chaos or negligence n.
Skip this Video
Loading SlideShow in 5 Seconds..
Chaos or Negligence? PowerPoint Presentation
Download Presentation
Chaos or Negligence?

Chaos or Negligence?

206 Views Download Presentation
Download Presentation

Chaos or Negligence?

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. 1976 Crown Redevelopment 1976 Crown Redevelopment Corp initiated plans for a Hyatt Regency Hotel Chaos or Negligence? Note – these slides contain material from Texas A+M University NSF Grant Number DIR-9012252 And “Hyatt Regency Walkway Collapse” presentation by Jack Gullium June 2004

  2. A Fast-Track and Team • Design Team • Made of Architects • GCE the Structural Engineering work • Construction Team • Eldridge Construction Company • Numerous subcontractors and fabricators • Shop drawings were to be done by fabricators • Inspection Team • Two inspection companies • Construction Managers • Investigating Engineer (Seiden and Page) • Project being built as it was designed • Structural engineer was to sign off on shop drawings before built in the field

  3. Suspended Walkways Between the Guest Tower and Event Center Note that 2nd and 4th floor Walkways Are Suspended Above And below Each Other.

  4. The Suspended Walkway Walkway hung from a Box been with rods Going through to suspend The decks. Bolts and washers on the Rod supported the box Beam that the walkway Was attached to.

  5. Who Engineered This? Design Load 20.3 Kips Test strength 20.5 Kips Building code – 1.67 times load Requiring 33.9 Kips (but the fabricator was responsible For planning the connections to Meet code requirements)

  6. How Did the Connection Hold Up? Of course fabricators buying cut-rate Steel with below design strength did not Help and field testing firms were actually Changed because the first testing firm Was not doing its job (part of the atrium roof fell in during Construction but that was problems with Other parts of the construction).

  7. A Matter of Communication The Structural Engineer Sketched This for the design The Draftsman drew this omitting engineering Details and the Structural Engineers sent It to the fabricators. (How were they suppose To meet the building code when no one told Them what the loads were?)

  8. A Matter of Practicality To Support two decks With a continuous rod Will require this rod to Be threaded all the way. The fabricators call the Structural engineers asking To be allowed to use two Rods. 4th floor hangs from The roof – 2nd floor from the 4th They are told to submit their proposal

  9. The Fabricator Sends a Stack of 42 Drawings to the structural engineer This is the revised drawing Of the connection using Two rods The structural engineers are busy and A technician filling on the project but Not actually working on it – checks the Drawings and affixes the P.I.s seal to The drawings. (The technician was Not a P.I. himself).

  10. The Fabricator Built This The 2nd Floor walkway hangs from The 4th floor walkway Now the rod connecting the 4th Floor to the roof has a double load But the same strength

  11. A Connection Loaded to Failure • During construction the walkway began to sag • It was visible to the naked eye and measured at 3/4th of an inch. • Handrail deformations end up on work list 130 times but the General Contractor never notifies the Structural Engineers or the owner • The Hotel opens in July 1980 • One month later a dry wall installer reports that the beams are distorting • No one does anything

  12. A Dance With 2000 People – July 17th, 1981 Dead - 114 People Injured - 200 People Party Ruined – for everyone

  13. The Connection The Rod pulled straight through the box beam

  14. Who’s at Fault • Is there an ethics question here? • The fabricator was charged to make sure connection were up to code • The Structural Engineers were to design the structures and affix the P.I. seal to those that were verified for construction • Engineers on site are to report and investigate quality control problems • Owners are to maintain the facilities they operate

  15. Another Collapse • You will read about the Crandall Canyon (Genwal) Mine Collapse of August 2007. • The miners were room and pillaring on advance to recover part of a barrier pillar in a near worked out coal mine • They had mined past the deepest cover and might seem to be “home free” • While the crew was working on the face the coal pillars exploded throwing enough coal into the entries to almost fill them • A chain reaction of pillar failures erased ½ mile of entries • The pillars broke through into a sealed area of the mine with little oxygen in the air • The oxygen deficient air swept across the miners suffocating anyone left alive • The entire mine face crew was killed

  16. The Blame Game Problem • Regulators, Plaintiffs Lawyers, and Politicians facing outraged voters will always go on the hunt for the guilty • Most guilt is a series of omissions and mis-communications none of which rise to the level of the consequence

  17. The Silent Killer • Mining is a small enough community that each life lost is directly linked to the lives of many others • The pain of lost friends and empathy for others • Our invisible secure world being shaken • A Reminder that a whole bunch of what happens to us we can’t control • The problem of Survivors Guilt • I’m alive and someone more worthy of life than me is gone • There is something wrong with the cosmic balance that left me behind • Second guessing yourself – if I’d done something else my friend would still be alive and his wife and children would not be crying for someone who will never come home • If you know one time line blew up your always going to consider that a different time line probably would not have

  18. Blame Game Preditors • Agencies/Lawyers on the hunt and insensitive • Even the tone of the questions accuses people who are already 2nd guessing or blaming themselves • A Mother brings in the groceries and is distracted for about 15 minutes • Her two kids die of heat exhausting in the car • A Prosecutor looking for votes attacks the Mother and charges her with neglect and manslaughter • Is there anything that he can do to her that will make this otherwise good Mother feel more like a piece of crap? • I’m not saying whether society should or should not punish neglect and failure • Societal Blame Games seldom weigh the personal grief that they compound

  19. Whats Worse Than 12 Dead Bodies at Sago? • Most serious accidents are followed by suicides • Sago has 2 or 3 more dead in its aftermath • If you made a small mistake that had a giant consequence and Preditors exploit your guilt so they can offer up a guilty party they can magnify many times over the seriousness of the failing • Sometimes its just down right 20-20 hindsight • Even if Survivors Guilt, Fellowship Loss and Blame Game Preditors don’t kill your people • Depression, Traumatic Shock Syndrome can devastate the productivity of the resources you and the community need to recover

  20. A Strong Stance • Get Grief Councilors in early • Take people’s pain seriously • Stand by your people • Don’t let the blame game team demean or magnify their guilt • Balancing between a circle the wagons maneuver with your lawyers and reaching out in sympathy to those who have lost loved ones is a difficult balance • There may be no such thing as a right answer (or at least one that someone else cannot pick apart)

  21. Examples of the Blame Game • Hyatt Regency is a classic case of engineering failure framed in many engineering ethics case studies • One that I looked at • Showed the initial walkway design • Indicated that Engineering Reviews found Gullium guilty of not communicating designs properly to fabricators • Said that he signed off and stamped the two rod design • Then showed a picture of the as built drawing (they left you believing that the as built drawing was approved by Gullium) • They went on to say he lost his license in two states and then went to work in another state • Then they ask whether people like this should be allowed to practice engineering anywhere else

  22. A Great Blame – But Was It True? • Gulliams draftsman failed to put the loads on the drawings they sent to the fabricators – the drawing was sent on • Sloppy workmanship [Fact] • An engineer at Gulliums firm suggested that the fabricators two rod design should be submitted for review when the fabricator called on the phone • It was in a drawing just as poor and undescriptive as what Gulliams draftsman had sent out. • Gullium let a technician unfamiliar with the project check the shop drawings • He allowed the technician to apply his seal (violation of the code of ethics) • The shop drawings showed two holes but never indicated a second rod was being added or that the 2nd floor walkway was to be hung from the 4th • The as built drawing was in fact never submitted for Gulliums review

  23. The Master of Disaster Who Went On • Gulliums business and several others went bankrupt • Gullium lost his license in two states • After the Investigation he went on • Became a lead advocate and lecturer for the engineering profession on the importance of thorough oversight by the Engineer of Record • He was one of the most vocal warning voices on the problems of turn-over and poor communications in construction management teams • (A problem that still has not been fixed and that he continues to teach others how to try to avoid)

  24. Point • People are rarely as guilty and negligent as blame game reports paint them out to be • (some reports are down right manipulative if not dishonest) • Sometimes the worst offenders are the people who have the most to give as they go on and try to help others be wiser than they were • NEVER feel like you have made mistakes so bad that you have nothing more to give • NEVER let the blame game people treat or make your people feel that way! • Jack Gullium carried weight as a warning voice and teacher that would never have been possible from anyone else

  25. The Genwal Case • The MSHA report will tell you that • GRI (Genwal Resources Inc) failed to check their consultants designs • They will tell you that GRI failed to report rock bursts on the north entries – thus depriving MSHA of information needed to avoid a disaster • That they failed to revise their roof control plan when rockbursts indicated it was unsafe

  26. Only By Careful Reading Will You Find • GRI had historically contracted out more complicated rock mechanics designs to specialists • APG (the consultant) had done successful designs for years on the Genwal mine • Both GRI and MSHA relied on designs done by a proven performer that neither party had ready inhouse staff to check • Rockbursts are not just sudden yes or no events • Anyone who has been in an underground mine at much depth as seen little pops and spalls (my house pops as load shifts when it cools off at night) • Genwal had little pops on the north entries, they had one case where a lump of coal shot out and hit someone in the face but did not injure them • APG was trying to use experience from the north entries to revise and produce better designs for the south entries

  27. Rock Bursts – How Serious • On the North entries in March during when the equipment was shut down a rock burst effecting a dozen pillars buried a miner • It took them a couple hours to get the miner dug out and the shift going • A rockburst that shuts down production more than 30 minutes is suppose to be reported to MSHA • This one didn’t shut down production but they did loose two hours of the shift start • GRI did not report it • MSHA said they should have • In all fairness GRI was really pushing the definition by not reporting it • 3 Days later a second burst effecting fewer pillars buried equipment • GRI’s people felt that they could not safely operate and shut the section down permanently themselves • They notified MSHA the next day that they had shut the section down because ground control conditions were so rough that the judged the section unsafe • They waited 24 hours to notify MSHA • They did not say the word rock-burst or show MSHA the drawings of which pillars had spalled

  28. The Rock Burst Follow-Up • Rock burst scenes are suppose to be preserved for an MSHA investigation • MSHA is to be notified promptly and then MSHA has 24 hours to decide whether to investigate • MSHA also can just look at the companies own report • Its not at all obvious that MSHA would have investigated rather than just looked at the report from the company (we will never really know) • GRI did not notify of the first rock burst because it did not stop production (well sort of did not) • When a face is taking load usually one of the worst things to do is stop • We know that the face blew out a second time 3 days later even though it was kept moving • If they had stopped the face – and if MSHA had chosen to investigate we can only guess what could have happened • Some of the Possibilities are not very pretty

  29. The Second Rock Burst • 3 Days later there was a second rock burst • MSHA’s ultimate weapon – the K order • If MSHA believes an entire mine or any portion of a mine is unsafe they can issue a K order • A K order withdraws miners until MSHA believes it is safe for them to go back • After the 2nd Rock Burst GRI did not notify MSHA • But they did issue their own K order and shut the entire north pillar mining system down for good • GRI matched MSHA’s own maximum enforcement • GRI did notify MSHA they were pulling out (but not until after 24 hours – the scene would still have been available had MSHA wanted to see it – BUT • What would they have done – Issued a K order?

  30. The Roof Control Plan • The South pillar roof control plan was issued and approved by MSHA prior to the 2 March rock bursts • The March rock bursts could not have been used as a basis for GRI or MSHA to have known the South pillar plan was unsafe • The MSHA report suggests GRI was negligent in not stopping use of the South Pillar plan after the rock bursts on the north • One must read closely to find that the South Pillar plan was already suppose to be improved to give better mining conditions • FACT – GRI and MSHA both had reason to believe the south pillar plan was better than the north • Its not at all obvious (except by 20-20 hindsight that the south pillar plan should be revisited after the rock bursts) • APG did supposedly take a look at the south pillar plan after the north rock bursts but offered no reason to change it.

  31. Should They Have Known to Revise the South Pillar Plan • MSHA’s report says yes • But both GRI and MSHA watched the south pillar mined for 6 months without saying anything • The South Pillar plan advanced under the deepest cover without incident or warning signs like there had been on the north • The South pillar collapse was a sudden catastrophic event

  32. The Tragedy that Kept on Giving • When the pillars blew MSHA and GRI both believed they had failed under the deepest cover and maximum load • That meant a nice healthy air and safety pocket probably existed for the miners on the face (reality – the collapse initiated on the face at the entries were out for twice as far as anyone believed at the time) • MSHA and GRI raced to clear out and support the gobbed up entries to get to the miners • Bob Murry was constantly at the face trying to see that his teams got to his miners fast • As they cleared away the GOB compressing the damaged pillars they burst again as the team was putting up the supports • Three more people died including an MSHA inspector • The people on the face pulled the other team members out • Bob Murry was not hurt but was just back from the accident

  33. Villain or Victim? • Many have tried to frame GRI and American Coal as a reckless and negligent operator • GRI in fact did several things that were wrong, illegal, or would make a good debate on whether they were illegal • If GRI knew their mine design was fatally flawed do you really think Bob Murry would have been down there or taken in CNN camera crews? • Just Maybe the rescue was run by people who felt the pain and concern of the families with loved ones missing • No one talking about the reckless Genwal talks about the fact that American Coal has some of the best equipped and trained fire fighting teams in the business

  34. The Lesson • Be diligent, thorough and consciences in the practice of engineering before anything goes wrong (and maybe it never will) • Always be trying to improve your skills • Integrity and Honesty must always be who you are! • Practice like the welfare of people depend on you – because it does • If errors and failings result in tragedy • Never give up on yourself • Never give up on your people • Learn to forgive • Rebuild the lives and hearts of those who bleed (sometimes the victims and villains really do cry together) • Remember that sometimes those who learn from tragedy the most and have the most to give going forward are those who have been at the front lines of mistakes.