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Learning from Failure | Near misses

Grenfell pa (30)

When a structure collapses or a train crashes, there is usually an independent investigation.

Sometimes – not always – a report into the causes of the disaster is eventually published and made public, and the construction industry can learn how to avoid a similar disaster happening again.

This is what happened after the partial collapse of the Eindhoven airport car park in May this year. But what happens when a disaster is narrowly averted? How do we learn from such near misses?

Things can go wrong – in the design office, on site, during a structure’s or system’s lifetime. Almost always somebody picks up such faults and errors in time and corrective action is taken. Traditionally, however, and for understandable reasons, such episodes were usually kept under wraps, and valuable lessons that might have been learned were lost to the wider profession.

Confidentiality issues

Sometimes individual engineers would see faults that could compromise safety on a number of structures – but would be pressured to keep their concerns to themselves. Given the regrettable consequences inflicted on whistleblowers in society, it is hardly surprising that such engineers were reluctant to stick their heads over the parapet. And until 2005 there was no way they could report their serious concerns to the relevant authorities in complete confidence.

In that year the ICE and the Institution of Structural Engineers (IStructE) came together to launch the Confidential Reporting on Structural Safety (Cross) scheme, modelled closely on Chirp, the established UK Confidential Reporting Programme for Aviation and Maritime.

Cross’s genesis, however, was triggered eight years earlier, in New Civil Engineer’s office.

There had been calls for a confidential reporting system from as early as 1994, primarily from the Standing Committee on Structural Safety (Scoss). Despite wide support from industry and the professions, nothing happened. And despite a series of collapses in the 1990s – the 1994 Ramsgate walkway tragedy, the Heathrow Express tunnel collapse in the same year; and the partial collapse in 1997 of an ageing multi-storey car park in Wolverhampton – nothing happened.

heathrow collapse

heathrow collapse

Heathrow Heathrow Express collapse: Contributed to momentum leading to Cross’ establishment

Believing that such a scheme was urgently needed, New Civil Engineer approached the ICE and the IStructE and Scoss and offered to help get it off the ground by facilitating an independent working party.

Initial reactions were positive. A series of meetings between the institutions and the head of Chirp eventually came up with a system that would ensure confidentiality while at the same time allowing the publication of anonymised reports.

However, there were concerns about the projected £40,000 cost of a 12 month trial, and the possibility that employer groups would see such a scheme as a whistleblowers’ charter.

Eventually, however, there was a series of rail disasters – at Ladbroke Grove  in 1999, at Hatfield in 2000, and at Selby in 2001 – which might well have been avoided had such a scheme been in operation. These finally unblocked the logjam.

Civil engineer Alastair Soane was given the task of running the scheme for a trial period of six months: 12 years later he now heads up Structural-Safety, a hybrid organisation that combines the function of Cross and Scoss.

Cross has effected a cultural change within the profession, thanks to its wide circulation

Scoss was formed in 1976 to advise the presidents of the ICE and IStructE. It was later joined by the Health & Safety Executive. In 2011, however, Scoss secretary John Carpenter retired, and Soane took on the extra role. In 2012 the connection was formally recognised by the founding of the umbrella organisation.

When it was first launched, reports to Cross arrived at the rate of around one a week, and were mostly devoted to relatively minor matters.

The number of reports increased year on year and reports these days can relate to “potentially more serious” problems, Soane confirms.

He also points to a report in the latest Cross newsletter as a good example.

The reporter was commissioned by a building owner to carry out a technical due diligence survey prior to its sale. Numerous serious fire risks were observed. The client insisted that these findings not be reported, as they would jeopardise the sale, and any such report would be a breach of contract.

Dangerous and illegal

But as the newsletter comments: “The defects discovered were dangerous and illegal. It would be unethical and irresponsible not to report them,

It has been suggested – and indeed the ICE’s post-Grenfell report questions – whether Scoss and Cross have wide enough reach.

Newsletters are published in January, April, July and October via email to 8,000 subscribers, but Scoss believes internal sharing means the number of people with access to the re ports is greater than that.

Indeed, the chief executive of one construction firm calls a meeting with  his managers when a newsletter is published and uses the contents as the agenda.

But it is a fact that Structural-Safety’s Scoss arm has been busy since the Grenfell Tower tragedy. On 5 September communities and local government secretary Sajid Javid told the House of Commons that he had requested Scoss to advise on some of the structural shortcomings uncovered during post-Grenfell inspections of suspect local authority tower blocks.

This included the discovery that some local authorities had reacted to the 1968 Ronan Point disaster by cutting off gas supplies to similar large panel system blocks rather than by carrying out expensive strengthening work. Perhaps if Cross had been in existence back then some concerned engineer would have reported his doubts about such penny-pinching.

Cultural change

Soane for one believes that Cross has effected a cultural change within the profession, thanks to its wide circulation. Almost all consultants, contractors and local authorities have taken it on board: 20% of the newsletter’s readership is outside the UK.

There is said to be considerable international interest in the Cross philosophy. Cross may have been inspired by Chirp but it in turn drew inspiration from the long-established US Aviation Safety Reporting System.  

Now the inspiration appears to be flowing in the opposite direction. Recently Soane has been in discussions with the American Society of Civil Engineers’ Structural Engineering Institute with a view to the creation of “Cross-USA”.

“Cross-GDE” is also a possibility, following talks with Germany’s prestigious Association of Proof Engineers. There have also been contacts with interested parties in Australia, France and South Africa.

In the longer term, Soane dreams of an international Cross hub, using a common format accessible to anyone from around the world.

Two decades on from that seminal initiative from New Civil Engineer the Cross concept has grown way beyond anything that could have been imagined back then.

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