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Learning from Failure | Looking at risk

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Learning from failure is a particularly tricky subject. Late last year, when New Civil Engineer began discussing what this month’s big issue should be called, the response from industry figures consulted was one of reticence and aversion to anything that could be deemed too negative or contentious.

More palatable to many was the more corporate-speak-friendly “managing risk”. The sentiment is understandable given that is what engineers know and do on a daily basis, but is it the right one?

The catastrophic Grenfell Tower fire and its fallout will be felt far and wide and has certainly whipped up an appetite for transparency like never before.

ICE report

The ICE is alert to this. Last month it released an interim report of its investigation into risk in the infrastructure industry. Notably, it was undertaken in the fallout from Grenfell, but importantly it refrains from specifically investigating that incident, not least because of the imperative to avoid prejudicing official investigations or inquiries.

But the ICE, and then President Tim Broyd, was determined that such concerns should not deter it from taking a deep look.

“The reason we’re doing this is important; because we are trained to look at risk – that’s what engineers do,” explains ICE past president Peter Hansford, charged by Broyd with leading the work.

“Given the mood in the aftermath of Grenfell, we think it’s the right time to be saying: ‘are we missing anything?’ Have we allowed any gaps to grow in our defence? This is an opportunity to take stock of these important issues.”

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Screen shot 2017 11 09 at 16.33.13

“It may actually result in us saying ‘we’re confident’ or ‘we feel we’ve got sufficient [defence]’, or it may result in some changes,” he adds.

The work was carried out by Hansford and six industry leaders who together formed the panel (see box). Hansford was speaking to New Civil Engineer  ahead of the report, which the ICE deliberately opted to call In plain sight – reducing the risk of infrastructure failure. It affirmed that the ICE sees that the focus should be on the core requirement of engineers to engineer out risk.

The report also clarifies what it means by failure: “By infrastructure failure, the panel means an incident leading to loss of life, multiple injuries or serious economic disruption,” it says.

There is a note of caution throughout the report, and from Hansford himself – both going to great pains to offer assurance that the panel, through its two month initial phase, has found no major cause for concern.

The view we’ve reached is that unless we have problems — or blind spots — in multiple lines of defence, we think the risk of failure is low

Peter Hansford, ICE past President

“We have in place a number of lines of defence against failure. And [the panel] tried to work out what those lines of defence might be. The view we’ve reached is that unless we have problems – or blind spots – in multiple lines of defence, we think the risk of failure is low,” Hansford says.

But he concedes there is room for greater scrutiny of those lines of defence and the conclusion of the report is that there is more work to be done through the set up of three “task and finish” groups, to be run by the ICE over the next few months. These would look at the issues of lesson sharing, competence and governance.

One of the most interesting and candid observations in the report is the recognition that findings into disasters can be, likely unintentionally, inadequate. It illustrates this with the investigations into the 2013 Santiago de Compostela rail disaster in Spain in 2013. The primary focus on the cause of the crash – responsible for 80  deaths – was on the driver’s behaviour in the lead up to the accident, despite investigators now looking more broadly at railway systems for further explanation (New Civil Engineer, 8 August 2013).

Another example closer to home, but not cited by the ICE report, is the Hatfield train crash. There, it was only the last of the various Health & Safety Executive reports into the rail crash published in 2006, three years after the legal proceedings and six years after the tragedy, that recognised manual track inspection failures as the prima facie cause of the disaster. These facts had not been made available to the industry until then.

Clouding the issues

An appetite for clarity and a desire to avoid a repeat of such failures can cloud the real issues. Engineers are well motivated to change the world for the benefit of society. But anxiety about failing to do this immaculately, to the highest safety requirements, cannot be allowed to prevent anyone from taking a close look at whether there is more that can be done to prevent failure or learn from it when it does happen.

The fatality on London’s mega construction project Crossrail offers another stark reminder of why this matters. Renè Tkácik, 43, died after being crushed by falling wet concrete on 7 March 2014 as he worked on a section of tunnel at the Fisher Street site.

Soon after the accident, Crossrail chair Terry Morgan told New Civil Engineer: “The incident happened at a working face and we have a large number of these across our many working sites. We stood down associated SCL [sprayed concrete lining] works pending completion of an assurance review involving all contractor sites. We have confidence that the correct processes are being followed so felt able to restart.” (New Civil Engineer, 13 March 2014)

Given the mood in the aftermath of Grenfell, we think it’s the right time to be saying: ‘are we missing anything?’ Have we allowed any gaps to grow in our defence?

Peter Hansford, ICE past president

However, this year, Westminster Magistrates Court heard that contractor Bam Nuttall, Ferrovial, Kier (BFK), the joint venture responsible for that section of underground works, was lacking in its health and safety measures.

It was widely understood at the time that Tkácik was in an exclusion zone, where he should not have been. However, the court heard from the prosecution that, although workers were aware they should not have gone beneath the wet concrete until a strength test had been carried out by an engineer, there was confusion about where the exclusion zone began as it was unmarked. BFK admitted breaches of the Regulation 10(2) of the Work at Height Regulations 2005, and was fined £300,000 earlier this year (New Civil Engineer, September).

The aim of any investigation is to find the culprits where wrongdoing has occurred but, perhaps more importantly, to disseminate learnings when they become available. What the Crossrail incident proves is that it can be difficult to do the latter without inadvertently impacting on the former.

In February 2016 Crossrail published a good practice document called Sprayed Concrete Lining Exclusion Management and placed it on its Learning Legacy online portal and made it available through the British Tunnelling Society website.

Fostering a more open culture

But more can be done by many organisations to foster a more open culture, says Hansford. “We do have to be able to share information and share information at the earliest stage,” he says. He adds: “Including learning not just from failure but learning from near misses. We want to get a culture where we become much better at learning and where far less of this information is held back.”

The ICE report is also clear on this point: “A lack of public acknowledgement of near misses and a tendency to see such events as a success was a particular concern [to the panel].

“In Plain Sight – reducing the risk of infrastructure failings”

Review panel members

Peter Hansford FREng FICE, University College London, ICE past president (panel chair)
Liz Baker MICE, Nichols Group
Julie Bregulla FICE, BRE
Tim Chapman FREng FICE, Arup
Mike Gerrard FICE, Independent
Margaret Sackey MICE, ICE Health & Safety Panel
Matthew Symes MICE, Concerto Partners

The panel considered the reports written on a number of major incidents. These included the 1984 Abbeystead disaster, the 1989 Piper Alpha oil platform explosion, the 2005 explosion at the Buncefield oil refinery and the independent inquiry into the construction of Edinburgh schools published in 2017.

Contributors included: Association of Directors of Environment, Planning & Transport, Amec Foster Wheeler, Aon Benfield, Arcadis, Arup, Bam Nuttall, Bill Harvey Associates, Bill Grose Consulting, BSI Group, CAA, Campbell Reith Hill, Civil Engineering Contractors Association, CH2M, Costain, Fenwick Elliot, Get it Right Initiative, Habilis, IChemE Safety Centre, Imperial College London, Infrastructure & Projects Authority, Interserve, Jacobs, KPMG, London Underground, Loughborough University, Mott McDonald, MSS Group, Natural Resources Wales, Network Rail, Northern Ireland Department of Infrastructure, Office of Road & Rail, Pinsent Masons, Scottish Futures Trust, Standing Committee on Structural Safety, Sunbeam Management Solutions, Transport for the North, United Utilities, University College London, University of Bath, University of Bristol, University of Lancaster, University of Liverpool, University of Manchester, University of Salford, University of South Wales, Ward Williams Associates, 12 senior independent consultants.

The fear of corporate, HR or legal retribution for speaking out must be challenged, according to Hansford. “It’s a difficult area, but we do have to overcome it.”

He adds: “We’ve got to find ways of sharing information on a non-attributable basis. I would like to encourage much more discussion, and much more learning, between projects and incidents. We’ve got to find a way of doing that notwithstanding the legal and insurance issues associated with it.”

ICE regions, with their more intimate connection to workers and projects locally, could have input here. But mostly, whistleblowing organisations, such as the Confidential Reporting on Structural Safety (Cross) initiative, should from now on play a more prominent role, according to Hansford and the panel.

This area of the role of the engineer and the engineer’s voice throughout the life cycle is I think an area that really needs addressing

Peter Hansford, ICE past president

The report highlights the fact that despite Cross enabling anonymous reporting by anyone – members of the public or professionals – of any concern they have about structural safety, the knowledge of and use of Cross’s reports “appears .. to be limited despite institutional endorsement and funding”.

“I think not enough people know about Cross,” says Hansford. “There’s some great [work] in Cross, but I think this could be an opportunity to broaden, or to increase significantly, the use of Cross and similar confidential reporting mechanisms.

Attention will be given to engineers’ skills through the next phase of work by the task groups. “A number of areas [being looked at come] under competence,” says Hansford. “We need to take a careful look at that and say: ‘are we confident that we’re ensuring that people are doing the necessary development?’ Because in a changing world, are they keeping up with [CPD]. And is our regime appropriate for that.

Working within competence

“Professional conduct also goes with this: are we confident that our members are working within their competence?”

This is increasingly important given the changes that have happened to the way procurement and contracts affect the world of infrastructure in recent years – not least because of the need to identify responsible parties.

Hansford says: “There have been really good things that have happened [as a result of these changes] and I wouldn’t want to change those, but this is our opportunity to say: ‘has it introduced risk? And if it has introduced risk, are we protected against that risk?’ This area of the role of the engineer and the engineer’s voice throughout the life cycle is I think an area that really needs addressing.”

And that will be addressed through the work of the follow on groups, he pledges.

In response to questions regarding the shifts in the make-up of supply chains where there is now an increased use of design and build contracts managed by main contractors – architects and designers in turn working for contractors – for example, Hansford is interested to seek out more answers.

We do have to be able to share information, and share information at the earliest stage

Peter Hansford, ICE past president

“We’ve got to find ways of ensuring that the designer’s intent is actually taken all the way through construction and into operation,” he says. “And I think multiple interfaces is a problem with that – the handover from one party to another is an area of risk. And we’ve got to find ways of ensuring that we keep the integrity of the design intent all the way across those handovers.

“You talk about designers working for contractors — that’s a classic example of how the designer could be [pushed] further away from the finished product, the finished asset. It doesn’t have to be the case but there is a risk of that.”

There are further questions to be asked about the structure and oversight of how engineers work. And contributors to the review echoed sentiments expressed in New Civil Engineer immediate after Grenfell.

Qualified assesors

In light of clear questions surrounding the robustness of fire inspection regimes, New Civil Engineer has called for the introduction of a government-backed National Fire Risk Register of qualified assessors, which would comprise similar expertise to that seen among the Reservoir Panel Engineers (New Civil Engineer, August).

The Reservoir Panel advises the relevant secretary of state on reservoir safety and comprises suitably qualified and experienced civil engineers who are appointed for five years. This competence is demonstrated by factors, which include evidence of CPD and health & safety training.

“Several respondents and interviewees suggested wider adoption of such approaches would create an important line of defence against the risk of asset failure,” says the ICE report, but Hansford is cautious about how far reaching this should be.

“We already have in place some panels – the Reservoir Panel is a good example. We should look to see whether there is a case for having that on a wider basis,” he says. “I don’t think this is all about having lots and lots of panels, I think this is having a look to make sure that the panels we’ve got, and the registers we’ve got, are the right ones.”

Return to clerk of works

“Some people have said we should move back to the days of clerks of works or resident engineers. That may be the case, but we think it’s far more important to look at the form of scrutiny that’s currently taking place and whether or not that’s sufficient,” he says. “This is not about turning the clock back. We have made advances and many of the advances we have made are positive. But the question is: have we missed something and have gaps crept in and could this be one of them? I’m not sure,” he adds.

Hansford is more adamant when it comes to facing the facts of today’s engineer. He says the industry must be mindful of that and how it might affect risk management.

“The role of the engineer is, or should be, moving toward the role of whole life asset steward,” he asserts. “Somebody who looks at the integrity of the asset over its whole life – and the question I’ve got is: ‘has that been in some ways reduced by the changes that we have in contractual arrangements, by the various things that have happened in recent years?”

The first phase of the Task and finish group work is due to be complete by spring 2018.

So far, led by Hansford, the panel has sought contributions at the highest level from clients, consultants and key contractors, among others.

It will be interesting to see how the changes in supply chain relationships will be reflected in the future work of this review – there has been limited specialist contractor involvement (see box) in this first phase. This is particularly vital given the report’s finding that: “Contributors have identified potential vulnerabilities at all levels in the design, build and operation of economic infrastructure: from decision making in boardrooms, through to engineering design, construction and the management of assets.”

The industry will no doubt watch what happens next with great interest.

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