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Round Table | Learning from Failure

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Three kilometres from Grenfell Tower, and three months after the fire that claimed at least 80 lives and caused 70 injuries, a debate is staged on “Forensic Engineering: How to learn from failure”.

The roundtable debate, hosted by Arup and New Civil Engineer, was arranged before the disaster but the incident serves as a stark reminder of the topic.

With multiple inquiries into Grenfell ongoing, Arup director Tim Chapman referred to the disaster early in the discussion: “This is a bit of a heartfelt plea: how can we build something bigger and better, whereby governments can procure projects in a much better way, towards the long term outcomes it wants to achieve?”

What has the industry learned?

Other questions for debate included: what has the industry really learnt, if disasters keep happening and systems do not change from project to project? Indeed, what is the best way to learn? And are the lessons being passed on in the right way?

Examples where good learning has occurred were discussed, including the Abbeystead gas explosion in 1984 and, the Heathrow Express tunnel collapse in 1994.

In these cases, lessons were outlined in technical journals, with strong leadership urging problems to be understood, and rigorous processes were put in place. Will the same things happen following Grenfell?

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Keith waller bw crop

Waller: Culture of sharing what goes wrong

Infrastructure & Projects Authority senior advisor Keith Waller said change was more likely to happen than in any other time in his career: “When I started in construction things were a lot less safe, but if things went wrong there wasn’t really a culture of sharing what went wrong, outside the chief executive and Health & Safety executive. Now, say there’s an accident on one of the highways projects, there’s immediately a network, not just among the clients but among all the main suppliers. Immediately the lesson is shared with everyone saying ‘we value the lives of our workers. Let’s learn from this, as an industry’.”

Director of Acumen7 business network Simon Murray said this was true, but questioned whether what was shared was merely the immediate circumstances of the event, rather than its proper root cause.

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Simon wright bw crop

Wright: “People” issues are key

“The aviation industry, I see them being a lot better at this – air crash investigations are done much better, in a dispassionate way, quickly arriving at root causes,” he said.

Some noted that aircraft and car makers are known for their testing and safety standards. Others noted that they have the luxury of making identical products again and again, to a relatively small scale. Meanwhile, construction has a different challenge: bespoke products, on massive scales. Does construction need to adapt a factory model?

Cabinet Office head of construction David Hancock urged those around the table not to dwell too much: “The problem is, major projects, when they fail, they fail in a major way.

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David hancock bw crop

Hancock: Statistically some projects will fail

“Statistically, predictably, some of our major projects will fail, that’s something we’re going to have to live with. We should reduce the consequences when they fail. But we’re doing 150 major projects… on the government’s portfolio. Of which, a normal company would only take one or two of those. We can’t expect them all to go swimmingly well, regardless of what your corporate governance is, or how good your people are.”

Crossrail programme director Simon Wright said the “people issues” – organisational communication and collaboration – were key. “We’re much less good at looking at that, because it’s seen as the softer side, not technical, ‘not really engineering is it?’ And we leave all that to be badly managed. Errors in communication, a lack of collaboration are really major parts of what often does go wrong.

But Mace chief executive Mark Reynolds was unconvinced: “To review root cause analysis is absolutely right at the time. But these are really big technical challenges that require technical solutions, and leadership, in terms of driving it through.

“This is about responsibility,” he stressed. “If someone doesn’t comply with the standards, then they have to suffer the consequences. And the consequences should be so massive that complying is the only option.”

Kate bw

Kate bw

Hall: Resistance to “lessons learned” discussions

Reynolds said having standards was still essential. “I could have the best culture in the world, but if I’ve got no rule book to follow, then how do I know I’m doing the right thing?”

Arup director and commercial leader of infrastructure UK David Van-Bruggen said many of the industry’s failures resulted from fragmentation of responsibilities: outsourcing and private training which hollow out the corporate core. “Our fragmented industry has always had that problem, and makes it more difficult.”

All in attendance agreed that independent design panels were essential on major projects, despite cost. They allow an extra perspective untainted by the pressures of programme and timeline. HS2 Ltd design director Kate Hall said High Speed 2 has no less than five independent design panels.

Mark reynolds bw crop

Mark reynolds bw crop

Reynolds: Standards are essential

But Hall said the industry’s somewhat defensive culture allows blind spots to develop: “We’re built up on ‘our knowledge is our worth’ and if you display any… weakness in your technical knowledge, then you’re declared a not fit person. And while we’ve still got that culture and endorse that behaviour you’re not going to see significant changes.”

Hall added that mentioning “lessons learned” in the office is met with audible groans.

“I encourage doing lessons learned, but if you use that phrase, ‘lessons learned’, then the whole team dreads it.

“I would say: ‘let’s go back to behaviours. We have post mortems, why not have mid-mortems’?”

Waller questioned why the topic of safety only comes up after a disaster: “The responses we have to extreme events and tragedy means that we almost have a culture of ‘firefighting’ – we need to have a culture of ‘fire prevention’; we love responding to things going wrong, we need to be much more in love with preventing things going wrong.”

At the Round Table

Clare Anderson associate director, Arup

Miles Ashley director, Wessex Advisory

Denise Bower executive director, Major Projects Association

Tim Chapman director, leader of infrastructure London Group, Arup

Chris Dulake major projects portfolio director, Mott MacDonald

Kate Hall design director, HS2 Ltd

David Hancock head of construction, Cabinet Office

Mark Hansford editor, New Civil Engineer

Simon Murray director, Acumen7 Network

Mark Reynolds chief executive, Mace

Mark Sneesby chief operating officer, Tideway

David Van-Bruggen director, commercial leader of infrastructure UK, Arup

Keith Waller senior advisor, Infrastructure & Projects Authority

Simon Wright programme director, Crossrail

Alexandra Wynne deputy editor, New Civil Engineer

In association with

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Aruplogo2010 k





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