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From the editor's desk: Never again

June 2024 News


Kim Roberts, Editor

The recent building collapse in George shook me as it was just down the road. I experienced first hand the impact that it had on people’s lives, and the devastation caused by the loss of loved ones, family breadwinners and bright young artisans ready to take on the world. Now the focus is on trying to understand what happened and why. It’s important not to point fingers and jump to conclusions, but I couldn’t help taking note of an engineer with 50 years of experience in the business who said: “Buildings do not collapse unless there are huge design shortfalls or construction shortcuts.” Practically, this boils down to five things: the foundations are too weak, the building materials aren’t strong enough, workers have made mistakes, the load is too heavy, and the strength hasn’t been tested. One of the early findings was the importance of workers at every level and in every industry being registered with an accredited organisation that can monitor these things. In the case of the Built Environment this is ECSA.

Small things stack up to a tragedy

This made me think about some of the other manmade disasters over time. There’s no need to say anything further about what happened – Bhopal, Three Mile Island, Aberfan, Fukushima, Chernobyl, Piper Alpha, the Challenger Space Shuttle, Coalbrook − and the list goes on.

In all of them there were a sequence of small incidents that went unnoticed, or were not fixed until things spiralled out of control, resulting in catastrophe. Manmade disasters are triggered by an event or error, but are almost always the result of small factors that seem insignificant on their own, but when combined have terrible results. They may be small, but the list is long: negligence, inadequate training, communication failures, poor maintenance, a weak safety culture, design flaws, environmental erosion, economic pressures, or inadequate risk assessment. Here are some examples.

The fire in Grenfell Tower in London in 2017 started when a broken refrigerator caught fire. The building had recently been renovated with the addition of external cladding, and the polyethylene material in the cladding was the cause of the fire’s spread. Compounding this was the enforcement of a disastrous stay-put policy in the building, and broken smoke extractors.

In 1988, a series of explosions ripped through the Piper Alpha oil platform in the North Sea. Many lessons were drawn from the terrible events, but they boiled down to poor management of a change in design, a pump being restarted before maintenance was complete, inadequate transfer of information during handover of shifts, a lack of emergency evacuation procedures, and a culture of complacency (everything’s fine).

In 1960 Coalbrook became the worst mine disaster ever in South Africa. The disintegration of 900 underground pillars supporting the tunnels caused a massive collapse, and trapped 435 mineworkers 180 metres underground. There were no survivors and no bodies were ever recovered. The accident was caused by cascading pillar failure. Contributing to the collapse was the process of top coaling to get more coal out, which raised the height of the tunnels and pillar, while panel mining reduced the size of the structures holding up the tunnels. A small rockfall two weeks earlier went unreported.

The Chernobyl disaster in 1986 was the result of a combination of operator errors, made much worse by poor decision making during the crisis. During a midnight safety test, operators disabled critical control systems, leading to a reactor meltdown. Their mistakes were compounded by a lack of both adequate training and an understanding of the reactor’s design.

The Challenger Space Shuttle disaster in 1986 is another example of organisational complacency. NASA’s culture prioritised schedules and budget over the safety concerns raised by engineers about the O-rings in cold temperatures. The decision to proceed with the launch was made, despite the known risks.

Overlooking environmental factors can also lead to catastrophe. The Fukushima nuclear disaster in 2011 was a result of the plant’s inadequate preparation for a tsunami, despite being in a tsunami-prone region, coupled with insufficient protective barriers.

The pressure on engineers in today’s process automation plants is huge. They have to cope with containing costs, minimising downtime, maintaining product quality, keeping up with technology, complying with an increasing number of regulatory requirements, meeting tight deadlines in the face of resource constraints, keeping customers happy, and a whole lot more. On top of all that, they have to consider safety − yet another pressure. But by understanding what small things can lead to disaster, they can put into place simple measures that can prevent future catastrophes, and have some peace of mind.


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