Failure

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

  1. identify leading (non-medical) causes of death at home/work.
  2. create an FMEA for an activity in the home. cooking? garage? yard work?
    • identify changes that could be made
  3. 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
  4. visit a working environment and document safety measures in place.
    • take pictures
  5. interview manager in charge of safety
    • discuss leading causes of accidents on the job
  6. Walk through someone else’s kitchen
    • take photos
    • perform a risk assesment
  7. 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

Videos

Challenger

Chernobyl

NE Blackout

Exxon Valdez

Hindenburg

1989 San Francisco Earthquake

Safety on Fire

Tacoma Narrows

Love Canal

Three Mile Island

Minneapolis Bridge Collapse

External Resources

Assignment: M16 Reading

https://www.theatlantic.com/magazine/archive/1981/06/m-16-a-bureaucratic-horror-story/545153/ Questions name three contributing factors which led to the failure of the M16 adoption process, according to this article.

Books on Failure

Failure in General To Forgive Design: Understanding Failure Henry Petroski

failure misc

Subjects Date Link Challenger Holiday Inn Tacoma Narrows Minnesota Bridge Columbia Titanic Genoa Bridge Schools in China Takada Air Bags Chernobyl Three-Mile Island Fukushima Pompeii Ford Explorer Tires Corvair McDonalds Coffee Wrigley Gum Apollo 13 UniversityBridge Collapse HawaiiAirlines BuildingInSamFrancisco KatrinaLevee Standards IEEE ASME Codes Testing