University of Technology, Sydney FACULTY OF ENGINEERING 49006 RISK MANAGEMENT IN ENGINEERING Assessment Tasks 2 & 3 - Autumn Semester, 2017 Weighting: 20% + 10% = 30% Due: 9 am Thursday, 1 June 2017 Working in your allocated Group you will produce a Report and make a PowerPoint type presentation of this Report to the class. For the purposes of this assignment you are to consider your Group is a team within a risk management consultancy employed to produce a report and present this report to Engineers Australia Risk Society. You are to consider yourself a professional risk consultant employed within this consultancy that specializes in risk management. An electronic copy of the Group_X.docx report file, Group_X.pptx file, speaker_presentation_notes_X.docx, and pdf copies of all the refereed Journal articles (6+) will be submitted to the Subject Coordinator in a Group_X.zip file at the start of the scheduled lecture on the due date. One hard copy of the report, presentation, and presenter’s notes shall be submitted at the start of the scheduled lecture on the due date. No late submissions will be accepted. Group Assignment – Report (20%) The report will be a minimum of 6000 words in length and be formatted in accordance with the 49006 Report Template. It is anticipated that students will undertake professional theoretical research on the allocated topic. It is expected that this research will extend beyond the material that is presented in the Brief of Engagement, the Textbook (LRM), the Standards, and any other courses offered at UTS. The report must include a variety of material that supports the discussion and all content must be fully referenced. Marks will be awarded for reports that demonstrate a high level of professionalism and well thought-out technical content. Marks will also be awarded for reports that show logical and robust methodological argument that supports the discussion. Marks will be deducted for reports that are unfocused and do not effectively address the allocated topic or add value to the ‘Brief of Engagement’. Also see ‘49006 Assessment Task 2 and 3 Marking Sheet’ for guidance. Group Oral Presentation of Report (10%) Your Group will make a 20 +0/-2 minute PowerPoint type presentation on your allocated topic to the class. The presentation order will be random and Groups that are not in attendance and available to present will be penalised. Marks will be awarded for the professionalism and technical content of this presentation. Marks will be deducted for presentations that are unfocused and do not effectively address or add value to the ‘Brief of Engagement’. Marks will be deducted for presentations that are unstructured, lack clarity, miss the intended audience, don’t address the appropriate areas of Risk Management and do not submit speaker presentation notes. Marks will be deducted for presentations that go overtime. Brief of Engagement: ‘Learning from engineering failures’ Identify and describe in detail one ‘Australian-based’ engineering failure for each of the following categories: • Large and localised (eg Granville train accident 1977). • Medium and localised (eg Thredbo landslide 1997; deaths during the construction of the Sydney Harbour bridge 1922-1932; Childers backpackers hostel fire 2000; Sydney Bowlers Club fire 1994; Dreamworld accident 2016). • Small and localised (eg Hoyts theatre retractable seat accident 1997; Soccer goal post collapse 2003; Lend Lease/UTS crane fire 2012). • Large and widespread (eg Esso Longford gas explosion 1998, CSR-James Hardie asbestos contamination of both commercial and domestic premises? Australia 1948-2013). • Medium and widespread (eg magnets in children’s toys 2010; blinds, curtains and window fitting childhood strangulations 2010, Orica soil contamination 1990-2013; Mt Isa lead levels in children 2007-2013, Queensland CSG contamination 2013). • Small and widespread (eg Sydney water cryptosporidium and giardia contamination 1998; bunk beds childhood falls 2005; Backyard trampoline non-compliance 2003-2013). Whatever failure you choose, it must be an engineering failure for which you can readily obtain information. You are required to provide a brief background to the failure and why you believe your example qualifies as an engineering failure (as distinct from a non-engineering failure). You may choose each individual failure from different engineering disciplines. Place yourself in the seat of an engineer who was causally involved in each failure and answer the following questions for each failure: • How would you have done things differently? • What should have been the barriers that prevented the failure occurring? • What lessons were learnt from this failure? • What were changes and/or improvements to Law, Codes, Standards, work practices and technology that flowed from this failure? For each failure: • Define the Inherent Risk. • Describe in detail the causal chain (ie show causality from the root cause(s) to the failure event) and provide a causal diagram for each failure (as an Appendix). • Conduct a risk assessment to quantitatively verify the magnitude of the risk exposure in terms of deaths/injuries/damages/costs using a recognised method. • Would the pre-failure mitigation have passed the HSE Tolerability of Risk (ToR) test (ie you need to demonstrate the consequences of the failure in terms of deaths/injuries/damages/costs to confirm whether they were/weren’t 10x or more greater than the sacrifice/investment entailed with the implementation of any pre-accident counter- measures). Some Background Engineers have an important role in society. They are responsible for designing, building or creating something based on a specification or guideline to meet a particular need. What they develop must function without failure, for its intended lifetime. Engineers are responsible for ensuring that the product of their work meets its intended purpose and level of performance, and avoiding failure, especially a catastrophic failure that can result in damage to property, environment, and even loss of life. Engineering is about managing risks. It is technically impossible to remove risk altogether and lowering risk commonly involves a substantial cost. Engineering as a Profession progresses through both its successes and its failures. As a Profession we need to learn from failures. Many of the examples used in this subject were disasters. One might be led to conclude that this subject is all about avoidance of large-scale failures. This is not the case: whenever a well-know failure was used as an example, its use is a matter of convenience. The assumption is that the failure doesn’t need to be described in detail for you to understand the principles involved. By analysing failures engineers can learn what not to do, and how to reduce the chance of failure. This may seem paradoxical but is widely accepted. Failure often can spur on innovation. In Engineering it is important to review failures, and mistakes. It is harder to learn from success, but you should always learn from failure. This is not the best practice in some engineering projects where failure results in human and property damage, however when a failure does occur it is very important to analyze it and learn from it. Failures have elements in common. The lessons that we learn from them can help engineers predict and avoid failures. A skill that all professional engineers need is the ability to predict and avoid failures no matter what their scale or magnitude from small or localised to large or widespread. Factors such as human error, decisions to reduce project duration or cost and failure to comply with existing Laws, Regulations, Codes and Standards have historically led to failures. Engineering Failures are typically the result of: • Human factors – both ‘ethical’ and accidental failure; • Design flaws – typically a result of unprofessional or unethical behaviour; • Materials failure; and • Extreme conditions. The report will consider any unethical practices that may have led to engineering failure. Engineering failures can be categorised based on the size of the impacted region, and the level of impact on the region. Size of impact: • Localised – this type of failure will only have an impact on the immediate area where the incident occurs; and • Widespread – although the causing incident was localised it has effects distributed over a large geographical area. Level of impact: • Small – Minor Injuries and property damage, may not result in loss of life; • Medium – Some loss of life, multiple serious injuries, or serious property damage; and • Large – Catastrophic failure, with extensive loss of life, and severe irreparable property damage. The United Kingdom Health and Safety Executive (HSE) espoused a framework otherwise known as tolerability of risk (TOR). TOR is used for worst-case considerations, utility-based conditions that entail the societal unacceptability of risky situations, and technology-based cases that tend to ignore the trade- offs between benefits and costs. The HSE includes principles that require risks to be reduced to as low as reasonably practical (ALARP). This allows the cost of reducing risks to be considered when determining whether to invest in a risk reducing activity. In general, project owners are required to invest proportionately higher levels of funds towards reducing higher risks, particularly for a risk with severe consequences. It is expected that each of the six failures should be analysed to determine the costs that should have been invested in the project to prevent the failure, and the cost of the consequences of the failure with regards to death, injuries, damages and cost. For each of these failures, the costs that were incurred after the project failure shall be calculated. What it would have cost to put measures in place to avoid the failure shall also be calculated. The multiplier or ratio is used as a measure to confirm whether society should have invested more funds to prevent this failure1. The results should be consolidated into a summary table. By analysing past failures, engineers can prevent future failures, both minor and catastrophic. It is often the catastrophic failure that receives professional and public attention, but as you will discover, catastrophic failures are comprised of multiple smaller errors in design, communication and/or judgement. Engineering is a constantly evolving discipline due to both advances in technology and the integration of lessons learnt through failures into laws, standards, work practices and technology. Despite the wide variety in the size and impact of the failures in this Assessment Task, many of the lessons applicable to improving risk management are the same. First, all projects should include a risk management process and a thorough assessment of the risks. In each of the case studies, risks that contributed to the catastrophic failure could have been identified and 1 Health Safety and Executive (2001), Reducing Risks Protecting People HSE’s decision–making process [Online], Available: http://www.hse.gov.uk/risk/theory/r2p2.pdf [Accessed Apr. 21, 2013]. mitigated through a risk management process. Second, independent reviews of design drawings and specifications greatly increase the chance of detecting human errors and failures to comply with existing codes, laws and regulation. Human error will never be abolished, but safeguards can help mitigate the impact. Third, time, cost, quality and scope constraints can have significant negative impacts on the outcome of the project or product. While all projects operate within these constraints, the impacts of these constraints need to be part of the risk assessment. Engineering failures are very subjective due to the perception and amplification of risks by society. Engineering failures are thought of more critically as there usually is no control over the incident from the people involved. One example is airplane travel: more people die on the roads annually, than by flying. However as there is no control over the plane by the passengers it is regarded as a much more serious failure. Engineering failures typically involve a sequence of events that lead to the failure. There are documented failures that contained complex and/or multiple causal events such that if even a single causal event were prevented or removed the incident would not have occurred. The sequence of events is typically preventable by removing a single element from the sequence. The cost of these fixes is often very small compared to the overall cost after the failure has occurred. Some risks are out of the control of engineers, and these must be managed in other ways. Although they all involve physical component failure or malfunction the cause of failures is commonly due to human interaction, either by cutting costs, pushing availability or having improper communication channels.