COMPLEXITY, COMMUNICATION AND INTERFACES

Enhancing the potential for successful risk management may lie in directly addressing the perceived constraints. However ensuring an acceptable level of safety is essential and presents special challenges in construction innovation. Innovation is also fundamentally important but its benefits often remain untapped due to complex issues that surround the construction process. Typical constraints include tradition, lack of awareness or expertise, risk aversion, the desire for certainty, and of the time pressures on delivery.

6.7.1 Complexity

Generally, construction project management understands the project as an ordered and simple – and thus predictable – phenomenon which can be divided into contracts, phases, activities, work packages, assignments etc to be executed more or less independently. The project is also seen as a mainly sequential, assembly-like, linear process which can be planned in any degree of detail through an adequate effort and executed in accordance with the plans. As a consequence, project management acts top down, mainly by management-as-planning as suggested by Koskela and Howell (2002). Several authors have looked at project management from the complex systems’ point of view (Gidado 1996; Williams 1999; Wild 2002; Kim and Wilemon 2003); however, often these authors use a specific perspective to relay their messages. Williams (1999) characterises complexity as structural uncertainty and uncertainty in goals and methods only, whereas Wild (2002) looks at the social system in projects. These authors usually use complexity as a general characteristic of projects without applying the complex systems theory to their studies. Gidado (1996) as well as Kim and Wilemon (2003) take an ordered approach to assess complexity in projects.

6.7.2 Interfaces

In the analysis of the construction project as a system, there are underlying problems which circumscribe the course which the construction process must steer. Most of these problems assume the role of interfaces, which are a combination of product interfaces, system interfaces, subsystem interfaces, disciplinary interfaces and geographical interfaces to name but a few. Interfaces may be described as the facts, problems, considerations, practices, and or procedures shared by two or more construction disciplines; or a common boundary or interconnection between systems, equipment, concepts, or human beings (Mann 2008).

There has been a significant amount of commentary addressing interfaces between various construction disciplines and practices (Mann 2008). Interface areas can for example, include the linkages between procurement, design management or construction management (in project management); and operation and maintenance, or other ‘whole-life’ issues (in asset

management); as well as other potential synergies in the management of the projects and their resulting built environment assets. Interface areas may also be addressed through relevant issues in Public Private Partnerships (PPP), infrastructure security/resilience or sustainability etc. Most of the structures that civil engineers create interact with other engineering disciplines. The profession scarcely ever has the luxury of designing a civil or structural entity on its own and even when it does; there may be internal interfaces between ‘design’ and ‘construction’ or between ‘steel’ and ‘concrete’ for example. Furthermore, on complex projects, within ‘design’

there is an interface with analysis and its translation into reality, which is a human problem of comprehension between the ‘analyst’ and the ‘practical engineer’.

Burland (2006) has discussed problems on the interface between structural and geotechnical engineering. Since all these disparate skills are specialised, there are plenty of opportunities for misunderstandings so, whenever there is an interface, the rule is to be on guard. Those involved need adequate dialogue as, although civil engineers think of their work as technical, a vast amount is about comprehending the true system demand and thence communication about intent, design and construction. Within engineering circles worldwide this is a source of concern

(Burland 2006) and poor communication is a recurrent theme. There can be particular difficulties across technical and contractual boundaries.

6.7.3 Communication

As people develop their professional competence, they acquire a vocabulary and an

understanding of the meaning of different words when used in the contexts of their discipline (semantics). They also develop a lexicon – an understanding of how language and technical words relate to each other (Tutt et al. 2010). This language diversity is a prominent feature, leading to an inability to interpret messages regarding workplace hazards conveyed by supervisors, managers and peers.

6.8

UNDERLYING PROBLEMS WITH REPORTING AND RESEARCH

Because of the low probability of catastrophic events historical data is very sparse. Due to this very limited data, the sample sizes of statistical analyses would be very small, leading to high variances and poor (in the sense of imprecise) risk estimates. Without further knowledge, the likelihood and severity of low-probability, high-consequence events are thus difficult to estimate from historical data alone.

However, much has been written on the need to learn and remember the lessons of the past (Kletz 1991, 2008), and with it comes advanced opportunities for prediction, monitoring, feedback and teamwork opportunities for learning (Powderham 2002). However it is important to recognise the limitations of this type of approach. Some of the most significant limitations include various concerns about potential bias. Media accounts may suffer from biases of both inclusion and exclusion. They may report on sensational stories that are unimportant or inflated from the standpoint of societal impact. On the other hand, they may fail to report on important impacts for any number of reasons, lack of information, lack of awareness, and lack of attention if another issue is dominating the news cycle. These limitations suggest the need to validate and supplement data from accounts with information from actually case studies and other sources. However, it is reasonable to expect that reporting issues may be of lesser concern in the case of truly significant societal impacts; that is, a major fire that causes numerous deaths is likely to be reported in any circumstance.

In the introductory statement to the ‘Special issue’ of the ICE Proceedings, Byfield (2008:3) draws our attention to hindsight as “something that engineers must learn to harness”. Certainly obtaining good information on recent engineering failures or near misses can be difficult due to the complex and often protracted legal issues involved. The occurrence of an event can be brought about by a number of cascading problems such as arithmetic error, lack of essential training for key personnel, lack of experience, use of inappropriate software within a design office, or a failure to supervise. However there is often a tendency to draw conclusions from the immediate and sometimes apparently ‘obvious’ causes of a failure; but could engineers not learn

from ‘near misses’ instead? A point Collings (2008) raises repeatedly in a paper on bridge failures suggesting that often precedents are unnoticed and key warnings are ignored. The industry must be mindful of obvious conclusions as vital evidence and experientially crucial knowledge may be lost (Burgoyne and Scantlebury 2008).

Reporting and research into types of events that are embraced by this report should look at the physical causes of the incidents as well as focusing on the systemic management culture and human error processes that contribute to the event. Major Hazard incidents rarely just happen, but are usually the result of failures of technology, failures of people or a combination of both. These causes are seldom simple and singular. In modern technological systems causes

sometimes are complex constellations of directly contributing events and existing preconditions and system properties. Failures to report on single incidents or series of subsequent incidents may build up into a catastrophic event. The collection of data surrounding Major Hazard incidents involves three main stages:

1. Ensuring that all significant incidents are reported;

2. Checking for non-reporting of the type of incidents concerned; and

3. Recording details of the incidents reported in order to mitigate for such events in the future.

Unfortunately, the understanding of the underlying causes of many disasters can be stymied by the legal process, which can mean that the evidence is limited in its circulation. The profession needs to study and learn from its failures as much as its successes (Byfield 2008).

There are barriers to reporting and one is that the identity of the author, their employer, the client, the site, or a product may be revealed with negative consequences (Soane 2006). The model for CROSS was Confidential Human Impact Reporting Programme (CHIRP), the UK aviation system which in turn has links to the Aviation Safety Reporting System (ASRS) - the incident reporting service for pilots in the USA. The process for handling reports has been adopted by the construction sector and adapted from their procedures; this is clearly a move in the right

direction.

6.9

SUMMARY

This section of the report has provided an overview of the extant literature related to professional and public understanding of the immediate and underlying causes of catastrophic events in construction. This literature review has also sought to understand the effectiveness of current control measures and the need, if any, for further actions to improve the management of risks and their potential for causing catastrophic events on construction projects. The review has

highlighted that there is a paucity of relevant publications on major hazards in the context of construction. Nonetheless, examples from other industries and a legacy of ‘near miss’1 events suggest that approaches are needed to improve industry preparedness for future major hazards and their disruptive effects.

The literature reviewed has highlighted a number of key points, namely:

§ Despite attempts to learn lessons over the years, major accidents continue to be a threat. § Complex chains of events (including organisational policies and decisions, individual

behaviours and mechanical or technological failures) often combine to result in major hazard events or catastrophes.

1

§ The major consequences and impacts of catastrophes are likely to be: multiple deaths and serious injuries to site personnel and the general public; the serious disruption of

infrastructure and key services; damage or even destruction of organisations

commercially; and political implications – public enquiries, demands for new legislation. § The literature has identified failures based on fundamental systemic failure, for instance

failures within systems of organisation, communications and procurement. To date, focus has been directed at easily promotable risk and hazard reducing goals (for example ‘zero accidents’), rather than the processes and methods needed to achieve them.

§ Greater emphasis should be placed on the concept of ‘people, process and products’ in particular when developing the competence of the industry’s people in relation to risk and major hazards.

§ There is a need for further research and for advancing the use of confidential reporting mechanisms

There are a number of circumstances which contribute to the explanation of the problems which may manifest a major hazard into a catastrophe. However, it has been noted that it is impossible to submit broad policy recommendations for the construction industry and the government on the basis of any one single case without raising methodological questions. This is compounded by the ever increasing complexity of building and construction systems.

Past incidents within (and outside of) the construction industry suggest that there needs to be ongoing monitoring of incidents (national and global) and ongoing evaluations of the systems in place. The following sections, that present the findings from an on-line survey, 62 case studies and numerous industry consultations, will provide a more detailed discussion and analysis of these key issues.