hyatt regency walkway collapse

5/28/2018 Hyatt Regency Walkway Collapse

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HYATT REGENCY WALKWAY COLLAPSE

INTRODUCTION

On July 17, 1981, two suspendedwalkways collapsed in the HyattRegency Hotel in Kansas City,Missouri during a dance festival

As the United States' mostdevastating structural failureinterms of loss of life and injuriestheKansas City Hyatt Regency walkwayscollapse left 114 dead and an excessof 200 injured.

In addition, millions and millions ofdollars in costs related to lawsuits,etc., resulted from the collapse, andhundreds of lives were adverselyaffected.

A powerful, painful lesson about themeaning and practice of ethics inengineering.


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What part of the walkway do you think failed?

What part of the support structure could have failed to cause both the

second and fourth-floor walkways to fail?

What evidence would you look for to decide what part actually failed?


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HYATT REGENCY WALKWAY COLLAPSE:

BACKGROUND TO THE CASE

March 1976

Crown Center Redevelopment Corporation began to design Hyatt Regency Hotelin Kansas City, Missouri

April 4, 1978

Actual contract entered into by Gillum-Colaco, Inc., a Professional EngineeringFirm, G.C.E. and the architect, PBNDML Architects, Planners, Inc. G.C.E. agreedto provide "all structural engineering services for a 750-room hotel project locatedat 2345 McGee Street, Kansas City, Missouri."

During that time, Jack D. Gillum (the supervisor of the professional engineeringactivities of GCE.) and Daniel M. Duncan (working under the direct supervision ofGillum, the engineer responsible for the actual structural engineering work on the

Hyatt project) assisted Crown Center Redevelopment Corporation (the owner) andPBNDML Architects, Planners, Inc. (the architect on the project) in developingplans for the hotel project and deciding on its basic design.

Spring 1978: Construction begins on hotel

December 1978

Eldridge Construction Company, general contractor on the Hyatt project, enters into

subcontract with Havens Steel Company. Havens agrees to fabricate and erect theatrium steel for the Hyatt project.


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The original design consisted of long suspension rods hanging down fromthe ceiling.

These hanging suspension rods would then support upper and lowerbeams.

The two beams would, in turn, bear the weight of the two walkway floors.

In the proposed design, the rods were hung from the ceiling, then theupper deck beams were threaded on and slid up the rods, then heavywashers and nuts where run up the rods to support the upper beam.

The lower beams were then similarly fitted onto the rods at the bottom, andagain were supported with nuts and washers under each end.

This detail was shown on the engineering drawings that had been

submitted to the fabricator, Havens Steel

Figure 1


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Wide flange beams were used on either side of the walkway upon which was hung a boxbeam

A clip angle welded to the top of the beam was connected to the flange beams with bolts

One end of the walkway was welded to a fixed plate while a sliding bearing supported theother end

Each box beam of the walkway was supported by a washer and nut which was threadedonto the supporting rod

The beams consisted of two 8-inch channel sections welded toe to toeto make up a boxbeam.

The ends of the box beams were then drilled to receive the rods.

The box beam consisted of two 8 x 8.5 MC channels

Figure 1


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The walkways were suspended from the

ceilings by long rods.

The rod would pass through the top

walkway and on down to the bottom

walkway.Under each walkway, a load-carrying nut

would be used on each of the rods to carry

the load of the walkway.

Since the original design called for running

the nuts 30 feet up the rods, the entire length

of the rods had to be threaded.Threading 30 feet of rod is difficult and

costly.

The fabricator decided to modify the original

design to make it easier and less costly to

construct.

Figure 1


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Over a year before the collapse (1979), the design of the walkway

hanger rod connections was changed in a series of events and mis-

communications between the fabricator (Havens Steel Company) andthe engineering design team (GCE)

Havens Steel, the fabricator, changed the design from a one-rod to a

two-rod system to simplify the assembly task.


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This design change, however, put a doubleload on the connector rod.

The deviations from the original design areas follows:

One end of each support rod was attachedto the atriums roof cross beams

The bottom end went through the box beamand attached with a washer and nut

A second rod was attached to the box beam4 inches from the first rod

They cut the rods in half and ran thosehalves from the roof to the top walkway andplaced nuts

They then drilled another set of holes,which was offset 4 inches inward along theaxis of the box beam, in the top walkwayand hung the other halves of the rods fromthe top walkway.


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In the modified design, the fabricator had to thread only about 6 inches ofeach end of each

rod, a considerably easier task.The workers failed to realize that this doubled the load on the nuts under the top walkway

compared to the original design.

In the original design, the load (weight) for each hanger rod was to be 90 kN.

With the revised design, the load was increased to 180 kN on the fourth floor box beam

connections

The National Bureau of standards (NBS) discovered that the cause of the walkway collapse

THE TWO SUPPORT MODELS


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Notice in diagram 1 that in the walkway design, Nut 1

supports only the walkway above it.

The weight of the second walkway is supported through

the rod. In the walkway built, Nut 1 not only holds the

weight of the walkway above it, but also the hanging

weight of the second walkway and the rods used tosupport it.

This proved to be more stress than the structure on which

Nut 1 was supported and it could not hold the extra load

of the other walkway.

Since the box beams were longitudinally welded, as

proposed in the original design, they could not hold theweight of the two walkways

THE TWO SUPPORT MODELS

Diagram 1


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The deformed 4thFloor Beam


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Suppose a long rope is hanging from a

tree, and two people are holding onto

the rope -- one near the top and one

near the bottom. Under the conditions

that each person can hold their ownbody weight, and that the tree and

rope can hold both people, the

structure would be stable.

However, if one person was to hold

onto the rope, and the other person

was hanging onto the legs of the first,

then the first persons hands must holdboth peoples body weights, and, thus,the grip of the top person would be

more likely to fail.


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The Deformed 4thFloor Beam


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Hanger rodbox beam connection


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The steel rods were of 31.75 mm diameter


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Design Change for the Worst

Original Design Modified Design


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Introduction to Forensic Engineering

Forensic Engineering involves the investigation, testing and analysis todetermine the cause of engineering failures.

Forensic engineers use their specialized knowledge of deteriorationmechanisms, behavior of construction materials, construction methods, andrepair procedures to determine the most suitable solution to the whytechnology fails.

Forensic engineering reports are often used as evidence for litigationsupport and many forensic engineers serve as expert witnesses in courts orinvestigations.

After an accident, forensics engineers examine broken parts and bringtogether a list of probable failure mechanisms to be investigated. Interviewsare conducted to determine a sequence of events.

Drawings, specifications, and operational procedures are reviewed. As-builtdimensions and operating parameters are compared to design requirements


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Introduction to Forensic Engineering

Typical Foci of Forensic Engineers Include:

Fire Investigations

Industrial Accidents (explosions, disasters)

Product Liability Engineering

Traffic Accident Reconstruction

Transportation Disaster Investigation (airplane, railroad crashes)

Civil Engineering Investigation (building collapses, building systemsfailures,

Environmental Systems Failures


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Forensic Analysis of Disaster

What was the (physical) cause of the collapse?

Shoddy structural materials (substandard inferior steel?)

Bad (slag and/or shallow) welds?

Faulty construction?

Were essential bolts and washers missing or not fastened?

Unexpected loads?

Did all the dancing create a harmonic vibration not taken into in

the original design? Fundamental Design flaws?

The researchers could only conclude that it was a fundamental flaw in

the design stage


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Sociotechnical Systems Analysis

Technical Factors

Fundamental Flaws in the Engineering Design Process

Human Factors

Unprofessional behavior of individuals involved

Organizational Factors

Major mis-communication between various organizations

involved

Careless managerial practices in various organizations

Socio-cultural Factors

Neglectful Local/State Inspection Administration


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ETHICS

O

H

T

S-C


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CAUSAL ANALYSIS OF THE DISASTER:

TECHNICAL FACTORS

Three Major Technical Factors can be identified:

1. Abrupt changes which resulted in high concentrations of stress on particular

areas

1. The original design was changed from one where the walkways were supported

by two nuts on one rod to one that was supported by two nuts on two rodscausing the amount of stress on each nut to increase.

2. Lack of consideration for every force acting on particular connections

1. By changing the design to two rods and not calculating new data for the design

change, a lack of consideration for all forces acting on that nut was

prevalent.

3. Failure to take motion and rotation into account in the design

1. The walkways were not designed for excessive motion. The walkways of theHyatt Regency were designed so that guests could pass from one side of the

hotel to the other They were not planned to be used as dance

floors. Unfortunately, the failure to take motion and rotation into account in thedesign proved to be deadly when the fourth floor.


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Fundamental Causes of Structural Failure

1. Improper design due to lack of consideration of all forcesacting on a connection or material, especially thoseassociated with volume changes

2. Improper design utilizing abrupt section changesresulting in stress concentrations

3. Insufficient provisions for rotation and movement

4. Improper preparation of mating surfaces and installation

connections5. Degradation of materials in a connection

6. Lack of consideration of large residual stresses resultingfrom manufacture or fabrication


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CAUSAL ANALYSIS OF THE DISASTER:

ORGANIZATIONAL FACTORS

COMMUNICATION FAILURES

The fabricator of the steel for the walkways and hanging rods, Havens Steel, insworn testimony before the administrative judicial hearings after the accident,claimed that their company (Havens) telephoned the engineering firm (GCE) for

approval change to the box-beam/hanging-rod design G.C.E., for their part, denied ever receiving such a call from Havens.

Havens claims that on February 16, 1979, they sent 42 shop drawingsincluding the all-important revised Shop Drawing 30 and Erection Drawing E-3)to GCE

Havens claims that on February 26, 1979, GCE returned the set of drawings to

Havens, along with Gillums engineering review seal, authorizing construction GCE claimed miscommunication because they argued that the drawings

prepared and sent to Haven were only preliminary sketches but were interpretedby Havens as finalized drawings.


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Communication Breakdown in the Hyatt-Regency Case

This communication failure resulted in confusion about engineering designresponsibility of at several levels of interaction between the GCE andHavens Steel, which ultimately led to the use of a design plan and materialsinadequate for supporting the loads acting on the box beam hanger

connections. The Hyatt Regency case drew immediate attention to the communication

patterns followed by structural engineers and highlighted the problems thatcan result when poor or ambiguous communication leads to amisunderstanding of responsibilities

The case illustrates the dynamics of communication systems in the

construction industry and illustrates the importance of greater awareness ofrole definition and communications networks in structural engineering

The dynamics of communication systems within the civil engineeringprofession as a whole are clearly illustrated by an analysis of the significantcommunication issues that the Hyatt Regency case highlights


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The Importance of Role Definitions

Roles and corresponding responsibilities of structural engineers and steelfabricators are defined according to four basic categories of work involved instructural steel construction:

1. Fabrication

2. Erection3. Materials

4. Engineering

1. In matters of engineering, there is often overlapping of responsibilities

2. In the Hyatt Regency case, overlapping responsibilities led to seriousbreaches in communication between these two team membersdesign

engineers and steel fabricatorswhich led to construction of faulty walkways3. In instances where engineer and fabricator can perform similar tasks, they

clarify their duties through available formal and informal communicationchannels, which includes written and oral communication as well as preciseand accurate structural and shop drawings


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Roles and Responsibilities in

Construction and Engineering

In the construction industry and civil engineering practice, a crucial distinctionis made between design and develop in defining the steel fabricators role:

1. DesignFabricator designs a connection if such work requires the steel fabricatorto use engineering judgment to calculate loads and stresses

2. DevelopFabricator develops connections by simply following the structuralengineers instructionsby installing the necessary components and materials andconsulting the American Institute of Steel Construction (AISC) Manual, but withoutany exercise of engineering judgment such as calculation of loads.

It is the full responsibility of the structural/design engineer for defining theprecise role the steel fabricator will play in the design or development of aconnection

The structural engineer must communicate exact instructions to the fabricatorthrough the structural design drawings

These instructions depend, in turn,

1. on a clear understanding of the type of connections the drawing depictsSimple,Complex, or Special

2. On the nature of the designwhether it is Complete or Incomplete


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Communication of Design Responsibility

from Structural Engineer

to Steel Fabricator

Structural EngineersSection Detail Drawings

Type of

Connection?

Fabricator HasDesignResponsibilities

Fabricator HasNo DesignResponsibilities

ConnectionDesignShown

?

Extent ofConnection

Design?

Yes

Complexor Special

No

Complete

Simple

Incomplete


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Findings of the Deutsch Commission

In accord with Missouri law, the Missouri Licensing Board presented its case in front ofthe Administrative Law court to obtain permission to discipline the two engineers(Gillum and Duncan)

it is only upon a proper communication of the engineers desire or acquiescencethat the fabricator perform a function or obligation of design. -- Deutsch (1985)

During the hearings the design engineers argued that omission of any information onthe structural drawings should alert the fabricator to design responsibility

This decision does not conform to the general custom and practice that hasdeveloped in structural engineering, governing assignment of design responsibility(simple v. complex or special connections)

The determination of connection type and hence designation of design responsibilityfalls clearly within the parameters of the design engineers responsibilities. Deutsch

(1985) Relying on a subordinate to detect unspoken intent and perform the omitted

engineering calculations is not permissible. Deutsch (1985)

The structural engineer bears the burden of communicating his [sic] intent to thecontractor and assumes the risk of confusion or non-communication. Deutsch (1985)

The burden of and responsibility for clear communication lies with the engineer whoassumes the risk of ambiguity in his [sic] design drawings. Deutsch (1985)


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CAUSAL ANALYSIS OF THE DISASTER:ORGANIZATIONAL FACTORS CAUSES

On October 14, 1979, while the hotel was still under construction, more than 2700 square

feet of the atrium roof collapsed because one of the roof connections at the north end of

the atrium failed.

On October 20, 1979, G.C.E.'s Gillum wrote the owner, offering to undertake both an

atrium collapse investigation as well as a thorough design check of all the memberscomprising the atrium roof.

The management called in an independent engineering firm, Seiden-Page, to find the

cause behind the roof collapse.G.C.E. also investigated the roof collapse.

In order to save money, management neglected to have the rest of the building looked

over.

During testimony, G.C.E. stated that on three separate occasions they requested on-siteproject representation to check all fabrication during the construction phase

However, these requests were not acted on by the owner (Crown Center Redevelopment

Corporation), due to additional costs of providing on-site inspection.

The owner then declared the building safe after the investigation of the roof collapse.


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HYATT REGENCY WALKWAY COLLAPSE:

SOCIO-CULTURAL FACTORS

Role of Regulatory Mechanisms

Failure of either design to meet Kansas City Building Codes

following the American Institute of Steel Construction (AISC) standards.

The KCBD dictates that the minimum value for the mean ultimate loadcapacity for beams such as those in the Hyatt should be 151 kN.

Based on test results, the mean ultimate capacity of the single-rodconnection was approximately 91 kN, depending on the weld area.

Thus the ultimate capacity actually available using the originalconnection detail would have been approximately 60% of that expectedof a connection designed in accordance with AISC Specifications.

The second, modified and constructed design, therefore, only held 30%of the minimum weight put forth by Kansas City rules and regulations.

By mere calculations, the first design was obviously the more effectiveone even though it was faulty to begin with.

From the disastrous results, one can see the importance of having a

design that is structurally sound


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Study Faults Kansas City Building Inspection.

The New York Times, 7 Sept., 1981: 29

Experts at the International Conference of Building Officials (ICBO)conducted a lengthy, costly study of the Licensing and Inspection(L&I) practices of the Kansas City administers and inspectors

The study disclosed a number of deficiencies in the inspectionprocedures that were in effect when the walkways collapsed

It was discovered that the division of public works was not requiredto review all of the design changers

The study found that the city L&I codes administration division of thepublic works department rarely requires structural calculations for

a project and did not review all the design changes. The ICBO summary report said that the Kansas City L&I lacked the

expertise to keep up with its projects resulting from diminishedfunding and which led to hasty, neglectful instruction practices


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Summary of Causal Analysis:

Forensic Engineering Ethics

Structural Design Failure

Poor Management Communication

Mis-understandings in design modifications Inadequate attempts to properly review facilities for safety

purposes

Ineffective local and state regulatory system


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LEGAL RAMIFICATIONS

Deutsch Commission(1985):Report of the Administrative Hearing Commission,State of Missouri, Case No. AR-84-0239, Missouri Board for Architects, ProfessionalEngineers and Land Surveyors vs. Daniel Duncan, Jack Gillum, and GCE, Inc,Jefferson City, MO.

While Kansas City did not convict the engineers of criminal negligence due to lack ofevidence, the accident investigation concluded that G.C.E., in preparation of their

structural detail drawings, "depicting the box beam hanger rod connection for the Hyatt atrium walkways,

failed to conform to acceptable engineering practice. [This is based] uponevidence of a number of mistakes, errors, omissions and inadequacies containedon this section detail itself and of [G.C.E.'s] alleged failure to conform to theaccepted custom and practice of engineering for proper communication of theengineer's design intent."

Following the accident investigations, on February 3, 1984, the Missouri Board ofArchitects, Professional Engineers and Land Surveyors (MBAPELS) found Daniel M.Duncan, Jack D. Gillum, and G.C.E. Inc., guilty of:

gross negligence, incompetence, misconduct and unprofessional conduct in thepractice of engineering in connection with their performance of engineeringservices in the design and construction of the Hyatt Regency Hotel.


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LEGAL RAMIFICATIONS

Evidence showed that neither due care during the design phase, norappropriate investigations following the atrium roof collapse wereundertaken by G.C.E.

In addition, G.C.E. was found responsible for the change from a one-

rod to a two-rod system.

Further, it was found that even if Havens failed to review the shopdrawings or to specifically note the box beam hanger rod connections,the engineers were still responsible for the final check.

Evidence showed that G.C.E. engineers did not "spot check" theconnection or the atrium roof collapse, and that they placed too muchreliance on Havens.

As a result of the findings of the State as well as the MBAPELS,Duncan and Gillum lost their licenses to practice engineering in theState of Missouri (and later, Texas), and G.C.E. had its certificate ofauthority as an engineering firm revoked.


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Statement from the Deutsch Commission

There is no single procedure proscribed by the engineering

profession for review and approval of shop drawings. The ultimate

objective of any such shop drawing review procedure is to provide

assurance that all structural engineering work performed by others on

connections is done in accordance with acceptable engineering

practice and that a qualified design professional has either performed

such engineering work or reviewed such work prior to acceptance.

Engineering and design work on such connections should be

reviewed so as to determine that it is of such a quality as to assure

the engineer of record that such work was actually and properly

performed or thoroughly reviewed by himself or another professional

engineer.


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PROFESSIONAL RESPONSIBILITY FOR SAFETY IN DESIGN

It is always important that an engineer puts the safety of the public above all

else (Paramountcy Clause). G.C.E. failed to do this.

Violation of Due Care Principle

First of all, G.C.E.s original and second design of the walkway failed to meet

the requirements of the Kansas City Building Code 5 by not supporting therequired 151kN. The investigation ruled that this reflected negligence by GCE.

By failing to meet building codes, G.C.E. also failed to put the publics welfareabove everything else. Their design did not adhere to the ASCE EngineeringCode of Ethics.

The engineers failed to do a final check or even aspot checkof theirdesign. They neglected to check the safety and load capacity of the hangerconnection to begin with. Then, when Havens did change the design from asingle to a double hanger rod box beam connection, G.C.E. failed to look over

the shop drawings one last time.

The engineers failed to put the publics best interest first in this case.


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Violations of Principles of Professionalism

(1) Having and using appropriately sophisticated and theoretical

knowledge

This was not adhered to when the engineers created and approved

both the original as well as new designs(2) Serves the public good

This was a disaster!!They never serve the public good

(3) Organized by a special society or organization controlled by members

who set industry standards an draft codes of ethics

The engineers involved have done their profession a great injusticeby straying from top levels of technical competency and

irresponsible behavior


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Violation of ASCE Code of Ethics

Engineers shall hold paramount the safety, health, and welfare of the pubic in the performance of theirprofessional duties.

Violated from the very design stage and onto the construction stagethe change rendered thestructure hardly able to hold its own weight.

If the engineers were at all concerned with the potential risks the change would produce, the flawed

design might not have been constructed Engineers shall issue public statements only in an objective and truthful manner.

The attempts, by GCE, to accuse others of the faulty design and claiming the design change wasnot approved violated this code

Engineers shall act in such a manner as to uphold and enhance the honor, integrity, and dignity of theengineering profession.

The charge of gross negligence, incompetence, misconduct and unprofessional conduct in thepractice of engineeringgreatly tarnished the dignity and respectability of the engineering profession

Engineers shall not complete, sign, or seal plans and/or specifications that are not of a design safe tothe public health and welfare and in conformity with accepted engineering standards.

Routine computations should have revealed the inadequacy of the walkway supports

Violation of Standard of Care Principle Services performed in a manner consistent with that degree of care and skill ordinarily exercised by members of the

same profession currently practicing under similar circumstances.


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VIOLATIONS OF CODES OF ETHICS

The Engineers in the case violated the following ASCE Codes, which obligatethe engineer:

To accept responsibility in making engineering decisions consistent with the safety,health and welfare of the public

To disclose promptly factors that might endanger the public or the environment.

To seek, accept, and offer honest criticism of technical work, to acknowledge and

correct errors, and to credit properly the contributions of others. The engineering firm decided to make a change in the design of the ceiling

support rods, but the public safety was not kept as a primary objective.

The design of the support rods were not thoroughly checked to see if the initialdesign, or the re-design, would comply with the Kansas City Building Code formaximum load capacity.

The design of the suspended walkway support system was altered so as tosave money and time for the owner as well as for the contractors.

In actuality, both the revised and the initial designs for the support rods did notmeet the safety standards.

Soon after the disaster, the ASCE formally adopted a statement that statesstructural engineers have full responsibility for design projects


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ASCE Disciplinary Hearing

In 1985, the board of the ASCE found the

Engineer of Record (EOR) vicariously responsible

for error in shop the drawing process, but notguilty of gross negligence or unprofessional

conduct

His membership was suspended for a period of 3

years As a result of the Hyatt Regency Walkways Collapse, ASCE adopted a report

that states structural engineers have full responsibility for design projects.


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ETHICAL ANALYSIS OF THE CASE

The responsibility for, and obligation to, design steel-to-steel connections

in construction and issues of negligence and an engineers designresponsibilities lies at the heart of the Hyatt Regency Hotel project

controversy. A typology of Responsibility

The design engineers are at (moral) fault for improperly designing the rod

and not checking the shop drawings to make sure they would adequately

support the walkways.

The fabricators are at (moral) fault for not realizing that the design that they

had modified and assembled would not be enough to hold up the walkways.

The owners of the hotel are at (moral) fault because on three separate

occasions requests were made for on-site inspections that could have

revealed the problem while it was still being built.


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Responsibility of Design Engineers

Possible reasons for design engineers agreeing to the design change:

fast-tracknature of the projectcommon-place practice in theconstruction industry to begin actual construction of a building before the

design work is completed, primarily to avoid the effects of rising

construction costs during the design and construction periods saving time;

saving money;

avoiding a call for reanalysis, thereby raising the issue of a request to

recheck all connector designs following the previous year's atrium roof

collapse; following his immediate supervisor's orders;

looking good professionally by simplifying the design;

misunderstanding the consequences of his actions; or

any combination of the above.


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When the engineer's actions are compared to professional

responsibilities cited in the engineering codes of ethics, an abrogation

of professional responsibilities by the engineer in charge is

demonstrated.

The engineers at GCE had a professional obligation and duty to take

into consideration the possibility that Havens Steel may have

overlooked a problem with the design or design change

Due Care Principle

The process in which GCE revised and approved their drawings had tobe deficientif the design had gone through the requiredprocessmeetings,the fatal flaw may have been detected and the disaster mayhave never occurred


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Drafting errors in transcribing the conceptual detail of the connectionfrom the designers detail to the drawing

Checking errors by not verifying the detailed connections

Outside peer review, following the atrium collapse did not check shopdrawings

In-house design check questions following the atrium collapse were notverified

The engineer relied on the fabricator to design the connection as well asall other steel-to-steel connections in the atrium (Was this the industry

custom at the time?) The fabricator transferred partially completed shop drawing details to an

outside firm to complete

The firm assumed that the connection was the final design


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Responsibility of Fabricators and Contractors

Design by fabricator judgment was motivated by:

Strict adherence to the structural drawings,

as prescribed by the AISI manual,

under the fabricators discretion. The materials selected for the fabrication were standard

strength, size, and grade of material, rather than what

should have been used to compensate for the added

stress of the altered design.


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Responsibility of Crown Redevelopment Corporation

Failure to issue full on-site inspection of

hotel construction after the collapse of the

atrium roof months earlier


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The Hyatt Regency Case and the Utilitarian Logic

of Ethical Reasoning


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The Hyatt Regency Case and the

Logic of Deontology in Ethical Reasoning


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Logic of Contractarianism in Ethical Reasoning


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Logic of Virtue in Moral Reasoning


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Lessons Learned

The Hyatt Regency walkway collapse:

Resulted in a nationwide re-examination of building codes and the subsequentdevelopment of more stringent guidelines in the design and construction of structures

Engineered structures such as buildings, bridge, etc. are now inspected much more carefullyand the design plans examined more carefully

Led to to substantial changes in professional codes on structural engineering andconstruction management practices

The disaster could have easily been avoided/prevented had structural engineersexamined their designs, plans, and construction and communication practicesmore carefully

Draws attention to the need for more extensive licensing and certification in the

engineering fieldsit should be required for work in business and industry (theindustry exemption approach is wrong!)

Periodic recertification for license renewal

The case is applicable, not only, to structural, materials, construction, andarchitectural engineers, but to all engineers who are responsible for development anddesign of products and systems that involve interaction with the public


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Lessons Learned

The case underscores the risk factor in poorly organized communications systems incivil engineering and in the construction industry

Illustrates the need for uniform understanding of the means by which specificresponsibilities are communicated from one member of a construction project teamto another

The case helps identify areas of overlapping responsibility for design and indicated theimportance of developing procedures for assigning tasks and reviewing work on severallevels and at various stages in project design

Responsibility issues in all fields of engineering can be effectively resolved only by adhering tothe principle that responsibility and authority must be exactly identical

It draws attention the the need for better role definition and unambiguous understandingof technical responsibility within the engineering professions

There must be common rational agreement about role definitions and clearconsensus about designations of particular tasks associated with each role

The case sharply focuses on the essential ethical and professional responsibilities ofstructural engineers as they assume overall responsibility for their design

Accident analysis is meaningful only to the extent that other engineers learn somethingabout failed engineering design or innovation

The lessons the case teaches must add to the general knowledge of the profession and

guarantee that no accident like it ever happens again.


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Lessons Learned

The confusion resulting from undocumented telephone approvalsdemonstrates the clear necessity of keeping track of important decisionsmade in informal channels of communications such as telephoneconversations

All professionals should keep written records of critical communications toinsure that

design intent is clear

that the interests of safety are served

To protect against legal liability in cases where something goes wrong

A peer review should involve formal review of each and every detail on the

structural drawings, as opposed to spot checking to get an overall feel forthe quality of the design

The peer review should encompass connection details as well as primarystructural systems and elements, even if this means that the peer reviewer muststudy all shop drawings

Changes in concept, however small or seemingly insignificant, should be handledthrough a formal process that forces participants to focus on all the details


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Questions

1. To what extent did Gillum and Duncan consider the relevant moral issues beforedeciding to act and behave in certain ways? If asked, what moral justification doyou think they would give for their reasons for acting the way they did? Howwould you morally evaluate their conduct?

2. What specific provisions of the ASCE Code of Ethics were violated in this Case?

The NSPE Code?3. Should Gillum and Duncan be allowed to practice engineering in other states?

What moral principles underlie your judgment?

4. Who is ultimately responsible for checking the safety of final designs as depictedin shop drawings?

5. Although the engineering firm (GCE) was found ultimately accountable for the

disaster, does that take the fabricating firms (Havens) engineers or managersoff the (moral) hook? What moral principles justify your judgment?

6. In terms of meeting building codes, what are the responsibilities of the engineer?The fabricator? The owner?

7. Even if responsibility rests with the fabricator for violating building codes, wouldthe engineers involved in the case be off the hook?


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Questions

1. What measures can professional societies such as the ASCE, ASME, NSPE, etc. take toensure that catastrophes like the Hyatt Regency do not occur? What moral principlesunderlie your judgment?

2. What responsibility, if any, does the steel fabrication company, Havens Steel, bear towardthe disaster? What liability, if any? How doe you evaluate their conduct from a moral

perspective? What moral principles ground your decision?3. What responsibility, if any, does the Crown Center Redevelopment Corporation, bear for

the disaster? What liability, if any? How doe you evaluate their conduct from a moralperspective? What moral principles ground your decision?

4. What responsibility, if any, does the construction, bear for the disaster? What liability, ifany? How doe you evaluate their conduct from a moral perspective? What moralprinciples ground your decision?

5. How does Dr. Edward O. Pfrang, director of the NBS, finding thatthe changes made inthe design made the structure considerably easy to buildand this time and labor savedprovided a financial incentive for the Steel Company.effect your moral analysis of thecase?

6. Given the distinction betweendesign workanddevelopment work,who do you think ismore responsible for the disaster, the design engineers or the steel fabricators? Howwould you evaluate their conduct in terms of ethics?


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Questions

1. Do you agree with this statement:The negligence of the designers, fabricators, andbuilding inspectors have done the citizens of Kansas City a great injustice by sacrificingtheir safety and well-being for a quick and easy building procedure.

2. Respond to this statement:The failure involved not a basic architectural concept buta small detail, and yet it killed more people than any other building failure in the United

States. If there is any lesson in it, it is that we musts consider every detail.3. How many opportunities were there to discover the design-communication errors before

disaster struck? What does that tell you about the need for national standards in theconstruction engineering industry?

4. The 1983 Administrative hearing found the parties innocent of any illegal wrongdoingbecause they determined that the engineers involved where not aware, at any time, ofthe design problems and so did not cover any thing up ofdeceive.Do you agree or

disagree with this ruling?5. Some argue that engineering is not a profession because engineering experiments fail

with disastrous consequences much more frequently in the engineering professions ascompared to professions such as medicine and law. Such disasters would never betolerated in medicine and law. IF they did, the individuals involved would be seriouslypunished. What does this tell us about the the status of engineering as a profession?

About the lack of effectiveness of professional engineering societies?


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QUESTIONS

Respond to this sentence: This case is a case of communication

failure, not one of engineering negligence or malpractice.

Could it be both a communications failure as well as faulty engineering

practice? Thought for reflection: Duncan and Gillums license revocation may be

a first in the history of engineering self-regulation, but did it start a new

era of social responsibility in structural engineering practice?

hyatt regency walkway collapse

Documents

walkway floors

thehyatt project

long suspension rods

lower beams

room hotel project locatedat

wide flange beams

basic design

proposed design