past.
SCOPE
1.1 This guide covers procedures and material for examining fires in oxygen systems for the purposes of identifying potential causes and preventing recurrence.
1.2 This guide is not comprehensive. The analysis of oxygen fire incidents is not a science, and definitive causes have not been established for some events.
1.3 The procedures and analyses in this guide have been found to be useful for interpreting fire events, for helping identify potential causes, and for excluding other potential causes. The inclusion or omission of any analytical strategy is not intended to suggest either applicability or inapplicability of that method in any actual incident study.
Note 1: Although this guide has been found applicable for assisting qualified technical personnel to analyze incidents, each incident is unique and must be approached as a unique event. Therefore, the selection of specific tactics and the sequence of application of those tactics must be conscious decisions of those studying the event.
Note 2: The incident may require the formation of a team to provide the necessary expertise and experience to conduct the study. The personnel analyzing an incident, or at least one member of the team, should know the process under study and the equipment installation.
1.4 Warning—During combustion, gases, vapors, aerosols, fumes, or combinations thereof, are evolved, which may be present and may be hazardous to people. Caution —Adequate precautions should be taken to protect those conducting a study.
1.5 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use.
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Designation: G145 − 08 (Reapproved 2016)
Standard Guide for
Studying Fire Incidents in Oxygen Systems
This standard is issued under the fixed designation G145; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope 2. Referenced Documents
1.1 This guide covers procedures and material for examin- 2.1 ASTM Standards:
ing fires in oxygen systems for the purposes of identifying E620 Practice for Reporting Opinions of Scientific or Tech-
potential causes and preventing recurrence. nical Experts
E678 Practice for Evaluation of Scientific or Technical Data
1.2 This guide is not comprehensive. The analysis of oxy-
E860 Practice for Examining And Preparing Items That Are
gen fire incidents is not a science, and definitive causes have
Or May Become Involved In Criminal or Civil Litigation
not been established for some events.
E1020 Practice for Reporting Incidents that May Involve
1.3 The procedures and analyses in this guide have been
Criminal or Civil Litigation
found to be useful for interpreting fire events, for helping
E1138 Terminology for Technical Aspects of Products Li-
identify potential causes, and for excluding other potential
ability Litigation (Withdrawn 1995)
causes. The inclusion or omission of any analytical strategy is
E1188 Practice for Collection and Preservation of Informa-
not intended to suggest either applicability or inapplicability of
tion and Physical Items by a Technical Investigator
that method in any actual incident study.
E1459 Guide for Physical Evidence Labeling and Related
Documentation
NOTE 1—Although this guide has been found applicable for assisting
qualified technical personnel to analyze incidents, each incident is unique E1492 Practice for Receiving, Documenting, Storing, and
and must be approached as a unique event. Therefore, the selection of
Retrieving Evidence in a Forensic Science Laboratory
specific tactics and the sequence of application of those tactics must be
G63 Guide for Evaluating Nonmetallic Materials for Oxy-
conscious decisions of those studying the event.
gen Service
NOTE 2—The incident may require the formation of a team to provide
G88 Guide for Designing Systems for Oxygen Service
the necessary expertise and experience to conduct the study. The personnel
analyzing an incident, or at least one member of the team, should know the
G93 Practice for Cleaning Methods and Cleanliness Levels
process under study and the equipment installation.
for Material and Equipment Used in Oxygen-Enriched
1.4 Warning—During combustion, gases, vapors, aerosols, Environments
fumes, or combinations thereof, are evolved, which may be G94 Guide for Evaluating Metals for Oxygen Service
present and may be hazardous to people. Caution —Adequate G114 Practices for Evaluating the Age Resistance of Poly-
precautions should be taken to protect those conducting a meric Materials Used in Oxygen Service
study. G124 Test Method for Determining the Combustion Behav-
ior of Metallic Materials in Oxygen-Enriched Atmo-
1.5 This standard does not purport to address all of the
spheres
safety concerns, if any, associated with its use. It is the
G126 Terminology Relating to the Compatibility and Sensi-
responsibility of the user of this standard to establish appro-
tivity of Materials in Oxygen Enriched Atmospheres
priate safety and health practices and determine the applica-
G128 Guide for Control of Hazards and Risks in Oxygen
bility of regulatory limitations prior to use.
Enriched Systems
1 2
This guide is under the jurisdiction of ASTM Committee G04 on Compatibility For referenced ASTM standards, visit the ASTM website, www.astm.org, or
and Sensitivity of Materials in Oxygen Enriched Atmospheres and is the direct contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM
responsibility of Subcommittee G04.02 on Recommended Practices. Standards volume information, refer to the standard’s Document Summary page on
Current edition approved Oct. 1, 2016. Published October 2016. Originally the ASTM website.
approved in 1996. Last previous edition approved in 2008 as G145 – 08. DOI: The last approved version of this historical standard is referenced on
10.1520/G0145-08R16. www.astm.org.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
G145 − 08 (2016)
2.2 Compressed Gas Association (CGA) Standards: Discussion—Contamination and cleanliness are opposing
G-4.4 Industrial Practices for Gaseous Oxygen Transmission properties: increasing cleanliness implies decreasing contami-
and Distribution Piping Systems nation.
G-4.8 Safe Use of Aluminum Structured Packing for Oxy-
4. Summary of Guide
gen Distillation
4.1 Following a fire incident in an oxygen-enriched
2.3 National Fire Protection Association (NFPA) Standard:
atmosphere, the equipment, operating procedures, and area are
NFPA 53 Fire Hazards in Oxygen Enriched Atmospheres
considered in light of other incidents, potential contributing
NFPA 921 Guide for Fire and Explosion Investigations
factors, suggested analytical strategies, and demonstrated labo-
2.4 Occupational Safety and Health Act:
ratory results. The goal is to determine direct cause(s) of the
OSHA Process Safety Management Compliance Manual
incident in order to prevent a recurrence.
2.5 ASTM Adjuncts:
Video: Oxygen Safety 5. Significance and Use
5.1 This guide helps those studying oxygen system inci-
3. Terminology
dents to select a direct cause hypothesis and to avoid conclu-
3.1 Definitions—See Guides G63, G94, and G128 for the
sions based on hypotheses, however plausible, that have
terms listed in this section. proven faulty in the past.
3.1.1 oxygen compatibility, (also oxidant compatibility),
6. Abstract
n—the ability of a substance to coexist with both oxygen and
a potential source(s) of ignition at an expected pressure and
6.1 A series of possible causes and common scenarios are
temperature with a magnitude of risk acceptable to the user.
described to assist those seeking to understand incidents in
oxygen-enriched atmospheres. Many easily misinterpreted fac-
3.1.2 qualified technical personnel, n—persons such as
tors are described to help avoid faulty conclusions. Several
engineers and chemists who, by virtue of education, training,
suspected but unproven incident scenarios are described. Select
or experience, know how to apply the physical and chemical
laboratory data are presented to support assertions about direct
principles involved in the reactions between oxygen and other
causes of incidents.
materials.
3.1.3 oxygen-enriched, adj—a fluid (gas or liquid) mixture
7. Direct-Cause Analysis
containing more than 25 mole % oxygen.
7.1 In this guide, the direct cause of an incident is the
3.2 Definitions of Terms Specific to This Standard:
mechanical or thermodynamic event (such as breakage of a
3.2.1 incident, n—an ignition or fire, or both, that is both
component or near-adiabatic compression), the physicochemi-
undesired and unanticipated, or an undesired and unanticipated
cal property (such as heat of combustion), the procedure (such
consequence of an ignition or fire that was anticipated.
as a valve opening rate), or any departure(s) from the intended
3.2.2 direct incident cause, n—the mechanical or thermody-
state of any of these items, that leads directly to ignition or fire,
namic event (such as breakage of a component or near-
or both. A fire might also be the result of a financial decision,
adiabatic compression), the physicochemical property (such as
worker skill, or manufacturing process—all of which can be
heat of combustion), the procedure (such as a valve opening
viewed as causes—but such factors are addressed more prop-
rate), or any departure(s) from the intended state of any of
erly in a system hazard review. It is noteworthy that some fires
these items, that leads directly to ignition or fire, or both.
are anticipated and the risks (whether human or economic) are
addressed by such things as shielding (for example, to control
3.2.3 fractional evaporation, n—the continuous evaporation
human risk) or acceptance (for example, to address economic
of a quantity of liquid that results in a progressive increase in
risk). In these cases, a fire is not an “incident” unless some
the concentration of a less-volatile constituent(s).
aspect of the event exceeded expectations the initial parameters
3.2.4 Contaminant, n—unwanted molecular or particulate
(for example, the shielding did not provide the expected
matter that could adversely affect or degrade the operation, life,
containment, or the cost exceeded projections). This guide
or reliability of the systems or components upon which it
seeks to identify the material choice, equipment design, assem-
resides.
bly procedure, or other factor that led directly to the fire—and
3.2.5 Contamination, n—(1) the amount of unwanted mo-
more specifically, to distinguish the physical object or action
lecular non-volatile residue (NVR) or particulate matter in a
that caused the fire to start, to continue, or to be injurious or
system; (2) the process or condition of being contaminated.
destructive. Remedial actions are found in other documents
such as Guides G63, G88, and G94, and Practice G93, as well
as NFPA 53, CGA G-4.4, and G-4.8, OSHA Process Safety
Available from Compressed Gas Association (CGA), 4221 Walney Rd., 5th
Management Compliance Manual, and others.
Floor, Chantilly, VA 20151-2923, http://www.cganet.com.
7.2 Example—The direct cause of an incident may be
Available from National Fire Protection Association (NFPA), 1 Batterymarch
Park, Quincy, MA 02169-7471, http://www.nfpa.org.
concluded to be the use of an incompatible material, for
Available from Occupational Safety and Health Administration (OSHA), 200
example, a polyacetyl component was installed when a mate-
Constitution Ave., NW, Washington, DC 20210, http://www.osha.gov.
7 rial such as PTFE (polytetrafluoroethylene) or CTFE (chloro-
Available from ASTM Customer Service, 100 Barr Harbor Drive, West
Conshohocken, PA 19428-2959. Request Adjunct ADJG0088. trifluoroethylene) was preferred. The direct cause was not that
G145 − 08 (2016)
the budget was inadequate to cover the cost of PTFE; nor that Prevention can focus on cleanliness. Initiating Event: ignition
specific frictional properties of polyacetyl were required for of an incompatible oil. Direct Cause: contamination of the
mechanical purposes; nor that an incorrect part was installed in system.
error. Note that in this example, PTFE and CTFE might be
8.4.1.2 Example 2—Records may show that a component
needed to prevent or cope with ignition and fire, but that they
broke and produced a rub in a piece of machinery just before
might introduce non-fire-related issues such as loss of me-
an incident. This factor alone can ignite a fire and could be
chanical strength or production of toxic decomposition prod- identified as the direct cause. If the component broke because
ucts when exposed to heat of compression.
it contained a flaw, the flaw might be determined to be the
direct cause. However, if the part was selected because it
8. Elements of a Study offered economy, then the direct cause is still the inadequate
part—not a misguided effort to economize. Prevention in this
8.1 Overview—The study of an oxygen incident typically
case can focus on component quality. Initiating Event: friction
begins (preferably promptly) after the event has concluded.
during the rub. Direct Cause: Mechanical failure.
The fire is extinguished and any safety requirements or
8.4.1.3 Example 3—Deviation from an important operating
immediate needs are addressed (treating injuries, returning
practice, such as first equalizing downstream pressure with a
systems to a safe state, and so forth). Then the investigator can
bypass valve before opening a quick-opening valve, may be
begin to document the event, to preserve the artifacts, and to
established as the direct cause of a fire. The reasons for
detect how they may have been altered or compromised by the
departing from mandated practice are important, but they are
event and follow-up activities. Although many of these steps
not the direct cause. Here, prevention can focus on following
are itemized here, the intent of this guide is not to specify how
standard operating procedures. Initiating Event: approximately
or in what order they should be conducted. Rather, information
adiabatic compression. Direct Cause: incorrect operation.
is offered about certain procedures that have been effective in
8.4.2 An incident might be understood adequately when a
the past, as well as some that have led to faulty conclusions.
conservative tactic has been identified that would have pre-
Typically, good scientific and laboratory skills are useful and
vented or safely managed the event.
adequate. Forensic skills and procedures can be helpful in
8.4.2.1 Example 1—If an item of machinery cannot employ
many cases, but may not be practical in all. For example, the
oxygen-compatible materials because they compromise its
forensic Guide E1459 can assist with managing post-incident
operating economy, and it becomes the site of a fire and injures
artifacts, and related Practices E1492, E620, E678, E860,
someone, then the event may be understood adequately (re-
E1020, and E1188, as well as Terminology E1138, may have
garding preventing recurrence of injury rather than fire) when
other uses. However, when a forensic approach is needed
inadequate shielding or inadequate mechanical design or some
because a legal action is involved, the insights in this guide
other comparable factor is identified singly or in combination
may effectively supplement it.
as the direct cause.
8.2 Documentation—Urgent post-incident efforts include:
8.4.3 The study is complete when the direct cause has been
photographing or videotaping the site and any damaged equip-
determined. Preventing the repetition of an event is the
ment; obtaining system drawings, supporting design analysis,
function of a hazard review using well-established techniques,
process hazards analysis, and any other hazard-evaluation
including the use of related standards from ASTM Committee
materials; interviewing persons knowledgeable about the
G04. The hazard review may be integral to the incident study
system, operating procedures and the events before, during,
and may involve some or all of the same people, but it is a
and after the fire; collecting specimens, operati
...
This document is not an ASTM standard and is intended only to provide the user of an ASTM standard an indication of what changes have been made to the previous version. Because
it may not be technically possible to adequately depict all changes accurately, ASTM recommends that users consult prior editions as appropriate. In all cases only the current version
of the standard as published by ASTM is to be considered the official document.
Designation: G145 − 08 G145 − 08 (Reapproved 2016)
Standard Guide for
Studying Fire Incidents in Oxygen Systems
This standard is issued under the fixed designation G145; the number immediately following the designation indicates the year of
original adoption or, in the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. A
superscript epsilon (´) indicates an editorial change since the last revision or reapproval.
1. Scope
1.1 This guide covers procedures and material for examining fires in oxygen systems for the purposes of identifying potential
causes and preventing recurrence.
1.2 This guide is not comprehensive. The analysis of oxygen fire incidents is not a science, and definitive causes have not been
established for some events.
1.3 The procedures and analyses in this guide have been found to be useful for interpreting fire events, for helping identify
potential causes, and for excluding other potential causes. The inclusion or omission of any analytical strategy is not intended to
suggest either applicability or inapplicability of that method in any actual incident study.
NOTE 1—Although this guide has been found applicable for assisting qualified technical personnel to analyze incidents, each incident is unique and
must be approached as a unique event. Therefore, the selection of specific tactics and the sequence of application of those tactics must be conscious
decisions of those studying the event.
NOTE 2—The incident may require the formation of a team to provide the necessary expertise and experience to conduct the study. The personnel
analyzing an incident, or at least one member of the team, should know the process under study and the equipment installation.
1.4 Warning—During combustion, gases, vapors, aerosols, fumes, or combinations thereof, are evolved, which may be present
and may be hazardous to people. Caution —Adequate precautions should be taken to protect those conducting a study.
1.5 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility
of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory
limitations prior to use.
2. Referenced Documents
2.1 ASTM Standards:
E620 Practice for Reporting Opinions of Scientific or Technical Experts
E678 Practice for Evaluation of Scientific or Technical Data
E860 Practice for Examining And Preparing Items That Are Or May Become Involved In Criminal or Civil Litigation
E1020 Practice for Reporting Incidents that May Involve Criminal or Civil Litigation
E1138 Terminology for Technical Aspects of Products Liability Litigation (Withdrawn 1995)
E1188 Practice for Collection and Preservation of Information and Physical Items by a Technical Investigator
E1459 Guide for Physical Evidence Labeling and Related Documentation
E1492 Practice for Receiving, Documenting, Storing, and Retrieving Evidence in a Forensic Science Laboratory
G63 Guide for Evaluating Nonmetallic Materials for Oxygen Service
G88 Guide for Designing Systems for Oxygen Service
G93 Practice for Cleaning Methods and Cleanliness Levels for Material and Equipment Used in Oxygen-Enriched Environments
G94 Guide for Evaluating Metals for Oxygen Service
G114 Practices for Evaluating the Age Resistance of Polymeric Materials Used in Oxygen Service
G124 Test Method for Determining the Combustion Behavior of Metallic Materials in Oxygen-Enriched Atmospheres
G126 Terminology Relating to the Compatibility and Sensitivity of Materials in Oxygen Enriched Atmospheres
This guide is under the jurisdiction of ASTM Committee G04 on Compatibility and Sensitivity of Materials in Oxygen Enriched Atmospheres and is the direct
responsibility of Subcommittee G04.02 on Recommended Practices.
Current edition approved Sept. 1, 2008Oct. 1, 2016. Published October 2008October 2016. Originally approved in 1996. Last previous edition approved in 20012008 as
G145 – 96 (2001).G145 – 08. DOI: 10.1520/G0145-08.10.1520/G0145-08R16.
For referenced ASTM standards, visit the ASTM website, www.astm.org, or contact ASTM Customer Service at service@astm.org. For Annual Book of ASTM Standards
volume information, refer to the standard’s Document Summary page on the ASTM website.
The last approved version of this historical standard is referenced on www.astm.org.
Copyright © ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States
G145 − 08 (2016)
G128 Guide for Control of Hazards and Risks in Oxygen Enriched Systems
2.2 Compressed Gas Association (CGA) Standards:
G-4.4 Industrial Practices for Gaseous Oxygen Transmission and Distribution Piping Systems
G-4.8 Safe Use of Aluminum Structured Packing for Oxygen Distillation
2.3 National Fire Protection Association (NFPA) Standard:
NFPA 53 Fire Hazards in Oxygen Enriched Atmospheres
NFPA 921 Guide for Fire and Explosion Investigations
2.4 Occupational Safety and Health Act:
OSHA Process Safety Management Compliance Manual
2.5 ASTM Adjuncts:
Video: Oxygen Safety
3. Terminology
3.1 Definitions—See Guides G63, G94, and G128 for the terms listed in this section.
3.1.1 oxygen compatibility, (also oxidant compatibility), n—the ability of a substance to coexist with both oxygen and a potential
source(s) of ignition at an expected pressure and temperature with a magnitude of risk acceptable to the user.
3.1.2 qualified technical personnel, n—persons such as engineers and chemists who, by virtue of education, training, or
experience, know how to apply the physical and chemical principles involved in the reactions between oxygen and other materials.
3.1.3 oxygen-enriched, adj—a fluid (gas or liquid) mixture containing more than 25 mole % oxygen.
3.2 Definitions of Terms Specific to This Standard:
3.2.1 incident, n—an ignition or fire, or both, that is both undesired and unanticipated, or an undesired and unanticipated
consequence of an ignition or fire that was anticipated.
3.2.2 direct incident cause, n—the mechanical or thermodynamic event (such as breakage of a component or near-adiabatic
compression), the physicochemical property (such as heat of combustion), the procedure (such as a valve opening rate), or any
departure(s) from the intended state of any of these items, that leads directly to ignition or fire, or both.
3.2.3 fractional evaporation, n—the continuous evaporation of a quantity of liquid that results in a progressive increase in the
concentration of a less-volatile constituent(s).
3.2.4 Contaminant, n—unwanted molecular or particulate matter that could adversely affect or degrade the operation, life, or
reliability of the systems or components upon which it resides.
3.2.5 Contamination, n—(1) the amount of unwanted molecular non-volatile residue (NVR) or particulate matter in a system;
(2) the process or condition of being contaminated. Discussion—Contamination and cleanliness are opposing properties: increasing
cleanliness implies decreasing contamination.
4. Summary of Guide
4.1 Following a fire incident in an oxygen-enriched atmosphere, the equipment, operating procedures, and area are considered
in light of other incidents, potential contributing factors, suggested analytical strategies, and demonstrated laboratory results. The
goal is to determine direct cause(s) of the incident in order to prevent a recurrence.
5. Significance and Use
5.1 This guide helps those studying oxygen system incidents to select a direct cause hypothesis and to avoid conclusions based
on hypotheses, however plausible, that have proven faulty in the past.
6. Abstract
6.1 A series of possible causes and common scenarios are described to assist those seeking to understand incidents in
oxygen-enriched atmospheres. Many easily misinterpreted factors are described to help avoid faulty conclusions. Several suspected
but unproven incident scenarios are described. Select laboratory data are presented to support assertions about direct causes of
incidents.
7. Direct-Cause Analysis
7.1 In this guide, the direct cause of an incident is the mechanical or thermodynamic event (such as breakage of a component
or near-adiabatic compression), the physicochemical property (such as heat of combustion), the procedure (such as a valve opening
rate), or any departure(s) from the intended state of any of these items, that leads directly to ignition or fire, or both. A fire might
Available from Compressed Gas Association (CGA), 4221 Walney Rd., 5th Floor, Chantilly, VA 20151-2923, http://www.cganet.com.
Available from National Fire Protection Association (NFPA), 1 Batterymarch Park, Quincy, MA 02169-7471, http://www.nfpa.org.
Available from Occupational Safety and Health Administration (OSHA), 200 Constitution Ave., NW, Washington, DC 20210, http://www.osha.gov.
Available from ASTM Customer Service, 100 Barr Harbor Drive, West Conshohocken, PA 19428-2959. Request Adjunct ADJG0088.
G145 − 08 (2016)
also be the result of a financial decision, worker skill, or manufacturing process—all of which can be viewed as causes—but such
factors are addressed more properly in a system hazard review. It is noteworthy that some fires are anticipated and the risks
(whether human or economic) are addressed by such things as shielding (for example, to control human risk) or acceptance (for
example, to address economic risk). In these cases, a fire is not an “incident” unless some aspect of the event exceeded expectations
the initial parameters (for example, the shielding did not provide the expected containment, or the cost exceeded projections). This
guide seeks to identify the material choice, equipment design, assembly procedure, or other factor that led directly to the fire—and
more specifically, to distinguish the physical object or action that caused the fire to start, to continue, or to be injurious or
destructive. Remedial actions are found in other documents such as Guides G63, G88, and G94, and Practice G93, as well as NFPA
53, CGA G-4.4, and G-4.8, OSHA Process Safety Management Compliance Manual, and others.
7.2 Example—The direct cause of an incident may be concluded to be the use of an incompatible material, for example, a
polyacetyl component was installed when a material such as PTFE (polytetrafluoroethylene) or CTFE (chlorotrifluoroethylene)
was preferred. The direct cause was not that the budget was inadequate to cover the cost of PTFE; nor that specific frictional
properties of polyacetyl were required for mechanical purposes; nor that an incorrect part was installed in error. Note that in this
example, PTFE and CTFE might be needed to prevent or cope with ignition and fire, but that they might introduce non-fire-related
issues such as loss of mechanical strength or production of toxic decomposition products when exposed to heat of compression.
8. Elements of a Study
8.1 Overview—The study of an oxygen incident typically begins (preferably promptly) after the event has concluded. The fire
is extinguished and any safety requirements or immediate needs are addressed (treating injuries, returning systems to a safe state,
and so forth). Then the investigator can begin to document the event, to preserve the artifacts, and to detect how they may have
been altered or compromised by the event and follow-up activities. Although many of these steps are itemized here, the intent of
this guide is not to specify how or in what order they should be conducted. Rather, information is offered about certain procedures
that have been effective in the past, as well as some that have led to faulty conclusions. Typically, good scientific and laboratory
skills are useful and adequate. Forensic skills and procedures can be helpful in many cases, but may not be practical in all. For
example, the forensic Guide E1459 can assist with managing post-incident artifacts, and related Practices E1492, E620, E678,
E860, E1020, and E1188, as well as Terminology E1138, may have other uses. However, when a forensic approach is needed
because a legal action is involved, the insights in this guide may effectively supplement it.
8.2 Documentation—Urgent post-incident efforts include: photographing or videotaping the site and any damaged equipment;
obtaining system drawings, supporting design analysis, process hazards analysis, and any other hazard-evaluation materials;
interviewing persons knowledgeable about the system, operating procedures and the events before, during, and after the fire;
collecting specimens, operating logs, and related information; and preliminary formulation and testing of hypotheses.
8.3 Analysis—The principal effort in a study will be analysis of the data and artifacts. This may require further examination of
the equipment and records, laboratory study of selected items, and perhaps even laboratory simulation of the incident.
8.4 Completion of Study—An incident study is complete when the qualified technical personnel involved in the study conclude
that the event is understood.
8.4.1 An incident might be understood adequately when a conclusion has been drawn about the direct cause of the event. The
following examples show the distinction between direct causes and causes that are not physicochemical or thermodynamic events.
8.4.1.1 Example 1—A substantial amount of hydrocarbon oil was introduced into a system just before an incident. This single
factor may be identified as the direct cause of the fire. Any reasons for introducing the lubricant may be important to a new hazard
review, but are not the direct cause of the fire. Prevention can focus on cleanliness. Initiating Event: ignition of an incompatible
oil. Direct Cause: contamination of the system.
8.4.1.2 Example 2—Records may show that a component broke and produced a rub in a piece of machinery just before an
incident. This factor alone can ignite a fire and could be identified as the direct cause. If the component broke because it contained
a flaw, the flaw might be determined to be the direct cause. However, if the part was selected because it offered economy, then
the direct cause is still the inadequate part—not a misguided effort to economize. Prevention in this case can focus on component
quality. Initiating Event: friction during the rub. Direct Cause: Mechanical failure.
8.4.1.3 Example 3—Deviation from an important operating practice, such as first equalizing downstream pressure with a bypass
valve befo
...
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