1. Presented By Jack D. Gillum, P.E. Configuration Management Benchmarking Group Conference June 6 – 9, 2004 Kansas City, MO © 2004 CMBG Hyatt Regency Walkway Collapse “A Personal Perspective & Insight” Presented By: Jack D. Gillum, P.E.

2. Two Walkways Collapsed 114 People Lost Their Life Failure of Hanger Rod Connection (4th Floor) Kansas City Hyatt July 17, 1981

7. OWNER: Crown Center Redevelopment Corp. DESIGN TEAM: ARCHITECTS Patty Berkebile & Nelson Herbert Duncan Monroe - Lefbvre Marshal & Brown STRUCTUAL ENGINEERS: Gillum Colaco Concordia Project Management Havens Structural Steel Eldridge & Son Construction General Testing Laboratories The Team Owner/Design & Construction Team

8. Entrance Hyatt General Layout

9. Entrance to Hotel and Atrium Kansas City Hyatt

10. 29 N Tower Function Block 4 TH & 2 ND FLOOR BRIDGES 3 RD FLOOR BRIDGE Bridge Plan

11. 29’ -Typical 15’-2+” 4@ 29+=120’ Atrium Roof Plan

12. 29 2929 N Guest Tower Function Block Atrium Connections Des. by Fabricator Physical description – Bridge Plan

13. Fast Track Project Project Engineer Leaves Project Designer Leaves QC Problems during construction SE request to perform inspection: Refused Screen Wall Changes Bridge Hanger Changes Portion of Atrium Roof Collapsed Walkway Bridge Collapsed Major Events Occurring Design Phase CHRONOLOGY OF EVENTS

14. CHRONOLOGY TIMELINE 1976 - MID 1977 Schematic Design (750 Rms, 35 Flr, 120’ Atrium Jan 1978 Fast-Track Design/ Construct-Contract w/GC

15. CHRONOLOGY TIMELINE April 1978 Structural Contract “All Structural Eng. Serv.” Jan - Aug 1978 Design continues during construction SE requested owner to be retained for inspection services DENIED

16. 29 N Guest Tower Function Block Atrium Connections Des. by Fabricator Physical description – Bridge Plan

17. No rod size No reaction No rod strength Design Phase – Bridge Connection Evolution

18. Changes During Shop Drawings Requested two rods by phone Approved by phone with caveat “submit through channels” Design Drawings v.s. Shop Drawings The shop drawings are checked by a technician who did not work on the project. Questions are raised about the strength of the rod

19. THIS CONNECTION WAS NEVER DRAWN NOR SUBMITTED FOR APPROVAL CONNECTION AS BUILT

20. Summer 1979 Erection of Steel for Atrium Contractor omits embedded inserts in Concrete for steel connection Needs to be modified by Engineer Owner (again) refuses Engineer request for field representation third time Owner fires testing lab due to poor performance during inspection of const. Chronology (Continued)

21. Construction Collapse / Design Checks Problems at connections along expansion joint at the interface between steel and concrete structures

22. Chronology (Continued) October 1979 Atrium roof collapse Deficiencies in modified construction at concrete/steel interface discovered Engineer initiates in-house check of Atrium roof Outside Peer Review Initiated & Completed

23. ATRIUM ROOF:STEEL TO CONCRETE CONNECTIONS Engineer Designed & Modified

24. Problems at the screen wall are uncovered EOR in-house check EOR issues correction details for screen wall Screen wall corrections are made in the field Problem with the bridge connection is not discovered Independent design check and field inspection does not uncover either error Construction Collapse / Design Check

25. * DURING THE SHOP DWGS Horizontals supporting splice points are moved for architectural reasons. The splice points on the truss drawings are not moved Design Phase – Screen Wall Changes

26. Chronology ( Continued ) Late-1979 to July 1980 Gen’l Contractor goes bankrupt and Crown Center takes over as contractor using personnel of Gen’l Contractor July 1980  Hotel Opened July 17, 1981  Walkway bridges collapse

27. Double rod connection failed Connection that failed was never shown on ANY drawings!! Engineering or Detailer Connection that failed was never designed Bridge Collapse

28. Video of Collapse

29. Why Did It Happen? Combination of :Personnel Errors A.Design Deficiencies B.Inadequate Oversight & Review Process C.Missed opportunities to discover error D.Poor Communication

30. Standard of Practice (During this period of time 1950’s -1980’s) Standard of Practice in the profession was for the Fabricator to design and detail all structural steel details (includes design of connections) unless detailed by the Structural Engineer Standard Originated with the fabricator’s to insure a least costly and practical connection from the fabrication viewpoint

31. Factors That Contributed to the Collapse Fast Track Process  Architectural design changes & conceptual re-designs  Drafting Errors  Checking errors-Shop Drawings  Invalid initial design concept of hanger Senior engineer personnel changes  Phone changes w/o follow-up by detailer or engineer in writing

32. Factors That Contributed to the Collapse No Structural Site Representation (Refused several times) Engineer Relied (ASSUMED) based on past projects on design of connections by Fabricator, w/no follow-up by Project Manager

33. Fabricators in-house engineer transferred fabricator’s partial shop dwgs to outside firm who assumed connection was designed Engineers technician, checked piece size but not connection. (Not Drawn or submitted) Outside Peer Review didn’t check shop dwg Factors (Continued)

34. “Design Check” questions answers not verified In-house design check questions following atrium collapse were not verified. No Follow Up Poor Testing & Inspection Factors (Continued)

35. Warning Signs!!! Never Transmitted to Engineer Walkway deflection of 3/4” observed by workman who notified architect’s site representative seven weeks B4 July 80 opening. No Follow Up General Contractor's attorney reported : “….from date of full dead load loading of 4th and 2nd floor bridges (July 1, 1980), box beams began to distort and distortions were visible to naked eye.”

36. Warning Signs!!! Never Transmitted to Engineer Handrail Deflection noted on punch list of 130 items (Aug, 1980) Feb 1981 Box Beam Deformations noticed by dry wall installer. (No one notified)

37. What Should Have Occurred ? Single Rod Concept detail on engrs dwg noted as conceptual only Fabricator design connection Picked up during shop dwg check as not designed After atrium collapse picked up during design re-check which should have been a thorough design document check

38. What Should Have Occurred ? EOR provide full time inspection Engineer Notified of warnings! Rundancy All of above

39. Procedures must be implemented that assure that all connections are designed by a competent professional Peer reviews and design checks should include a review of shop drawings Lessons Learned

40. When questions come up look at surrounding issues for related problems EOR should be retained to provide full inspection during construction of structure Owner needs on site qualified representation Lessons Learned

41. Design and construction is a collaborative process that requires professional integrity, judgment, and integrity on the part of all participants We have not yet clearly defined the nature of the design and construction process and the information flow that is required for success in all respects We have not learned to respect and teach the history of the profession and fully disseminate information of problems that occur Lessons Not Learned

42. WHAT IS THE FUNDAMENTAL ISSUE? WHO TAKES THE RESPONSIBILITY FOR ENSURING THE WHOLE OF THE PROJECT CONFORMS TO THE DESIGN INTENT AND THE SAFETY OF THE GENERAL PUBLIC ?

43. ALL MEMBERS OF THE DESIGN TEAM ARE RESPONSIBLE FOR WHAT THEY DO!  Take the time to check your own work!  DON’T ASSUME SOMEONE ELSE WILL! Continuing Maintenance and Inspections by OWNER ! Final Responsibility? The Engineer of Record!! Where does the buck stop?

44. What Has Been Done NY State Board of Regents Proposed Amendment (Adopted 6/96)  Only ancillary to main components  Clearly specified performance criteria  Performed by licensed professional  Primary Design Team must check & approve, i.e... “Each designer responsible for own work”

45. What Has Been Done (Cont’d.) States of Florida and Connecticut added legislation relative to checking shop drawings. (Both are different) Combined with NY, only these 3 states in 20 years have any legislation relative to who does what.

46. FINALLY!! ASCE: “Quality in the Constructed Project”, 2000 ( After 20 years) PP 17.3.2: Shop Drawings for Structural Components Conn. design by Fabricator to tailor to fabrication methods EOR has authority & responsibility for overall Design of Project Fabricator responsible for connections & details ASCE: “Quality in the Constructed Project”, 2000 (After 20 years)

47. FINALLY!! ASCE: “Quality in the Constructed Project”, 2000 ( After 20 years) Complex Structures (Two Approaches OK) EOR performs complete engineering design (including conn.) Fabricator provides services of PE to design or supervise design of components not completely designed in the const.doc’s. EOR responsible to Ck shop dwgs and design for either method ASCE: “Quality in the Constructed Project”, 2000 (After 20 years)

48. CONFIGURATION MANGEMENT Strictly Regulated Industry by Government Regulations state that design, processes, documentation, changes and records must be managed This is up to Producer/Operator

49. CONFIGURATION MANGEMENT As the result of design problems,worker errors and equipment malfunctions of Three Mile Island and the Salem ATWS event in 1983, CM has continued to evolve and improve following the NRC Bulletin 79-14 CM, reinvented under CMII and ISO 10007 Quality Management (3 tier/8 step program) Adoption of Risk-Informed Baseline Inspection Program

50. Configuration Management (cont’d) Non Regulated Industry Design and Construction have many similar problems Dissemination of problems (CR”s) and solutions to include CM processes and which includes all team members is important

51. Configuration Management (cont’d) Cost and time is always the problem Owners are reluctant to participate and have tight budgets if any during design, construction and very little(if any) after turn-over (exception may occur with with public, state and federal ownership

52. In Conclusion: While our industries are different the process remains essentially the same: Management Planning Programming Designing QC/QA Construction Turn Over Operation Maintenance Continual Inspection Oversight & Follow Through Requires: Integrity,teamwork, communication & personal responsibility by all involved in the process

53. “Responsibility issues in construction, as in most endeavors, can be effectively resolved by adhering to the principle that responsibility and authority must be exactly linked.” Consulting Engineer, Norman Scott recently wrote: The corollary principle is that everyone must be responsible for his or her own work and decisions