Hyatt Regency Walkway Collapse
Presentation by William J. Frey
Agenda
• Case Narrative
• STS Table
• Case Chronology
• Key Decision Point
• Ethical Issue—Responsible Design
• To Engineer is Human (Video by Petroski)
• Code of Ethics Issues
Case Narrative
• On July 17, 1981, the second and fourth story
walkways of the Kansas City Hyatt Regency
Hotel collapsed killing 114 people and
seriously injuring an additional 200.
• Cause:
– “A deviation in the design in the way the rods
connected the lower skywalk to the upper and the
upper to the ceiling of the atrium was clearly
described and zeroed in on as the ultimate cause
of the accident.” Petroski: 86
Case Narrative
• Warning Signs
– The Atrium ceiling collapsed during construction; but a study
carried out by an independent engineering firm found nothing
wrong with the skywalk
– Workers carrying loaded wheel barrows across the skywalk
complained about excess vibration and swaying
• Petroski
– “After twenty months of investigation, the U.S. attorney and the
Jackson County, Missouri, prosecutor announced jointly that
they had found no evidence that either a federal or state crime
was committed…” (TAMU Instructor Manual)
• However in an investigation carried out by the attorney
general of Missouri…
– Duncan, Gillium, and GCE International Inc. were found guilty of
“gross negligence, misconduct and unprofessional conduct in
the practice of engineering.” (TAMU Instructor Manual)
Chronology (Adopted from TAMU Instructor
Manual Chronology)
Date
Early
1976
July
1976
July
1976
Summe
r 1977
Late
1977
Event
Crown Center Redevelopment Corporation begins
project to build Hyatt Regency Hotel
Gillum-Colaco, Inc. selected as consulting structural
engineer
Project enters schematic design stage
Early
1978
Project prepared under regional building codes
GCE works with PBNDML architect to decide upon
basic design
Bid set of structural drawings and specifications
Chronology
Date
Event
April 4, 1978
Contract finalized between GCE and PBNDML
Spring 1978
Construction begins
August 28,
1978
Project specifications issued for construction based on AISC standards
(American Institute of Steel Construction)
December
1978
Eldridge Construction Company , general contractor, finalizes
subcontract with Havens Steel Company. “Havens agrees to fabricate
and erect the atrium steel for the Hyatt project.”
February
1979
“Havens makes design change from a single to a double hanger rod
box beam connection….” Havens claims GCE approved. GCE denies
approving this.
Oct 14, 1979
Atrium roof collapse
November
1979
Seiden-Page investigates collapse and carries out “a thorough design
check” of all elements of atrium roof. Assures owners of overall safety
of newly designed roof.
Chronology
Date
Event
July 1980
Construction of hotel completed
July 17,
1981
2nd and 4th story walkways collapse killing 114 and injuring 200.
February
3, 1984
“Missouri Board of Architects, Professional Engineers and Land Surveyors
files complaint against Daniel M. Duncan, Jack D. Gillium and GCE
International Inc., charginng gross negligence, incompetence, misconduct
and unprofessional conduct in the practice of engineering in connection
with their performance of engineering services in the design and
construction of the Hyatt Regency Hotel in Kansas City, Missouri.”
November
1984
“Duncan, Gillium, and GCE International Inc. found guilty of gross
negligence, misconduct and unprofessional conduct in the practice of
engineering. Subsequently, Duncan and Gillum lost their licenses to
practice engineering in the State of Missouri, and GCE had its certificate
of authority as an engineering firm revoked. American Society of Civil
Engineering (ASCE) adopts report that states structural engineers have
full responsibility for design projects. Duncan and Gillum now practicing
engineers in states other than Missouri.”
Component /
Value
Walkway
Design
Physical
Surroundings
People,
Groups, and
Roles
Procedures
Laws, Codes,
Statutes
Information
and
Information
Structures
Statics
Principles
Atrium with 60
foot high
ceiling.
Three
Walkways
suspended
from Roof
Large space
below
walkways on
first floor
Hotel Owner
Architecture,
Engineering
Design ,
Construction ,
and
Engineering
Investigating
Firms
Hotel Design
Process
Engineers
signing off on
plans
Contracting and
subcont
dividing
responsibility
Post Accident
Investigation
Engineering
Codes
Post accident
investigation
Contract , Civil
and
Criminal Law
US attorney
investigation
Experience with
past designs
Cement Floors
Rods and bolts
Box beams
Professional
Societies
Regulatory
authority
delegated to
Professional
Society
Governmental
Officials
Ease of
Construction
Difficulty of
constructing
with original
design
Designers hand
off to
constructers
Communication
between
designer and
constructer
Safety
Studying past
failures and
testing to
failure
Engineers
approving
design
Investigating
firm
Signing and
Signing plans
(licensed
engineer)
Elegance or
Beauty
Create a
“floating”
walkway
Walkway to
appear
suspended
Codes set stds
Legal system
punishes
violations
Trial by
Missouri attn
gen
Black Box:
account of case
in textbooks
Concepts related to Safety and
Risk
Risk Assessment
Risk Communication
Risk Perception
Risk Management
Safety
• “A thing is safe if, were its risks fully known, those risks
would be judged acceptable in light of settled value
principles.” (Martin/Schinzinger, Engineering Ethics,
108)
• Safety and risk are different sides of the same coin
– One is defined in terms of the other
• “Settled value principles” makes safety a matter of
public policy. Government plays a role. So does
business. Most importantly, so do members of the
public
Public
• “those persons whose lack of information, technical
knowledge, or time for deliberation renders them
more or less vulnerable to the powers an engineer
wields on behalf of his client or employer”
– Michael Davis. Thinking Like An Engineer
• The public is in an especially vulnerable position. They
stand subject to the risk. But they do not participate in
the project that generates the risk
• The public has the right to free and informed consent.
– This right is vulnerable if risk information does not get to
them, if the risk information is too complicated for them to
appreciate, or no provisions have been taken to include
them in the collective risk acceptability (=safety) decision.
Risk
• The other side of the coin
– Risk and safety are correlative and defined in terms of one another
• “A risk is the potential that something unwanted and harmful may
occur.” (MS 108)
• Risk has four dimensions (assessment, management, perception,
and communication)
• Since risk is the probability of harm and probability implies
uncertainty (lack of complete knowledge), the ethics of risk lies in
how this uncertainty is communicated and distributed.
– For example, does a government regulatory agency approve a product
unless it is proven harmful….
– Or does it withhold approval from a product until it is proven
completely safe.
– In the first, the burden of uncertainty falls on the public exposed to
risk, in the second on the manufacturer who can’t reap benefits from
selling the uncertainly risky product.
Risk Assessment
• The scientific and exact process of determining the degree
of risk
• Animal Bioassays
– Animals exposed to risk fact at intense level for short period of
time
– Projection from animal physiology to human physiology and
from short term/intense exposure to long term/less intense
exposure
• Epidemological Studies
– Comparison between populations exposed to risk and
populations not exposed to risk
– Search for significantly higher risk ratio. Three-to-one not
generally significant. Six-to-one is significant
• Ethics of Risk
– Since there is uncertainty in risk assessment, an ethical issue
arises as to how that uncertainty is distributed
Risk Assessment in Engineering
• Fault Tree
– “a diagram of the possible ways in which a
malfunction or accident can occur.”
– “enable an engineer to analyze
systematically the various failure modes
attendant to an engineering project”
– Determining why a car won’t start by
considering different failure modes
•
Harris, E., Pritchard, M., and Rabins, M. (2005). Engineering Ethics: Concepts and
Cases . Thompson: 156
Risk Assessment in Engineering
• Faiure Mode
– “way in which a structure, mechanism, or process
can function.”
• Event Tree Analysis
– “reason forward from hypothetical events to
determine what might have led to the final event”
– Reasoning from pipe break in nuclear reactor to
possible outcomes (release of radiation)
– Harris, E., Pritchard, M., and Rabins, M. (2005). Engineering
Ethics: Concepts and Cases . Thompson: 157
Limitations in Risk Assessment
• Cannot predict all possible failure modes
• Human error is also difficult to predict (See
Reason in Human Error for a possible account)
• Probabilities assigned are largely a matter of
guesswork
• “We can never be sure we have all of the possible
initiating events….
• Harris, E., Pritchard, M., and Rabins, M. (2005). Engineering
Ethics: Concepts and Cases . Thompson: 157-8
Different Kinds of Accident
• Normal Accidents (Perrow)
– Happens in tightly coupled systems
– Leads to non-linear causality
– Small failure proves difficult to isolate; spreads out to
create other failures; these cascade to produced
catastrophe
• Complexity of system makes it difficult to predict
accident and assess risk
– Ladd calls these “loss of control” accidents
• John Ladd. Bhopal Article
Human Error
• Reason treats accidents as pathogens that are
latent in a complex system
• When circumstances are right, a configuration
of events creates an opportunity for the
pathogen to emerge
• Reason argues that accidents come from
human cognitive procedures that usually work
for the best
Risk Communication
• Results of risk assessment are technical and subject to
different interpretations
• Public has a right to informed consent vis a vis risk
– To consent to take a risk (or withhold consent) they must
understand the risk and be able to make a coherent
consent decision
• This raises issues in risk communication
– Clear communication
– Comprehensive communication (not leaving out anything
significant)
– Communication that takes into account the perspective
from which the public will perceive the risk
Risk Perception
• The public perceives risk according to a clear perspective
• This renders risk perception rational because predictable
(to a certain extent)
• Factors which influence public perception of a risk’s
acceptability
–
–
–
–
–
Voluntariness
Expected benefits
Control over risk
Minimal dread factor
Minimal unknown factor
Risk Management
• Political process of determining if a certain
degree of risk is acceptable according to a
community’s settled value principles
• Value principles are identified via a process of
deliberative democracy which respect the metanorms of reciprocity, publicity, and accountability
• Community’s identify small scale project for
experimental analysis
– These validate settled values
– These also help to determine if larger scale action is
acceptable
Resources
•
Hyatt Regency Kansas City Walkway Collapse" Online Ethics Center for
Engineering 11/24/2010 National Academy of Engineering Accessed:
Thursday, December 16, 2010
<www.onlineethics.org/Resources/Cases/24338.aspx>
• Henry Petroski (1985). To Engineer is Human: The Role of Failure in
Successful Design. St. Martin’s Press: 85-97.
• http://ethics.tamu.edu/ethics/hyatt/hyatt1.htm
– The Kansas City Hyatt Regency Walkways Collapse
– Department of Philosophy and Department of Mechanical Engineering
Texas A&M University
NSF Grant Number DIR-9012252
• http://ethics.tamu.edu/ethics/hyatt/hyatt2.htm
– Photos by Dr. Lee Lowry, Jr. at TAMU