Professional Development Flashcards
Reflection Cycle
- Plan
- Do
- Review
Why such large consequences of Katrina?
- pumping system breakdown
- poor consideration of failure
- evacuations
How did such a weak system (New Orleans) eventuate?
- social context
- mixed responsibilities
- risk management for natural hazards
What can we learn from New Orleans?
- Great wall of Louisiana
- redirect river and retreat
- add resilience
- develop trust
Contributing Factors to Hyatt Regency
- fast-track project
- architectural design changes
- drafting errors
- phone changes without write-up
- change in senior engineering personnel
- reliance on other peoples design
What should have occured at Hyatt Regency
- 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
Lessons Learned from Hyatt Regency
- personnel transitions create a risk of error creeping in
- changes in concept should be handled through a formal process not over the phone
Lessons not Learned from Hyatt Regency
- 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
General Causes of Failure
- Aims
- Organisation
- Methods
- People
Aims Causes of Failure
- goal failure
- requirement failure
- unrealistic
Organisational Causes of Failure
- resource failure
- size failure
- organisational failure
- methodology
- planning/control
Methods Causes of Failure
- technique failure
- technology failure
People Causes of Failure
- people management
- personality failure
- wrong people
- user needs
Swiss Cheese Model
- James Reason, 1990
- popular for training and investigations
- suggests putting up more barriers, with fewer holes
latent failure
prior failure lying “dormant”
active failure
occured at the time of failure
Levels of Human Error
- Skill-Based
- Rule-based
- Knowledge-Based
Skill-Based Errors
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
Knowledge-Based Errors
- dealing with unfamiliar/novel situations
- often most crucial to major failures
- ultimately problems of complexity/diagnosis
Rule-Based Errors
mistakes
- patterns for dealing with familiar scenarios
- applying a strong but wrong rule
- ignoring later counter-indicators
- overload
- training can improve rule-based skills
Reduction of Errors
- Error Detection and Removal
2. Error Prevention
Error Detection and Removal
- slips are easiest to detect (often by oneself)
- requires some discrepancy between expected and observed
- “fresh pair of eyes”
Error Prevention
- training and practice
- right environment
- simulators
- good design
- checklists
- standardisation
- humans will still make mistakes and lapses
Allowing for Human Error
- backup systems or redundancy
- locks preventing unsafe actions
- minimise concurrent unsafe action
- extra factor of safety
You cannot design out failure
- because of our ignorance
- complex set of circumstances not yet considered can lead to failure
- failures are not inevitable
Dont economise on safety
what is the cost of human life?
Testing and Checking Pay Off
- probabilistic risk assessments can be used to justify testing
- don’t sit behind your desk/email
Number 8 wire vs she’ll be right
empower workers - but within their limits
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
Tunnel vision and stress can lead to failure
- stress –> anger –> hypervigilance –> decision paralysis
- overwork and fatigue
- plan for contingencies
Create a culture of bringing up issues
- near-miss reports
- acknowledge risk and manage it
Rickover’s seven principles of safe technology systems
- Commitment to improving quality
- highly capable people
- supervisors need to listen and also take problems to high levels
- everyone needs a healthy respect for the risks
- training must be constant and rigorous
- specific individuals should have allied functions of repair, safety, quality control and technical support
- Ability and willingness to learn from mistakes
Why is consultation with mana whenua required?
- RMA
- Greater Christchurch Regeneration Act 2016
- It makes good sense for your project
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
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
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
CIA
Cultural Impact Assessment
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
How to engage mana whenua
- building strategic relationships
- aligning values
- the right process
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
Heathrow Tunnel technical failure
- insufficient shotcrete thickness on tunnel walls
- problems with blockages and delayed delivery of shotcrete
Heathrow Tunnel non-technical failure
- apparent lack of experienced supervision team
- lack of communication between contractors and project manager engineers
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
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
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
mana whenua
traditional authority
importance of landmarks to Maori
act as identity markers
significant sites
- Otakaro
- Market Square
- Little Hagley Park
significance of Market Square
- important site of early trading
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
significance of Otakaro
supported extensive wetlands, food and resources
whakapapa
genealogy
Maori genealogy definition
- building and teaching traditional knowledge and understanding
- acknowledging ancestral stories
- strengthening pride and sense of belonging
- connecting people and place
kaitiakitanga
sustainability
Maori sustainability definition
- intergenerational responsibilities as resource caretakers
- obligation to protect resources
Manaakitanga
extending hospitality and reciprocity
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
mahinga kai
customary food-gathering places and practices
Maori key values
- whakapapa (genealogy)
- kaitiakitanga (sustainability)
- manaakitanga (extending hospitality and reciprocity)
- mahinga kai (customary food-gathering places and practices)
