EE15N: The Art and Science of Engineering Design Lecture 7: Why Things FailDefinition Of FailureEngineering Classification Of FailureCauses Of FailuresDealing With FailuresLearning From Failure: Hubble Space TelescopeLearning From Failure: Galaxy 4 SatelliteBenefiting From Failure: 3M’s Post-It NotesGulf of Mexico Oil SpillBasic FactsDamageBasic Techniques of Deep Sea Oil DrillingProblem & BarriersBlowout PreventerProblems with CementingProblems with Temporary AbandonmentProblems with Blowout PreventionPresidential Commission ConclusionsFailures by IndustryFailures by GovernmentOther Causes of Failure*: Management 101Group ExerciseGuest SpeakerEE15N: 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 ExerciseDefinition Of FailureAccording to Random House Dictionary, Failure is defined as:Nonperformance of something due or expected.Insufficiency.Deterioration or decay.Person or thing that proves unsuccessful.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 EngineeringCauses 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 FailureDealing 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 1997Learning 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.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 RadioBenefiting 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.Gulf of Mexico Oil SpillUS Coast Guard Photo – Oil Spill Presidential Commission ReportBasic 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 19Damage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 milesLargest accidental marine spill in history of petroleum industryBasic Techniques of Deep Sea Oil Drillinghttp://en.wikipedia.org/wiki/File:Pump_Jack_labelled.pngProblem & BarriersProblem: Failure to contain hydrocarbon pressures in wellBarriers:Cement at bottom of wellMud in well and riser Blowout Preventer (BOP)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, uncontrollableBlowout Preventerhttp://www.glossary.oilfield.slb.com/DisplayImage.cfm?ID=300Problems with CementingCasingLong string vs. linerNumber of centralizersFloat-valveAnomalous pressure readingsQuality of CementFoam cement testingProblems 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 barrierProblems 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 maintenancePresidential Commission ConclusionsOverarching Management Failures by IndustryRegulatory Failures by GovernmentFailures 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