1. Hyatt Regency Walkway Collapse
Presentation by William J. Frey

2. 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

3. 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

4. Case Narrative Warning Signs Petroski
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)

5. Chronology (Adopted from TAMU Instructor Manual Chronology)
Date
Event
Early 1976
Crown Center Redevelopment Corporation begins project to build Hyatt Regency Hotel
July 1976
Gillum-Colaco, Inc. selected as consulting structural engineer
Project enters schematic design stage
Summer 1977
GCE works with PBNDML architect to decide upon basic design
Late 1977
Bid set of structural drawings and specifications
Early 1978
Project prepared under regional building codes

6. 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.

7. Chronology Date Event July 1980 Construction of hotel completed
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.”

8. Physical Surroundings People, Groups, and Roles Procedures
Component / Value
Walkway Design
Physical Surroundings
People, Groups, and Roles
Procedures
Laws, Codes, Statutes
Information and Information Structures
Statics Principles
Experience with past designs
Cement Floors
Rods and bolts
Box beams
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
Professional Societies
Governmental Officials
Hotel Design Process
Engineers signing off on plans
Contracting and subcont dividing responsibility
Post Accident Investigation
Engineering Codes
Contract , Civil and
Criminal Law
Regulatory authority delegated to Professional Society
Post accident investigation
US attorney investigation
Trial by Missouri attn gen
Black Box: account of case in textbooks
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)
Codes set stds
Legal system punishes violations
Elegance or Beauty
Create a “floating” walkway
Walkway to appear suspended

9. Concepts related to Safety and Risk
Risk Assessment
Risk Communication
Risk Perception
Risk Management

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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 meta-norms 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

22. Resources
Hyatt Regency Kansas City Walkway Collapse" Online Ethics Center for Engineering 11/24/2010 National Academy of Engineering Accessed: Thursday, December 16, 2010 <
Henry Petroski (1985). To Engineer is Human: The Role of Failure in Successful Design. St. Martin’s Press:
The Kansas City Hyatt Regency Walkways Collapse
Department of Philosophy and Department of Mechanical Engineering Texas A&M University NSF Grant Number DIR
Photos by Dr. Lee Lowry, Jr. at TAMU