progress report complete
TRANSCRIPT
ENGG 404 – Engineering Safety & Loss Management
Team #9 – Incident Investigation
Sampoong Department Store Collapse
~ Progress Report ~
Team Members:
Lukasz Glistak
Shannon MacDonald
Cody McIntyre
Linda Nguyen
Brett Schroh
October 27th, 2010
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Contents
Incident Details.............................................................................................. Page 1 Losses With Respect to P.E.A.P.s.s............................................................... Page 1 Processes for Doing the Investigation............................................................ Page 2 People & Work Processes.............................................................................. Page 2 Appendix A – Incident Investigation Steps................................................... Page 3 Appendix B – Details of Team’s People and Work Processes..................... Page 5 Appendix C – Event Tree Analysis............................................................... Page 8 Appendix D – Fault Tree Analysis................................................................ Page 10 Appendix E – Additional Details for Immediate & Basic Causes............... Page 13 Appendix F – References............................................................................... Page 15
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 1 of 16
Incident Details The Sampoong Department Store collapse was a structural failure that occurred on June 29, 1995 in the Seocho-gu district of Seoul, South Korea. This event is documented as the largest peacetime disaster in South Korean history. On the morning of June 29, just after 8:00 AM, the Sampoong Department Store facilities manager discovered a note on his desk left by the night guard. The guard stated that he had heard strange noises coming from the roof. Upon investigation, the manager noticed large cracks in the rooftop, well aware that they had been caused by the improper removal of three air conditioning units two years prior. Approximately two hours later, the manager’s presence was requested in a restaurant on the fifth floor. Workers had noticed a large crack and sinking of the floor around the base of one of the columns. The manager instructed the workers to keep this information classified for now, as to not start any gossip that would negatively affect the reputation of the store. As noon approached, individuals on the 5th floor heard a disturbing sound and the rest of the building underwent mild vibrations. At 12:30 PM, the facilities manager decided to turn off the air conditioning unit, thinking that that was the source of the vibrations. By 4:00 PM, the cracks in the restaurant had widened to four inches and the facilities manager called a meeting between himself, the store owner and the structural engineer. The engineer recommended that the store be closed for repairs but the owner refused so that shopping would continue. At 5:40 PM, a loud bang was heard from the top floor and the ceiling shifted. At 5:47 PM, an even louder bang roared from the top floor. Finally, at 5:52 PM, a massive shock wave rocked the entire building and the five-storey building began to crumble. In less than twenty seconds, the entire building had collapsed to the ground. Approximately 1500 people were trapped inside. By the end of the rescue efforts, it was determined that 501 people died and 937 were injured.
Losses with Respect to P.E.A.P.s.s. People - Injury and death of many company employees, contractors, visitors, and public in close
proximity to the site at the time of collapse; 501 people died and 937 were injured - Short and long-term suffering to victims and families
Environment - Damage to public and neighbouring property Assets - All assets (e.g. furniture, equipment, products, etc.) were destroyed
- The building itself was demolished beyond repair - Resulted in about $216 million USD worth of property damage
Production - Complete loss of production due to desire for increased sales Sustainability - The department store has no future (i.e. no assets or capital to work with and extremely
negative public relationships)
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 2 of 16
Processes for Doing the Investigation
Organizing of the investigation was the first step. This included assembling the investigation team which was based on the Thomas Concept. The team proceeded to individually gather evidence and information relevant to the incident ensuring that all relevant sources were circulated. Evidence was found in the form of videos, specifically “From Disaster – Superstore Collapse” along with PowerPoint presentations and various other investigation documents. With sufficient evidence and information gathered, an appraisal process was started. The scope of investigation was established and focused on the managers, owners, engineers, and witnesses. Key players in this incident were identified including the Facilities Manager Young Lee, and the owners of the department store. Further organization of the evidence was conducted and the immediate cause was determined to be the structural degradation of column 5E. Basic causes were also identified and primarily point to management’s accountability and commitment to safety. A discussion regarding the evidence and events was conducted arriving at a tentative conclusion. This conclusion was a result of initial evidence analysis and discussion. Immediate and basic causes were identified and event and fault trees were constructed. The team is now proceeding to complete a detailed evidence analysis, make recommendation, compile a report and prepare a presentation.
People & Work Processes
The team assembled to conduct the investigation includes Shannon MacDonald, Linda Nguyen, Lukasz Glistak, Cody H McIntyre and Brett Schroh. Each member was selected based on their personal strengths following the Thomas Concept. The team has adapted particular “people and work processes” to ensure effectiveness while conducting the investigation. Communication between group members has been established through a Facebook group as well as e-mail and lastly by telephone. These three forms of communication have been implemented in order to ensure collaboration and cooperation. The decision making process will be modeled on a democratic system with a prerequisite of references when considering a decision. The initial resolution of minor disagreements or conflicts is to be done on a one-on-one basis before bringing it to the attention of the group. If the conflict remains unresolved, it may then be addressed during a group meeting. A vote on the subject will be conducted provided adequate references are available allowing the group to make an informed decision. Group management will mimic a self-directed structure with an outlying leader. This structure was selected due to its effectiveness in aspects such as organization, communication and work output. Shannon MacDonald has been selected as our group leader due to the strength of her organizational skills. All essential roles, as well as individual responsibilities, have been assigned (refer to Appendix B). The tasks were distributed based on each individual’s strength and skill set. Work will be conducted on an individual basis primarily due to scheduling constraints. However, there will be dates set for mandatory meetings. These meetings will be conducted Monday’s at 2:00 pm when required. It may be necessary to conduct meetings on other days depending on particular deadlines and constraints. These meetings will be held Wednesdays and Fridays at 5:00 pm when necessary.
Timeliness, professionalism and respect were chosen to be the group norms. Group team values include active participation, a high standard for work quality, schedule adherence and recognition of the aforementioned values. When discovered, sources of information are circulated to all group members providing everyone in the team with the same resources. This will prevent conflicting information and unhealthy competitiveness.
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 3 of 16
Appendix A
Incident Investigation Steps
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 4 of 16
Incident Investigation Steps
Organize the Investigation: • The team was assembled during the team building workshop. By determining everyone’s personal operating style,
team members with different qualities were selected based on the Thomas Concept. This ensured all future conclusions, actions and decisions would be looked at from multiple angles resulting in a comprehensive investigation.
• The group assembled to conduct the investigation includes Shannon MacDonald, Linda Nguyen, Lukasz Glistak, Brett Schroh and Cody H. McIntyre.
Gather the Evidence: • Each individual gathered evidence and circulated it to the rest of the team. All team members proceeded to
familiarized themselves with the incident through online sources such as videos, news clippings and articles. • The main source of evidence was a film called “Seconds from Disaster – Superstore Collapse”. It included
observation statements from people that were either involved in or witnesses to the collapse. • Evidence was also collected from websites and articles that describe the incident. All of the evidence presents
details and explanations of why the building collapsed. This included the actions of management and what happened throughout the day leading up to the incident.
Appraise What Happened: • The first step was a general appraisal which included establishing the scope of the investigation. The scope of the
investigation will focus on the managers, owners, engineers, and witnesses. • Key players in this incident were found to be the Facilities Manager, Young Lee, and the owners of the
department store.
Organize the Evidence and Determine Immediate Cause: • To ensure all necessary information and data was collected, everything was posted on the group page. This
included a detailed description of the incident, event and fault trees, and a thorough description with respect to P.E.A.P.s.s., outlining what was lost in the incident.
• With all evidence gathered and collected, the immediate cause was determined. It was found that the immediate cause was the failure of the column 5E.
• A consensus was reached regarding the immediate cause. No addition evidence was required to rule out other possible immediate causes.
Analysis, Tentative Conclusions/Discussion • A discussion regarding the evidence and events was conducted arriving at a tentative conclusion. This was arrived
at as a result of initial evidence analysis and discussion. Immediate and basic causes were identified and event and fault trees were constructed.
Future Steps
• Detailed evidence analysis • Final conclusion • Make recommendations/actions • Compile report • Present report
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 5 of 16
Appendix B
Details of Team’s
People and Work Processes
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 6 of 16
Details of Team’s People and Work Processes
• Communication between group members has been established through a Facebook Group as well as e-mail and lastly by phone. Communication shall be attempted in that order.
• The decision making process will be modeled on a democratic system with a prerequisite of references when considering a decision.
• Tasks based on each group members skills and strengths have been assigned. • Conflict resolution will be conducted during group meetings where the issue at hand will be addressed
before the entire group. A vote on the subject will be conducted provided adequate references are provided allowing the group to make an informed decision.
• A Self-directed structure with an outside leader has been selected due to its effectiveness. • Shannon MacDonald has been selected as our group leader due to the strength of her organizational
skills. • All essential roles as well as individual responsibilities have been assigned (refer to Table 1 below) • Work will be conducted on an individual basis primarily due to scheduling constraints. However there
will be mandatory meetings set. Timeliness, professionalism and respect are to be the norms of the group. The initial resolution of minor disagreements or conflicts is to be done a person to person level before bringing it to the attention of the group. If the conflict remains unresolved, it may then be addressed during a group meeting.
• Team values include active participation, a high standard for work quality, schedule adherence and recognition of the aforementioned.
• When discovered, sources of information are circulated to all group members providing everyone in the team with the same resources.
• During meetings each group member will summarize their progress and findings with the team. • Meetings shall provide an opportunity for all group members to ask questions and get opinions free from
negative criticism. • Meetings will be conducted Monday’s at 2:00 pm when required. There may be a need for meetings on
other days depending on particular deadlines and constraints. These meeting will be held Wednesdays and Fridays at 5:00 pm when necessary.
• Each member is to work to a schedule agreed upon by all group members. • All group members will have completed their individualized tasks prior to set meeting dates.
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 7 of 16
Investigation Team
Group Member Responsibility
Shannon MacDonald - Group Leader
- Investigate Incident losses with respect to P.E.A.P
Lukasz Glistak - Provide an overview of the team’s process for doing the investigation.
- Describe the team’s people and work processes including details.
Cody H McIntyre Description of our groups investigation steps
Brett Schroh Event Tree complete with a brainstormed list of all other possible consequences.
Linda Nguyen Develop a fault tree analysis staring off at immediate causes leading up to basic causes allowing for
Table 1 – Investigation Team
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 8 of 16
Appendix C
Event Tree Analysis
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 9 of 16
Event Tree Analysis
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 10 of 16
Appendix D
Fault Tree Analysis
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 11 of 16
Fault Tree Analysis
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 12 of 16
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 13 of 16
Appendix E
Additional Details for
Immediate & Basic Causes
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 14 of 16
Additional Details for Immediate & Basic Causes
Immediate Cause
The immediate cause is the structural degradation of Column 5E. Two years before the collapse of the building, management received noise complaints regarding working air conditioning (A/C) units. In response, the A/C units were moved using rollers instead of cranes, which in turn, caused visible cracks on the roof. Due to each A/C unit weighing 15 tons, the roof experienced more stress, which propagated to each of the columns. Additionally, when the new A/C units were turned on, vibrations were sent along the roof and the supporting columns, whereby Column 5E seemed to be affected the most. Eventually, cracks around Column 5E widened until the column could no longer withstand the stress incurred, thus causing the fifth floor concrete slab to crumble and the entire building to collapse. Basic Causes
The immediate cause along with many other substandard practices led to the collapse of the building. One of the basic causes includes the approval of the extra fifth floor and then the approval of using restaurants to fill that extra fifth floor. Originally, the building was intended to have only four floors. However, management wanted to have more space, and therefore concluded on adding an additional 5th floor. The floor's initial plan was mainly comprised of a roller skating rink, but later changed to include eight restaurants. Incorporating the eight restaurants required a thicker concrete slab to accommodate floor heating. When the contracting construction company was informed of this change, they informed management that this change was not feasible due to the structure not designed to support the extra weight. Consequently, management fired and replaced the contractor. Another basic cause is the use of poor construction materials and poor building designs. It was determined that the concrete used for the columns and floor slabs was of substandard quality. Furthermore, the building designs did not reflect engineering load-bearing calculations, possibly due to time and budget constraints. Nevertheless, management was well informed of these inadequate materials and designs, but continued with the construction of the building. Design changes, poor materials, and incompetent designs ultimately relate to the basic cause of an ineffective safety program. It appears as though the safety program was nonexistent for the fact that any person or company that reported any flaws in design or materials was quickly removed and replaced with ones who complied. Also, management failed to fully reevaluate potential hazards for each change in design. Accordingly, there was little priority placed on the safety and wellbeing of not only current construction workers, but also future patrons of the department store. Management was driven solely by profit and disregarded the building regulations that are in place to prevent harm against society.
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 15 of 16
Appendix F
References
ENGG 404 – Engineering Safety & Loss Management Sampoong Department Store Collapse - Progress Report - Group 9
October 27th, 2010
Page 16 of 16
References
[1] Sampoong Department Store Collapse. (2010, October 6). Received from Wikipedia: http://en.wikipedia.org/wiki/Sampoong_Department_Store_collapse
[2] Wilson, L., McCutcheon, D. (2003). Industrial Health, Safety and Risk Management – The Integrated Approach. In Industrial Safety and Risk Management (Chapter 1). Retrieved from http://books.google.ca/books?id=_Rr_BRvp30EC&lpg=PA5&ots=fNcOnZE8My&dq=peap%20people%20environment%20assets%20production&pg=PA6#v=onepage&q&f=false
[3] Oshiro-Momohara, A., Watanabe, B., Miyahara, R. Sampoong Department Store Collapse [PDF Document]. Retrieved from http://students.seattleu.edu/watanab5/web/Sampoong%20Powerpoint.ppt
[4] National Geographic. (2006). Seconds from Disaster – Superstore Collapse. United States: National Geographic Society and Darlow Smithson Productions. Retrieved from: previously published information in the public domain.
[5] Sampoong Department Store Collapse. (2010, October 16). Wikipedia. Retrieved October 19, 2010, from http://en.wikipedia.org/wiki/Sampoong#investigation
[6] Winkel, G. (2010). Faculty of Engineering – ENGG 404 – Engineering Safety and Risk Management – Fall Term 2010. University of Alberta, Custom Courseware.
[7] Gardner, N.J., Huh, J., Chung, L. (2002). Lessons from the Sampoong Department Store Collapse. Cement and Concrete Composites 24 (2002) 523-529.