EE15N: The Art and Science of Engineering Design Lecture 7: Why Things Fail

1. EE15N: The Art and Science of Engineering DesignLecture 7: Why Things Fail • Announcements: • Due tonight at 11:59PM: Weekly team meeting summaries, Morph Chart. Optional: Prototype/model/proof of concept • When Bad Things Happen To Good Projects • Case Study: • Gulf of Mexico Oil Spill, April 2010 • Group Exercise

2. Definition Of Failure According to Random House Dictionary, Failure is defined as: • Nonperformance of something due or expected. • Insufficiency. • Deterioration or decay. • Person or thing that proves unsuccessful.

3. Engineering Classification Of Failure • Definition Of Failure: • Inability of a component, structure, or facility to perform its intended function. • Types of Failures: • Safety Failure: involves death, injury, or placing people at risk. • Function Failure: involves compromise of intended usage of structure or facility. • Ancillary Failure: includes factors that perversely affect schedules, cost, or intended use. Source: David W. Fowler, The University of Texas at Austin, Forensic Engineering: Detective Engineering

4. Causes Of Failures • Insufficient knowledge 36% • Underestimation of knowledge 16% • Ignorance, carelessness, negligence 14% • Forgetfulness, error 13% • Relying upon others without sufficient control 9% • Objectively unknown situation 7% • Imprecise definition of responsibilities 1% • Choice of bad quality 1% • Other 3% Source: Department of Materials Science and Engineering, State University of New York at Stony Brook, Engineering Disasters and Learning from Failure

5. Dealing With Failures • Acknowledge failures: • Failures happen. • Acknowledge, Analyze, & Advance. • Learn from failures: • There is the greatest practical benefit in making a few failures early in life. Thomas Henry Huxley, On Medical Education - 1870 • Benefit from failures: • Historians have uncovered new evidence of Edison’s enormous talent for appropriating techniques that failed in one instance and using them to great effect in another. Seth Sullivan, Unlocking the Legacies of the Edison Archives, Technology Review, Feb/Mar 1997

6. Learning From Failure: Hubble Space Telescope • In 1990, first images sent from telescope back to Earth was fuzzy. • Problem was result of a human error made years before launch: telescope’s mirror had been grounded into the wrong shape. • Mirror was tested prior to launch and functioned properly on its own. • Manufacturers relied on computer simulations to determine that separate components would work together. • Simulation did not take into account the possibility of misshapen mirror.

7. Learning From Failure: Galaxy 4 Satellite • In 1998, Galaxy 4 Satellite spun out of position • Disrupted radio, television, pager, bank machine, & other satellite services across North America. • Satellite did not return to service. • Failure due to one unresponsive computer component on satellite. As communications technology has rapidly advanced, the ability to concentrate ever-greater amounts of information into single satellites, cables, and other systems has grown enormously. This has brought great economies, but also has geometrically increased the impact of failures. Lauren Weinstein, National Public Radio

8. Benefiting From Failure: 3M’s Post-It Notes • In the early 1970s, Spencer Silver tried to develop a strong adhesive for tape. • Didn’t succeed. Only create a weak adhesive. • Arthur Frye thought of using adhesive to create a new type of bookmarks. • One that would not damaged the marked page. • From bookmark idea, new type of notes was created. • Silver’s failed adhesive is the key ingredient of 3M’s best-selling product.

9. Gulf of Mexico Oil Spill US Coast Guard Photo – Oil Spill Presidential Commission Report

10. Basic Facts • Location: Mississippi Canyon Block 252, Gulf of Mexico, United States • Direct Cause of Explosion: Failure to contain hydrocarbon pressures in well • Spill timeline: • Explosion: April 20, 2010 • Leak Stopped: July 15, 2010 • Well Officially Sealed: September 19

11. Damage • 13 deaths, 17 injured • Amount of oil spilled: Up to 4,900,000 barrels or 206,000,000 gallons • Area affected: 2,500 to 68,000 square miles Largest accidental marine spill in history of petroleum industry

12. Basic Techniques of Deep Sea Oil Drilling http://en.wikipedia.org/wiki/File:Pump_Jack_labelled.png

13. Problem & Barriers Mistakes and failures to appreciate risk compromised each of those potential barriers, steadily depriving the rig crew of safeguards until the blowout was inevitable and, at the very end, uncontrollable • Problem: Failure to contain hydrocarbon pressures in well • Barriers: • Cement at bottom of well • Mud in well and riser • Blowout Preventer (BOP)

14. Blowout Preventer http://www.glossary.oilfield.slb.com/DisplayImage.cfm?ID=300

15. Problems with Cementing • Casing • Long string vs. liner • Number of centralizers • Float-valve • Anomalous pressure readings • Quality of Cement • Foam cement testing

16. Problems with Temporary Abandonment • Negative-Pressure Test • Conducted and interpreted improperly • Replace mud with seawater • Placed more stress on cement at bottom of well • Set cement plug 3,300 feet below mudline • Displace mud from riser before setting surface cement plug or other barrier

17. Problems with Blowout Prevention • Kick Detection • Crew missed or misinterpreted signals • Replace mud with seawater • Placed more stress on cement at bottom of well • Well not sealed by Blowout Preventer • Emergency Disconnect System (EDS) did not work • BOP Automatic Mode function (Deadman system) failed possibly due to poor maintenance

18. Presidential Commission Conclusions Overarching Management Failures by Industry Regulatory Failures by Government

19. Failures by Industry BP’s management process did not adequately identify or address risks created by late changes to well design and procedures. Halliburton and BP’s management process did not ensure that cement was adequately tested. BP, Transocean, and Halliburton failed to communicate adequately. Transocean failed to adequately communicate lessons from an earlier near-miss to its crew. Decisionmaking processes at Macondo did not adequately ensure that personnel fully considered the risks created by time- and money-saving decisions.

20. Failures by Government Government failed to provide the oversight necessary to prevent these lapses in judgment and management by private industry. Efforts to expand regulatory oversights, tighten safety requirements, and provide funding to equip regulators with the resources, personnel and training needed to be effective were either overtly resisted or not supported by industry, members of Congress, and several administrations. MMS lacks personnel with the kinds of expertise and training needed to enforced those regulations effectively.

21. Other Causes of Failure*:Management 101 • Insufficient of knowledge 36% • Underestimation of knowledge 16% • Ignorance, carelessness, negligence 14% • Forgetfulness, error 13% • Relying upon others without sufficient control 9% • Objectively unknown situation 7% • Imprecise definition of responsibilities 1% • Choice of bad quality 1% Other Causes of Project Failure • Lack of clear definition of success • Inability to adapt • Failure to identify/communicate with customers • Poor/no communication between design teams • Lack of project leadership • Conflicting goals for people in leadership positions • Many others From material science dept.

22. Group Exercise • Suppose you are building a complex engineering system, for example • A station to live on Mars • A robotic device to do heart surgery • An automated highway system • The new world trade center in New York City • Chose your own For your choice of system, what is most likely to fail and how would you design the system to avoid such failures.

23. Guest Speaker Judith Estrin JLabs