‘Unavoidable accidents’ was how some prominent railroad managers described the wrecks due to broken rails in an article which appeared in the New York Sun during 1892.… Iron Age  took them to task for their complacency : “When the gentlemen referred to above say that they inspect and test their rails, they do not really mean anything of the kind…. but that each individual rail has merely been looked at and that comparatively few of them have been subjected to any other test whatever, and if the finished rail has a presentable exterior, it is passed regardless of the hidden flaws it may contain……inspection should begin at an earlier stage of the manufacture, where the flaws resulting from the methods of manufacture may be easily discerned.”

Over a century has passed since then. Steel manufacture has improved and eddy current and ultrasonic inspection methods have been developed that can detect cracked rails some time before they are likely to fail. Yet, in spite of these advances, a rail known to be cracked shattered into 300 pieces at Hatfield last October and caused a disastrous rail crash. Apart from the injury and  loss of life and possibly  £500 million to replace all cracked rails across the network, one estimate puts the additional knock-on cost to the nation at over £5 billion. Whoever made the decision to delay rail replacement, perhaps in a misguided belief that they would save money, cannot have imagined the potential consequences, otherwise they would have decided differently. Perhaps too they had never have been taught at their mother’s knee that “a stitch in time saves nine”.  As the 18th Century American scientist Benjamin Franklin put it : ”A little neglect may breed great mischief. For want of a nail the shoe was lost; for want of a shoe the horse was lost; and for want of a horse the rider was lost.” How much other neglect is out there even now breeding great mischief?

Trevor Kletz in his introduction to his book Lessons from Disaster (1993) says : ”It might seem to an outsider that industrial accidents occur because we do not know how to prevent them. In fact,  they occur because we do not use the knowledge that is available. Organisations do not learn from the past or, rather, individuals learn but the leave the organisation, taking their knowledge with them, and the organisation as a whole forgets.”

This last year has seen a fine crop of other accidents, failures and disasters that may serve as examples of  Kletz’s organisational forgetfulness in action. First, take the Concorde crash. There must have been previous occasions where an aircraft has been damaged by debris on take off. Keeping a runway clear would not seem to be a particularly difficult task for an airport management to organise. No doubt the runway was swept from time to time, but not, it seems, regularly and in particular not before that particular Concorde took off.  Equally, designers of aircraft might expect that every now and again a bit of debris might hit the underside of an aircraft and, anticipating that possibility, design to prevent catastrophic damage. Neglect of the fairly obvious, it seems, was the root cause of this and many other failures, which is of itself disturbing. Second, take the Millennium Bridge. Nobody, least of all the designers, should have been surprised by its bouncing.  It is in the nature of  bridges to deflect and oscillate in various different modes, and for the oscillations to build up, given a source of excitation.
 

enlarged picture

I treasure a photograph of my father, then a young Lieutenant in the Royal Engineers,  crossing one such bouncing bridge above a rapid flowing river in Chitral in the 1930’s. The bridge, of elemental simplicity, comprised three catenary wires linked together at intervals in a V. The bottom wire was to support the feet and the other two acted as supports for the hands. Such bridges were easy to put up, cost effective, terrifying to the uninitiated,  undeniably bouncy and probably inadvisable to attempt more than one person at a time, especially with baggage. Had the Millennium Bridge designers experienced a bouncing Chitrali bridge, then perhaps they would have better appreciated the possibility of human-induced oscillations in their own catenary bridge and designed in damping from the outset.

Murphy’s law, which comes in many variants and includes neglect of the fairly obvious, says that whatever can go wrong will. This goes equally for aircraft, bridges, grand projects, power systems, software development, automobile cruise controls, farming, the food chain, holiday plans and washing machines.  Bearing in mind the obvious benefits of wisdom before the event, it is surprising that society does not nurture it. All too often excellent and comprehensive failure reports and key samples of damaged material are later thrown away: whereas if archived or exhibited, they might have served to prevent similar failures from occurring. What this loss of knowledge costs each year is unknown, but it must be very considerable.

It is high time that instead of concealing our failures, disasters and cock-ups we should archive, exhibit and celebrate them. Perhaps the Antiques Road Show could be persuaded once in a while to devote a whole programme to past failures and disasters and to estimating the value of reports and samples of damage, much as they would Old Masters or Faberge jewellery. It would be interesting to hear the experts value a sample of wreckage from a bird-struck RB211, a piece of melted turbo-generator core or  a signed first edition report on the loss of the Herald of Free Enterprise.

But we still need some more permanent stimulus to the development of  wisdom before the event. I have in mind some sort of Centre for Disasters, Failures and Things Best not Repeated that would have as its objects the spreading of an awareness of the causes of failure and of the means that can be taken to anticipate and prevent them. This would house a library where all failure reports would be deposited by law and the national archive of failure damage, with illustrative examples, according to category, to act as permanent reminders of what has happened before and should not be allowed to happen again. Since failures affect everyone either directly or indirectly, they need to be brought fully into the public domain. So why should selected failure artefacts, demonstration models and reports not be bequeathed to the nation, with tax relief granted, according to the potential public benefit?

Now when I talk of failures and disasters, I don’t just mean engineering failures, such as the Tay Bridge Disaster of 1879, or the fatigue cracking that caused the early Comet passenger jets to crash, or the large scale collapse of  the electrical power generation and distribution system as occurred in the Eastern US in November 1965. I would include : failed projects that led to ultimate success, such as the first Atlantic Telegraph; projects that might have worked if organised differently, such as the Groundnut Scheme (Tanzania late 1940’s) ; and a whole host of projects that were late and overspent. There would be the Cambridge University model of the bouncing bridge that could be tried out by the public for a small fee. Nor would I confine myself to the world of industry. There would have to be a place for Noah’s Ark and the first lifeboat; bubonic plague, BSE and Foot and Mouth Disease; Tulip Mania, the South Sea Bubble, the Wall Street Crash and the rise and fall of the dot.com economy. There would be sections on experiments best not carried in a microwave oven and  how to avoid disastrous relationships and pyramid selling schemes. Master classes on how to spot con men and in the defensive use of sandbags against flooding might take place at weekends.

One of the problems with failure investigations, is that often there is no readily available space in which to carry them out. Therefore this proposed Failure and Disaster Centre should have lots of  free space where, on occasion,  large scale failure investigations of international importance could be carried out in an unhurried manner. We can imagine the public watching progress from a gallery and investigations being concluded with an exhibition and the invited guests sipping cocktails amongst the reconstructed wreckage.

This brings me to the question of the building. It needs to be very  large, well built, architecturally distinctive and easily reached. It would help if it was associated in the public mind with a whiff of failure rather than too much with success, so that it could the better come to symbolise the idea of turning failures to good account. Ideally it should be a building which still has to find a purpose in life, rather than one that has lost its original purpose. To my mind there is only one candidate that fits the bill for the new centre : the Millennium Dome. Would it pay for itself in its new role? I think probably yes, especially if it told the story of the successful engineering and the disastrous political, managerial and financial aspects of its first incarnation. Assuming operating costs of between £50 and £100 m a year, there should be no difficulty in saving several times this figure each year. Rather than leaving the Dome to rot or pulling it down, wouldn’t it be worth handing it over to Mr Yves Gerbeau with a clear mandate to create a rip roaring success in the disaster zone?

Antony Anderson

The Engineering Management Journal is published by the Institution of Electrical Engineers, Savoy Place, London WC2R 0BL and enquiries re this article should be directed to IEE Publication Sales, PO Box 96, Stevenage, Herts, Herts SG1 2GD, UK. Tel +44 (0) 1438 313311
 

Further Reading
 

• Safety & Knowledge Transfer in the Process Industries :Are We Doing Enough to Share the Lessons of Major Incidents?  By John O'Meara - Melbourne, Australia [This website has some useful hazard-related links]