Human Factors and Root Causes: Bridging the Gap

1May2018

Bridge Collapse - Incident Investigation

 

Amazingly, there are still people around who cannot see the link between root causes and human factors, and yet one cannot exist without the other. This is not to suggest that people deliberately make or introduce errors, but that the complexity of some operations creates ‘error inducing conditions’. Clearly, effective risk assessment and front-end planning should prevent incidents, and while mostly it does, major failures still occur.

On the 16th of March this year, six lives were tragically lost when a new pedestrian bridge at the Florida International University in Miami, designed to withstand a category five hurricane, collapsed onto the road below. To avoid traffic disruption, this cable-supported structure had been assembled at the roadside using a technique called ‘accelerated bridge construction’, before being lifted into place overnight.

So, what went wrong? It is too early to say at this stage, before there has been a detailed investigation and analysis, but the root cause will certainly include human factors. It must always be so. Outside of nature, everything has been designed and built by people.

Learning from history is so important. Bridge failures are far from new. Here in Scotland probably the most famous is the collapse of the Tay Rail Bridge in 1879, when a train and passengers fell into the river on a winter’s night. A short list of some other notable failures over the next 150 years or so includes the Tacoma Bridge in Washington State in 1940, and the West Gate Bridge over the Yarra River in Melbourne, Australia in 1970. Sadly, the list is endless, with cumulative fatalities running to hundreds of souls. Perhaps the most surprising, because it happened inside, was the failure of a walkway in the Kansas City Hyatt Regency Hotel in 1981, where an unbelievable 114 people were killed.

At Kelvin TOP-SET we also recently assisted in the investigation of two fatalities during bridge construction in the Far East, so we have a particular interest in this type of incident and the associated human factors.

Two useful publications in this area are Engineering and the Mind’s Eye by Eugene S. Ferguson, and Why Buildings Fall Down: How Structures Fail by Matthys Levy and Mario Salvadori. In reading these, it will be obvious that root causes are embedded in human factors with failures in front-end planning, risk assessment and design. We must try to absorb the lessons from these failings and apply learnings from the past to prevent such devastation.

 

https://mitpress.mit.edu/books/engineering-and-minds-eye

https://www.amazon.co.uk/Why-Buildings-Fall-Down-Structures/dp/039331152X

 

#incidentinvestigaton #TOP-SET #kelvintopset

 

 

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