Chaos or Negligence?

• 1976 Crown Redevelopment

• 1976 Crown Redevelopment Corp initiated plans for a Hyatt Regency Hotel

Note – these slides contain material fromTexas A+M University NSF Grant Number DIR-9012252And “Hyatt Regency Walkway Collapse” presentation by Jack Gullium June 2004

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

Suspended Walkways Between the Guest Tower and Event Center

Note that2nd and4th floorWalkwaysAreSuspendedAboveAnd belowEachOther.

The Suspended Walkway

Walkway hung from aBox been with rodsGoing through to suspendThe decks.

Bolts and washers on theRod supported the boxBeam that the walkwayWas attached to.

Who Engineered This?

Design Load 20.3 Kips

Test strength 20.5 Kips

Building code – 1.67 times loadRequiring 33.9 Kips(but the fabricator was responsibleFor planning the connections toMeet code requirements)

How Did the Connection Hold Up?

Of course fabricators buying cut-rateSteel with below design strength did notHelp and field testing firms were actuallyChanged because the first testing firmWas not doing its job(part of the atrium roof fell in duringConstruction but that was problems withOther parts of the construction).

A Matter of Communication

The Structural Engineer SketchedThis for the design

The Draftsman drew this omitting engineeringDetails and the Structural Engineers sentIt to the fabricators. (How were they supposeTo meet the building code when no one toldThem what the loads were?)

A Matter of Practicality

To Support two decksWith a continuous rodWill require this rod toBe threaded all the way.

The fabricators call theStructural engineers askingTo be allowed to use twoRods. 4th floor hangs fromThe roof – 2nd floor from the4th They are told to submit their proposal

The Fabricator Sends a Stack of 42 Drawings to the structural engineer

This is the revised drawingOf the connection usingTwo rods

The structural engineers are busy andA technician filling on the project butNot actually working on it – checks theDrawings and affixes the P.I.s seal toThe drawings. (The technician wasNot a P.I. himself).

The Fabricator Built This

The 2nd Floor walkway hangs fromThe 4th floor walkway

Now the rod connecting the 4th

Floor to the roof has a double loadBut the same strength

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

A Dance With 2000 People – July 17th, 1981

Dead - 114 PeopleInjured - 200 People

Party Ruined – for everyone

The Connection

The Rod pulled straight through the box beam

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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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?

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.

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

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

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

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.