Introduction
These are some of my disorganized thoughts on failure. Perhaps some day I’ll turn it into a class.
References
Failure examples
- Challenger
- Holiday Inn
- Tacoma Narrows
- Minnesota Bridge
- Columbia
- Titanic - 1500 people
- Genoa Bridge
- Earthquake in Sichuan Province, China
- Takada Air Bags
- Chernobyl
- Three-Mile Island
- Fukushima
- Pompeii
- Ford Explorer Tires
- Corvair
- McDonalds Coffee
- Wrigley Gum
- Apollo 13
- Deepwater Horizon
- Toyota Acceleration
- PG&E Explosion
- PG&E Fires
- Paradise, CA
- Bhopal Disaster - 4000 people
- University Bridge Collapse
- Hawaii Airlines
- Building In San Francisco
- Katrina Levee
- Bay Bridge Fiasco
- Boeing 737-Max - Sensor & algorithm failur? documentation failure? training failure? regulatory failure?
- AirFrance - Pitot Tubes
- The Hindenburg
- 2008 Economic Collapse
- Cleveland East Ohio Gas Explosion
- London Apartment Building Fire
Engineering Failure
- Fatigue
- Cracking
- Stress
Keywords
- “culture of safety”
- “factor of safety”
- “FMEA”
- “risk assessment”
- “threat assessment”
Ways to Mitigate Failure
Documentation
- Signs, Warnings, Labels
- Labels
- Safety Manuals
- MSDS
- Tagout
- Nutrition Information, ie “warning, contains ingredients processed on lines that handle nuts”, Phenalkenatics, etc
- Procedures: In case of emergency.
Personnel
- Safety Inspections
- Training
- Communication Standards
- On Belay / Belay On /Climbing
- Alpha Bravo Charlie vs greek
Studies
- Anticipatory Studies
- Simulations, models, analysis, equations
- Post-Mortems
- literally the coroner’s office
- exponent
- FAA
Technical
- Prevention
- Child-proof containers
- Redundancy
- Passwords
- Encryption & Permissions
- Keys & Locks
- E-stops
- Lockout
- Sensing
- Testing
- UL / CE
- drop test
- cycle test
- how they test planes
- How they test concrete
Regulatory
- Codes & Standards
- IEEE
- ASME Codes
- …
- Licensing
Assignments
- identify leading (non-medical) causes of death at home/work.
- create an FMEA for an activity in the home. cooking? garage? yard work?
- identify changes that could be made
- create , implement, and test a safety feature at home / work
- observe whether it works
- observe whether it makes the product more usable
- look for workarounds
- test with a child
- visit a working environment and document safety measures in place.
- take pictures
- interview manager in charge of safety
- discuss leading causes of accidents on the job
- Walk through someone else’s kitchen
- take photos
- perform a risk assesment
- Identify a man-made accident or disaster which is the result of human error
- find at least three(3) news articles
- document impacts: loss of life, damage, quality of life, health, safety, security, etc?
- document cause(s): there are often a mix of issues which lead to a disaster, including communication, safety culture, engineering mistakes, failure to anticipate conditions, stress, age, failure to test
- identify technical causes
- identify human causes
- identify key factor which served as the trigger. was it technical in nature or a human problem?
- document timeline or sequence of events in a page
- describe steps which would have 1) eliminated the risk
- describe factors which exacerbated damage or loss of life
- describe factors which could have reduced damage or loss of life
- categorize each type of failure: technical, regulatory? personnel? what kind(s)?
Final Project
- identify a business
- reach out to and obtain contact infor for safety manager
- interview
- visit
- identify a candidate process for performing an FMEA
- consider restaurants, manufacturing, day cares,
- must be unique
- perform an FMEA
- propose a solution
- perform an FMEA on solution
- implement solution
- return and document changes, improvements
- discuss
