The Importance of Disaster Investigations for Systems Engineers

The Importance of Disaster Investigations for Systems Engineers

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The Importance of Disaster Investigations for Systems Engineers

- What is a Systems Engineer?

In the modern industry engineering systems are becoming more complex
by the day. Therefore a need for elite engineers i.e. the Systems
Engineer, capable of applying a wide range of engineering disciplines
to a variety of tasks from product design and development from
requirements analysis to simulation to manufacturing and marketing
etc… is essential.

Such engineers work within a team at the heart of the organisation
where the design and development of a project is carried out. At this
stage it is of great importance that every aspect of the design is
studied accurately in order to ensure the final product works
effectively, efficiently and safely. However, although maximum effort
is made during the design, it is impossible to produce a result 100%
efficient. This unfortunately leads to the occurrence of accidents and
in some extreme cases to a disaster. By carrying out investigations
into the disasters and their causation, lessons can be learnt and
employed in future designs. This allows the team of engineers to
improve the performance and efficiency of the system whilst
maintaining the maximum safety levels.

- Disasters and why they happened?

- Air disasters caused due to faulty design:

There have been historically countless cases of confusion in handling
the flaps and the gear controls on the DC3 aircraft as they are in
close proximity to each other and of similar shape. This is a problem
that should have been addressed by the system engineers before the
final go ahead for production was approved considering the importance
of such instruments and their role during the flight of the aircraft.

- Challenger disaster caused due to faulty design:

This incident saw the destruction of the United States space shuttle
Challenger 73 seconds after take-off from the Kennedy Space Centre on
January 28, 1986 killing the entire shuttle crew.

The disaster was caused by the failure of an "O-ring" seal in the
solid-fuel rocket on the shuttle's right side. The seal's faulty
design and the unusually cold weather, which affected the seal's
proper functioning, allowed hot gases to leak through the joint.
Flames from inside the booster rocket escaped through the failed seal
and enlarged the small hole. The flames then burned through the
shuttle's external fuel tank and cut away one of the supports that
attached the booster to the side of the external tank. The booster
broke loose and collided with the tank, piercing the tank's side.
Liquid hydrogen and liquid oxygen fuels from the tank and booster
mixed and ignited, causing the shuttle to tear apart.

It is quite clear from this example that had the design of the ring

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been suited to the environment in which it was to be used then such a
disaster could have been prevented.

- The Hillsborough disaster:

On the April 15, 1989 at the Sheffield Wednesday Football stadium the
worst disaster in British sporting history took place. The match was a
FA Cup semi-final between Liverpooland Nottingham Forest. The tragedy
occurred when police opened a main gate into the terraced area to
relieve pressures caused by a build up of people at the entrance
allocated to the Liverpool supporters. This caused a flood into the
packed terraces and people were crushed against the perimeter gates.
In total 96 Liverpoolfans lost their lives and another 400 were

The cause of this disaster proved to be a combination of human error
and faulty design. Primarily due to the poor and inefficient ground
control and crowd management system, and secondly the existence of
ground design faults which prevented the crowds from exiting the
stands in the event of an emergency. As a result football stadiums are
now designed without fences around the pitch and standing terraces
have been abolished.

How do Systems Engineers learn from disasters?

We are now going to take a look at a disaster that has occurred in the
past and see how this relates to the design cycle (Fig.1.1). By doing
this, the importance of feedback from disaster investigations for
systems engineers and how the information is incorporated will be

We will use the Chernobyl disaster as an example to relate to the

April 26, 1986saw the world's worst known nuclear reactor disaster to
date. The problem arose from an improperly supervised experiment
conducted at a nuclear plant in a Ukrainian town, Chernobyl, located
approximately 130 km north of Kiev. The experiment was undertaken with
the water-cooling system turned off which led to an uncontrolled
reaction, that in turn caused a steam explosion. The reactor's
protective covering was blown off, and approximately 100 million
curies of radionuclides were released into the atmosphere. Some of the
radiation spread across northern Europe and into Britain. Around 31
people died as a result of the accident, but the number of
radiation-caused deaths is yet unknown although expected to be much

Systems engineers are situated in the design area and are involved
with the organisations accumulated knowledge, process engineering,
codes of practice and tests and reviews.

The Chernobyldisaster problem originated in the operational management department. The approval of the experiment defied the organisations policies that no
activity should been undertaken without proper supervision. This
action from senior management allowed inexperienced staff to handle
very dangerous equipment. With practically no training in operating or
emergency procedures it was inevitable for disaster to strike. The
operators proceeded with the experiment and due to a misunderstanding
of the process instructions caused an explosion to take place that
polluted the environment with nuclear radiation.

So how does this feedback affect the Systems Engineer?

From this example we can see that the main fault rested with the
management section however the design and operating conditions of the
equipment can also be taken into consideration.

The way the equipment operates could be modified in order to cater for
human error. In this case for safety reasons for instance:

- The set up of the machinery could be designed to satisfy a computer
checklist before the reactor will function.

- Another possibility could be the aid of a computer i.e. automation
that would interact in the case of an emergency by either shutting
down the system or making the necessary changes to other machinery.

These are just a couple of possible considerations that system
engineers could bear in mind for future designs. Basically we are now
not only having to design the system but also design it against
possible short cuts that operators will take. Ignorance and human
errors are aspects of life which may be controlled but never

Designing to prevent:

To prevent disasters from happening there are a wide range of factors
to take in to consideration as we have seen. The information from
investigations has proved to be a crucial asset to the systems
engineer whose responsibility is on going as these systems become more

Unfortunately the best why we can prevent an incident occurring is by
learning from someone else's mistake.

Below is a short list of lessons learnt that hopefully will help
engineers in the future during the designs process:

- Primarily design for the environment and the operator, and secondly
for the task.

- Reduce the amount of stress inflicted on the individual as it has
been shown that where high levels of stress exist, errors are more
likely to occur.

- Design against human short cuts that could possibly have disastrous

- Use feedback from previous events to modify future designs.

- Ensure operating procedures and instructions exist and are

- Staff must be trained in every aspect of their operating condition
and in the event of an emergency should have a good understanding of
safety procedures.

- Ensure maintenance can be effectively carried out.

- The conditions of the working environment will have a serious
effect, for example a pilots performance will be effected if say the
cockpit has improper lighting or if the control panels vibrate due to
the aircraft's propulsion.


- The Microsoft Encarta Encyclopaedia 98

- The Cambridge encyclopaedia

- Lesson from disasters. Trevor Kletz

- Engineering psychology and human performance. C D. Wickens
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