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Engineering Failure

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Michelle Rodrigo

on 30 January 2013

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Transcript of Engineering Failure

AvertRisk Consultancy has arranged this conference to present to highlight the lessons learnt from engineering failure. This presentation is in accordance with the report produced for Engineers Australia Risk Society.

Today the top 6 engineering failures in Australia and from around the world according to 6 categories will be presented by: Top 6 Engineering Failures In Australia And Around The World
by AvertRisk Consultancy Introduction Julian Hayek- Medium and Localised: 1997 Thredbo Landslide Ray Dawood- Large and Localised: Granville Train Accident Michelle Rodrigo - Medium and Widespread: 1978 Ford Pinto fuel tank design flaw Janan Kako- Large and Widespread: 1986 Chernobyl nuclear power plant accident Joe Nader- Small and Localised: 2003 Soccer Goalpost Collapse 2003 Soccer Goal Post Collapse 1997 Thredbo Landslide 1977 Granville Train Accident 1978 Ford Pinto Fuel Tank Design Flaw 1986 Chernobyl nuclear power plant accident Elie Nahmy - Small And Widespread: 1998 Sydney Water Cryptosporidium and Giardia Contamination “Deemed To Comply” Goal post must pass one of the three in order to comply with standards:

Fall Over Test + Static Load Test (figure below)
Weight Test
Horizontal Pull Test Testing new portable goal posts

The incident could have been avoided if there was extensive work done to have new designs to posts prior to death of girl.

Poor quality of material used and heavy metal which can be easily collapsed. Should have used lighter material

To avoid disasters like 2003 goal post collapse design steps should be taken in accordance to AS - AS 4866.1-2007:

Net attachment/anchor method
Strength/unexpected collapse
Impact hazard
Stability Could it have been avoided Portable soccer goal posts Lack of research and precaution into goal post design since the previous incidents lead to the death of the young girl in 2003.

On a normal day, whilst watching gala day of soccer matches, girl was walking past the post (spectator).

Poor designs and material quality lead to collapse of the goal which struck the girl on the head.

Ambulance arrive at scene 20-30 minutes after the incident, where she along with her family were rushed to hospital.

1 Hour later the young girl passed away in hospital.

Not the only incident, where in 1990 a young boy was crushed by the post after it collapsed, along with another 5 other incidents from 1986-2003.

This event lead to NSW Department of Fair Trading consulting UTS engineering for research and development of new goal posts. Series of Events Soccer is a friendly and the largest growing and popular team sport in the world.

There are many dangers in the quickly growing and most popular team sport, not only in Australia, but worldwide

Main concern in these dangers is the threat of a tipping or collapsing goal post onto players and/or spectators.

Since 1986 a reported seven children have been killed by this incident, and most recently in 2003 a young 3 year old girl was struck in the head by a collapsing goal post. Introduction 2003 Soccer Goal Post Collapse 6 5 4 To stay diligent and committed to your occupational duties, emphasise significance of employee role within society

Always implement monitoring and control methods that are regularly revised to be as accurate as possible

Regularly re-iterate and encourage staff about safety and wellbeing

Give credit to all hazards accordingly regardless of its magnitude; take worst case scenario approach for each hazard to eliminate any chance of its occurrence.

Do not reuse trains that have been involved in any sort of collision or derailment as this is highly risky when dealing with people’s lives. Learning lessons A more thorough maintenance team

More precise safety controls to be implemented e.g. maintenance audits

Regular training of skills and increased awareness/education of safety standards

Not use a train that had previously been involved in a major derailment Could it have been avoided The train departed from Mt. Victoria at 6.09am and made its way towards Sydney CBD

One minute after departing Parramatta station the train approached Granville station on the Up Main Line 2km from Sydney at 8.12am.

Speeds were being reduced from 80kph to undertake a wide left curve and in preparation for a speed restriction the front right-hand wheel of train 4620 derailed and continued to travel in this state until reaching a set of facing points.

Train 4620 derailed completely and the first two cars were overthrown.

During the derailment of the train it completely knocked down the piers that were supporting the middle of the structure. Causing the bridge to collapse on the train. Series of Events Train derailments are an unlikely event, however when they do occur they immensely impact on a large and localised scale.

Australia's most disastrous rail incident occurred on the Tuesday morning the 18th of January 1977.

This incident stopped the entire state in its tracks as it claimed 83 lives, 210 injured and 1300 affected.

This lead to an extensive state wide investigation to determine the failure modes of the incident. Introduction 1977 Granville Train Disaster 3 As a direct result, Sydney Catchment Authority was created to help manage these events in the future.
Better to be proactive than reactive!
No major outbreaks since
People should never be negligent when it comes to our drinking water! Where to go from here? 21st July 1998 – First traces of C & G found
24th July 1998 – C & G kept rising prompting for Sydney Water to increase intensity
27th July 1998 – 1st boil warning for CBD issued
29th July 1998 – 2nd boil warning issued for residents in Darling Harbour
30th July 1998 – 3rd boil warning issued for rest of Sydney!
4th August 1998 – Sydney water declared the infection has subsided back to normal. Series of Events Small and Widespread. 1998 Sydney Water Crisis Cryptosporidium and Giardia Contamination To put it quite simply, YES!

Sydney Water should have ensured:
Regular day to day checks
Increase on site staff
Constant dam maintenance Could it have been avoided? 11 Dams in Sydney
Biggest is Warragamba Dam, covers area of 9050 Km2 Warragamba Dam 1998 Sydney Water Contamination 2 By Charles Hayes ‘Safety First Is Safety Always’ Safe Design is a necessity for any product.

Duty Of Care must be held at the utmost importance no matter the consequence.

Conducting regular honest risk assessments

Uphold legal and moral responsibilities of engineers in relation to safety, follow the Code of Ethics and be aware of the irrelevance of cost-benefit analysis is for public safety decisions Lessons Learnt Social Changes Involving Law, Standards, Work Practices and Technolgy 2. Gas tank lined with a rubber bladder. Cost $5.08

None of the alternatives were incorporated in design.

Foreseeing tragedy and compensating a person’s life is unethical. Ford belittled human life and put a cost to it with their cost/benefit analysis. Pre-Failure Mitigation (2) The pre-failure mitigation would have passed the HSE Risk Tolerability Magnitude Test.

Four alternative ideas were tested to mitigate the risk (Dowie,M.1977)

Two most favourable:

1. A plastic baffle placed between the front of the gas tank and the differential housing. Cost one dollar and weighed around one pound. Pre-Failure Mitigation 3. The inaccurate cost/benefit ratio attributed to the failure of the fuel tank.

They estimated $137.5 M would be incurred in cost for fixing the vehicle compared to $49.5M benefit if they compensated by payout.

Barrier: Having a clear definition of what is 'reasonably practicable' in the ALARP principle would have prevented Ford keeping up the pretence for 8 years. Chain Of Causation (3) 1. Shortened Production time from 43 months
to 25 months. This was a major cause for the
design flaw from occurring.
Barrier: Normal production time period would
have allowed design flaw to be thoroughly

2. Failures were detected from crash tests
but top Ford officials decided to manufacture
the car without any modifications even though
the car was not safe.
Barrier: High safety laws and standards
for withstanding rear-end collisions
at a specified speed. Chain Of Causation (2) The failure was labelled as a ‘firetrap’

Gas tank would rupture during rear-end collisions at relatively low speeds in the company crash tests. Background (2) The Ford Pinto Case is an classic example for the importance of safety in engineering.

Ford strived to be in the top of the competitive small-car market.
‘Strict design specifications were that the car was to weigh less than 2000 pounds and cost less than $2000' (ASCC 2006) Background 1978 Ford Pinto Fuel Tank Design Flaw Bryon Bloch Consultants Auto Safety Design (2010) Chain of Causation 1971 Chevrolet Impala Vs. 1972 Ford Pinto Rear-End Collision at 35Mp/h. It took 45 seconds to extinguish the flames. Crash Test 1

Analysing the disaster we have come to the conclusion that the disaster was not caused by engineering failures but human errors

Lack of understanding and inexperience caused the situation to escalate into chaos

To avoid disasters like Chernobyl from happening again we need too:

Implement a better education system
Employ experienced engineers and operators
Always have nuclear physicists and engineers on site at all times
Develop and design more advanced reactors
Update the safety procedures Could it have been avoided The series of events that led to the disaster were caused by human negligence and disregard for safety protocols

There was a sudden power output surge and attempts to correct system only enhanced the dangerous situation

When the emergency shutdown was attempted an extreme spike in power output occurred

The reactor vessels ruptured and a series of explosions occurred

Graphite reactor was exposed to the air, igniting it causing it to burn and release radiation into the atmosphere

This event leads to misguided deployment of fire fighters, police officers and other authorities who are killed immediately Series of Events The benefits of nuclear power in today’s technological advancing society are immense, especially if there is need for cheap electricity.

There are also potential hazards consequences that are present at nuclear power plants

Nuclear power has always been a dangerous source of energy, in the case of Chernobyl, it was and still is harming humans and the environment.

The Chernobyl incident occurred in 1986, led to the evacuation of 400000 people and contamination of 200000 km^2 of land (Source: World information service on energy) Introduction 1986 Chernobyl disaster We have learnt that Safety and the well-being of human beings is the most important thing when designing nuclear power plants

We have learnt the effects of radiation on nature and human beings giving us a different perspective in nuclear energy Learning lessons In 1978 standards for withstanding rear-end collisions at a specified speed was created called
‘Light Vehicle Forward-Looking, Rear-End Collision Warning System Performance Guidelines’ Thank You For Your Patience.
Are there any questions??? Conclusion We, as a group have:
Identified engineering failures for dynamic categories affecting human life,
Reported our findings towards these failures and ways in which we can further prevent these situations from occurring again.
Conducted risk assessments based on each failure

This has allowed AvertRisk Consultants to aid Engineers Australia Risk Society in minimizing the uncertainty of risk for relating situations. Conducting Risk Assessments

Consistently reviewing and updating procedures.

Evacuation and rescue methods should also be monitored and utilised to maximum effect.

Cost in court settlements and post incident construction far exceeds the cost for initial compliance with safety standards. Learning Lessons
We can securely determine that the Thredbo landslide was triggered by human laxity.

In the Coroner’s report, Derrick Hand blames the government authorities, including NSW National Parks and Wildlife Service (NPWS) for their carelessness in inadequately ensuring the structural stability of the Thredbo Village

Despite a previous landslide in same region (1964 Winterhaus landslide) the NSW government chose to continue with an unstable Alpine way.

A combination of a misengineered water main and neglected Alpine way was the cause and could have been avoided by regular and consistent service. Could it have been avoided According to Derrick Hand, NSW coroner’s report which was released on 29 June 2000, the landslide was caused by water from a leaking water main which should never had been approved.

Alpine way was unstable and never constructed for its intended use in its later years.

Originally built by the SMHEA as a construction thoroughfare during Thredbo’s development in the 1950’s.

Intended to last only 20 years.

Soil Creep’ caused the main to fracture which in turn saturated the slope which was already unstable and hence the collapse took place. Causation of event 1997 was the year which brought dawn to the disastrous landslide in the New South Wales ski resort, Thredbo.

Killing a total of 18 people, the destruction of the two ski lodges was New South Wales’ most catastrophic landslide.

Many argue whether this tragedy was a natural disaster or a man-made catastrophe waiting to happen.

It would be the pivotal scene which influenced the change in the Australian Geomechanic Society (AGS) to update their technical paper “Landslide Risk Management Concepts and Guidelines” (AGS, 2000) Introduction 1997 Thredbo Landslide Stage 1: 11:30 pm on 30th July 1997, Alpine way collapses from damage to a water main and pressure of heavy rain, melting snow and waterlogged landfill. 10000 tonnes of rock and mud tumbles towards the ski village.
Stage 2: 2000 square metres of liquefied soil currents down the mountainside.
Stage 3: the Carinya Lodge is sheared off its foundations and pushed down onto Bimbadeen lodge.
Stage 4: Approximately 100 people are trapped within the rubble and collapsed buildings.
Result: 65 hours of rescuing, 2 destroyed buildings and most importantly, a death toll of 18 people. Series of Events
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