1
Q
Reflection Cycle
A
- Plan
- Do
- Review
2
Q
Why such large consequences of Katrina?
A
- pumping system breakdown
- poor consideration of failure
- evacuations
3
Q
How did such a weak system (New Orleans) eventuate?
A
- social context
- mixed responsibilities
- risk management for natural hazards
4
Q
What can we learn from New Orleans?
A
- Great wall of Louisiana
- redirect river and retreat
- add resilience
- develop trust
5
Q
Contributing Factors to Hyatt Regency
A
- fast-track project
- architectural design changes
- drafting errors
- phone changes without write-up
- change in senior engineering personnel
- reliance on other peoples design
6
Q
What should have occured at Hyatt Regency
A
- design detail shown on engineer’s drawing
- fabricators connection design detailed on shop drawings
- absence of properly designed connection noted during checks
- EOR should have been hired for inspection
- EOR could have disclaimed responsibility
7
Q
Lessons Learned from Hyatt Regency
A
- personnel transitions create a risk of error creeping in
- changes in concept should be handled through a formal process not over the phone
8
Q
Lessons not Learned from Hyatt Regency
A
- impacts of structural failure too great for success to be defined through a low bid process
- city building departments can’t provide adequate checking
- structural engineers cannot let lawyers define good engineering practice, case-by-case, after the fact
9
Q
General Causes of Failure
A
- Aims
- Organisation
- Methods
- People
10
Q
Aims Causes of Failure
A
- goal failure
- requirement failure
- unrealistic
11
Q
Organisational Causes of Failure
A
- resource failure
- size failure
- organisational failure
- methodology
- planning/control
12
Q
Methods Causes of Failure
A
- technique failure
- technology failure
13
Q
People Causes of Failure
A
- people management
- personality failure
- wrong people
- user needs
14
Q
Swiss Cheese Model
A
- James Reason, 1990
- popular for training and investigations
- suggests putting up more barriers, with fewer holes
15
Q
latent failure
A
prior failure lying “dormant”
16
Q
active failure
A
occured at the time of failure
17
Q
Levels of Human Error
A
- Skill-Based
- Rule-based
- Knowledge-Based
18
Q
Skill-Based Errors
A
action slips/lapses
- basic skills and tasks learnt by practice/training
- sub-conscious patterns of behaviour
- usually due to inattention or overattention
- usually quick to identify or rectify
19
Q
Knowledge-Based Errors
A
- dealing with unfamiliar/novel situations
- often most crucial to major failures
- ultimately problems of complexity/diagnosis
20
Q
Rule-Based Errors
A
mistakes
- patterns for dealing with familiar scenarios
- applying a strong but wrong rule
- ignoring later counter-indicators
- overload
- training can improve rule-based skills
21
Q
Reduction of Errors
A
- Error Detection and Removal
2. Error Prevention
22
Q
Error Detection and Removal
A
- slips are easiest to detect (often by oneself)
- requires some discrepancy between expected and observed
- “fresh pair of eyes”
23
Q
Error Prevention
A
- training and practice
- right environment
- simulators
- good design
- checklists
- standardisation
- humans will still make mistakes and lapses
24
Q
Allowing for Human Error
A
- backup systems or redundancy
- locks preventing unsafe actions
- minimise concurrent unsafe action
- extra factor of safety
25
You cannot design out failure
- because of our ignorance
- complex set of circumstances not yet considered can lead to failure
- failures are not inevitable
26
Dont economise on safety
what is the cost of human life?
27
Testing and Checking Pay Off
- probabilistic risk assessments can be used to justify testing
- don't sit behind your desk/email
28
Number 8 wire vs she'll be right
empower workers - but within their limits
29
Avoid groupthink when faced with crises
- take off engineering hat and put on management hat
- how to make decisions when you cannot see for yourself?
- try to 'avoid failure' rather than solve the puzzle
30
Tunnel vision and stress can lead to failure
- stress --> anger --> hypervigilance --> decision paralysis
- overwork and fatigue
- plan for contingencies
31
Create a culture of bringing up issues
- near-miss reports
| - acknowledge risk and manage it
32
Rickover's seven principles of safe technology systems
1. Commitment to improving quality
2. highly capable people
3. supervisors need to listen and also take problems to high levels
4. everyone needs a healthy respect for the risks
5. training must be constant and rigorous
6. specific individuals should have allied functions of repair, safety, quality control and technical support
7. Ability and willingness to learn from mistakes
33
Why is consultation with mana whenua required?
- RMA
- Greater Christchurch Regeneration Act 2016
- It makes good sense for your project
34
Benefits of iwi consultation
- knowledge of the history of your site
- understanding the effects of your project
- written approvals from mana whenua to help avoid notification
- reduction to risk of processing delays or appeals
35
Iwi Management Plans: a tool for mana whenua to
- articulate aspirations in the takiwa
- express rangatiratanga and kaitiakitanga
- protect cultural values and relationships
- focus on mana whenua relationship with natural environment
36
Iwi Management Plans: a tool for local authorities and wider community to
- gain some understanding of who mana whenua are
- understand what is important to mana whenua and why
- meet statutory obligations
- guide consultation and engagement with mana whenua
- appropriately consider mana whenua values
37
CIA
Cultural Impact Assessment
38
Cultural Impact Assessment
- a report documenting Maori cultural values, interests and associations with an area or resource, and the potential impacts of proposed activity
- tool to facilitate meaningful and effective participation of Maori in impact assessment
- should be regarded as technical advice, just like a geotech report
39
How to engage mana whenua
- building strategic relationships
- aligning values
- the right process
40
Heathrow Tunnel brief description
- 3 tunnels collapsed during construction in 1994
- no loss of life or injury occured
- designed to connect Heathrow and Paddington station by rail
- new Austrian Tunnelling Method used for first time in UK
- 6 month project delay and over 130 million pound cost
41
Heathrow Tunnel technical failure
- insufficient shotcrete thickness on tunnel walls
| - problems with blockages and delayed delivery of shotcrete
42
Heathrow Tunnel non-technical failure
- apparent lack of experienced supervision team
| - lack of communication between contractors and project manager engineers
43
Heathrow Tunnel one way to prevent
- qualified independent construction monitor on site
| - empower with authority to shut down the site if engineer requests not met
44
Northridge Meadows conclusions
- lack of understanding of timber seismic behaviour
- codes did not account for magnitude of earthquake
- deviations in construction from original plans
- - could have been mitigated through appropriate inspections
- code revisions recommended
- - licencing requirements
- - amend professional practice to ensure continuing education
- - requirement for building owners to strengthen buildings
45
The eight safety failure lessons - most applicable to Northridge
cannot design out failure
- codes thought to be accurate and 'modern'
- did not consider large enough design earthquake
- not sufficient or accurate knowledge of the seismic behaviour of timber buildings
46
mana whenua
traditional authority
47
importance of landmarks to Maori
act as identity markers
48
significant sites
- Otakaro
- Market Square
- Little Hagley Park
49
significance of Market Square
- important site of early trading
50
significance of Little Hagley Park
- meeting and resting place for Ngai Tahu in colonial period
| - often travelled great distances to Christchurch to sell or trade
51
significance of Otakaro
supported extensive wetlands, food and resources
52
whakapapa
genealogy
53
Maori genealogy definition
- building and teaching traditional knowledge and understanding
- acknowledging ancestral stories
- strengthening pride and sense of belonging
- connecting people and place
54
kaitiakitanga
sustainability
55
Maori sustainability definition
- intergenerational responsibilities as resource caretakers
| - obligation to protect resources
56
Manaakitanga
extending hospitality and reciprocity
57
Maori definition of extending hospitality and reciprocity
- welcome, care for and feed visitors
- create environment which cares for all
- create environment which keeps whanau safe
58
mahinga kai
customary food-gathering places and practices
59
Maori key values
- whakapapa (genealogy)
- kaitiakitanga (sustainability)
- manaakitanga (extending hospitality and reciprocity)
- mahinga kai (customary food-gathering places and practices)
ProfDev
flashcards
Decks in class (4)
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