NPPE: IMPORTANT, Case History Summary from the Book of CANADIAN PROFESSIONAL ENGINEERING AND GEOSCIENCE PRACTICE AND ETHICS

In previous posts, we had a series of discussions about NPPE, you can find them here,


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Below lists the summary of those major case history from the book of CANADIAN PROFESSIONAL ENGINEERING  AND GEOSCIENCE PRACTICE AND ETHICS, to help you preparing the NPPE exam. It is recommended that you remember the name of the cases and the lessons learned from those cases. 


Case History

1.   THE QUEBEC BRIDGE DISASTER

Opened in 1919, the longest cantilever span in the world. Bridge was redesigned with a larger span and the dead weight calculations were not re-done. Then, there was a material failure in a bearing casting that temporarily supported the central span while it was being transported and lifted into place.

Lessons Learned:

·         You have to have enough money to pay all the people to do their jobs properly for large projects before you start them. (Mr. Cooper was not paid nearly enough to do the extra work to re-design nor was he really competent)
·         Hire capable competent professionals (not old or sick that can’t visit the construction site)
·         Clearly define duties, authorization and responsibility of professional personnel.
·         Discuss all design decisions and technical problems openly and listen receptively. (For 3 weeks, the chief engineer tried to contact Cooper about the strange bending of some steel parts and recommended some changes be made…Cooper didn’t listen)
·         Review details, especially engineering design calculations.  (Cooper did not re-do the calculations for dead weight after he changed the length of the structure.)
·         Monitor work on the site adequately.  (Cooper was too old and sick to monitor any of the building or fabrication)
·         Ensure that communication is rapid and accurate.  (It took 3 weeks for the chief engineer to reach Cooper with his concerns)

·         Provide adequate support staff for good money.

2.   THE VANCOUVER SECOND NARROWS BRIDGE DISASTER

June 1958, two spans of the cantilever bridge collapsed.

It was caused by the faulty design and eventual collapse of a temporary tower supporting the partially completed bridge.

The additional time and material needed to reconstruct the damaged portions of the bridge.

Lessons Learned:
·         Consulting engineers should recommend allowable stresses for temporary construction support structures.
·         The contractor should be required to submit all construction plans and calculations for approval prior to construction.

3.   THE WESTRAY MINE DISASTER

May 9th, 1992, mine blew up and killed 26 miners.

The floor, roof, and sides of the road should have been cleared and treated with stonedust  and proper ventilation procedures should have been followed despite delayed production.
  
Lessons Learned:

·         Production demands resulted in the violation of basic and fundamental safe mining practices.
·         Management ignored or encouraged many hazardous and illegal practices including 12-hour work shifts, improper storage of fuel, refueling vehicles underground, using non-flameproof equipment.
·         The methane gas from the coal needed to be properly ventilated out of the mine.
·         Proper permits and changes to the mine plans were not approved by the proper authorities.
·         Written orders to stonedust and to clean up the mine were not followed.
  
4.   THE LODGEPOLE WELL BLOWOUT

October 17th, 1992, a sour gas Amoco well blew out and they could not get it back under control.

The initial kick occurred primarily because drilling practices during the taking of cores were not followed, and this combined with the marginally adequate mud density used, permitted the entry of reservoir fluids into the wellbore.

They lost control of the well, and then it started on fire from some Muskeg that was burning underground.

There were also some equipment failures that attributed to not being ale to circulate the kick out quick enough

Lessons Learned:

·         Amoco did not apply the necessary degree of caution while carrying out operations.
·         Needed to be fully prepared in the event of a fluid influx.
  
5.   THE BRE-X MINING FRAUD

The samples had been “salted” – adding minerals like gold where none exist.

Lessons Learned:

·         The chief geologist had a responsibility to show due diligence in safeguarding the core samples and ensuring that the gold assay was properly done.  That the gold content, based on the samples, was accurately calculated and that the double-checks were made to confirm the results.

·         This emphasizes the critical dependence of the mining and resource industries on professionals with high ethical standards.
  
6.   THE CHALLENGER SPACE SHUTTLE EXPLOSION

On January 28, 1986, the accident was caused by hot gases blowing past one of the seals in the rocket boosters.  The seal had been unable to do its job properly because of the unusually low temperature in Florida on the day of the launch.

The manufacturer of the boosters, had this information but had decided to go ahead with the launch anyway.

 Lessons Learned:

·         In an enormously large organization, it is easy for decision making to fall through the cracks.

·         It is very easy for engineers to fall into the comforting belief that they are following a conservative course, when in fact they are deviating into dangerous territory.

·         Disasters are easy to create – safety comes hard.
  
3.     THE DC-10 PASSENGER AIRCRAT DISASTER

In 1972, a cargo door latch failed and the door blew out of a DC-10 over WindsorON and the explosive decompression of the cargo compartment caused part of the cabin floor to collapse.

This opened a large hole in the bottom of the fuselage and severed most of the hydraulic lines which caused the loss of control of the rudder and ailerons.  Everyone landed safely that day.

In 1974, another DC-10 over Paris, lost its cargo door.  The decompression of the cargo compartment again caused the cabin floor to collapse; control of the ailerons and rudder were lost, and the plane crashed, killing 346 people.

Lessons Learned:

·         The FAA failed in its role of safety watchdog.  It certified the cargo door design in spite of the failure during the ground test.  Then after the near-disaster over Windsor, they merely advised the airlines to follow the manufacturer’s service bulletin rather than issuing a directive that would have required all DC-10’s to be retrofitted.

4.     TOXIC POLLUTION: LOVE CANAL, MINAMATA, BHOPALSUDBURY

Improper disposal of toxic or environmentally harmful waste.

Love CanalNew York – Dioxin
·         In 1953, Hooker Chemical Corporation dumped over 18,000 tons of chemical waste, including dioxins until the canal was flat land again.
·         Then, they donated the land to the Board of Education but said nothing about the chemicals buried there.
·         Eventually, the chemicals were discovered in 1976 and the area was evacuated and treated.
·         Total cost of the cleanup was $250 million and Hooker wasn’t liable for any of it because of their contract when they donated the land.

Minamata BayJapan – Mercury Poisoning
·         In 1932, the Chisso Company, a nitrogen fertilizer company began producing acetaldehyde.  Mercury was needed as a catalyst.
·         During the production process, a portion of the mercury was lost – washed into the Bay with the waste water.
·         The organic mercury was absorbed by the shell fish, and eventually eaten by people.
·         By 1962, it was estimated that about 2900 people had contracted Minimata disease.

BhopalIndia – Methyl Isocyanate
·         In 1984, a poisonous cloud of methyl isocyanate gas escaped from the Union Carbide plant killing thousands of people up to 6 km away.
·         The incident happened when a worker was cleaning a pipe with water and the water mixed with the chemicals and over pressured the tanks causing them to release the gas.
  
SudburyOntario – Sulphur Dioxide
·         Nickel that is mined in Ontario is in the form of sulphied ore, and cannot be directly converted into metallic form.  It must first be smelted – burned to remove the sulphur which is done in huge “open roasts” which emitted huge toxic clouds of sulphur dioxide.
·         Sulphur Dioxide when dissolved in water, became acid rain.
·         This devastated the area around the plant; trees are stunted and sparse, lakes have no fish, no bird life.
·         Since then, about 3000 hectares have been reclaimed.
  
Lessons Learned:

·         Each of these incidents involves ignorance, carelessness, or incompetence, and most involve an arrogant lack of ethical action.
·         Consequences of negligence can be terrifying.
  
5.     NUCLEAR SAFETY

Three Mile Island

March 28, 1979, a routine maintenance operation, a pressure valve stuck open, allowing radioactive water to escape from the system for more than 2 hours leaving the reactor core partially uncooled.

More than 1/3 of the reactor core had melted and fallen to the bottom of the reactor vessel.  Thank goodness, the molten mass did not burn through the bottom of the reactor to penetrate the ground water table. (in a cynical version of this story, the molten mass continues to burn through the interior of the earth until it emerges in China (The China Syndrome).

It was not a disaster for the public, but the unit was destroyed and the clean-up cost nearly $1 billion.
  
Chernobyl

April 26, 1986, reactor number 4, exploded releasing a huge cloud of radioactive plutonium, cesium, and uranium dioxide into the atmosphere.

Accident occurred during a low-power test.  Because of the design, during lower power, the water in the core decreases.

To date, the number of related deaths is between 7,000-10,000.  They waited days, even weeks to admit that it had exploded and they took even longer to evacuate the people.

Lessons Learned:

·         The possibility of disaster might be very small, but it is not zero.
·         Such responsibility should never be treated casually.

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