What do Opal Tower and Swiss Cheese have in common?
What do the recent failure with the Opal Tower residential development and swiss cheese have in common?
The Swiss Cheese Theory is a risk management approach for complex systems prone to human error. The theory is often applied to prevent accidents in the workplace and keep people safe. System layers need to be coordinated to prevent failure. If something falls through one hole, it’s OK. Another layer will catch it and prevent an unwelcome incident. But if it falls through multiple holes, it can be catastrophic.
The fact that a new residential building is uninhabitable and dangerous months post completion highlights a system with too many holes. Such a system isn’t resilient to change, like a housing boom increasing demand.
As buildings have become more complex (or ‘smarter’), the building and construction industry has become increasingly fragmented. There are now many more contractors and sub-contractors involved in a single project than ever before. The design, construction and operation have become separate industries. Each requires contractors with very specific technical knowledge, without sufficient bridging between layers. Once each party is done with their specific niche, they are onto the next project.
Increased complexity in buildings inevitably brings increased risk for failure.
I see the issues when I go into buildings to complete post-occupancy evaluations. These are completed once it is occupied and past the defects liability period. The intended design of a building rarely matches operational performance. This is a useful feedback loop often not completed because it doesn’t fall within one of the niches. Without this process it is difficult to learn what went right or wrong. Issues are swept under the rug (which by the way is covering the underfloor air distribution system that isn’t working properly). Some just don’t want the headache of dealing with any problems, but not facing this head-on can turn a molehill into a mountain.
The circle of blame is ever present in building and construction. A poor outcome is the fault of the architect’s unrealistic design, the engineer’s over-engineering, the developer’s cost cutting, the client’s impossible demands, the LGA’s clunky design approval, the certifiers’s processes, on and on it goes.
Some eyes are rolling at calls for an industry review. But continuing to try and pin the blame on one party (in Opal Tower case the certifiers) won’t solve the issue. It is a challenging time in the industry. Profit margins are low. As well as managing the growing number of contractors involved, a lot of this comes down to bidding wars to win work. Prices are often not adequate to manage the complexity, impacting quality.
The whole supply chain needs to be considered. If a plane was forced into an emergency landing there would be an exhaustive review to uncover the issues and ensure it doesn’t happen again. The airline industry can also handle increased demand without system failure.
So how can we build a more resilient system? This one is for another blog, but a few places to start:
Objective, consistent and rigorous design review (influencing stronger briefing processes)
Keep it simple. The focus on new technology, new materials and big data drives up cost, but doesn’t always deliver operational improvements. A truly smart building must be flexible and consider how this technology integrates and changes.
Nail the governance for post-operational performance. This has been largely voluntary with low rates of adoption. Existing frameworks (such as Soft Landings) are great foundations.
A focus on diversity to refresh decision making and offer innovative perspectives to the current BAU. Some interesting research here from UNSW on the construction sector.