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Cite this article Research Article Keywords: education & training/failure/

Burrell PA (2018) Paper 1900003 knowledge management


What lies hidden behind structural errors and failures within the UK? Received 05/03/2019; Accepted 10/05/2019
Proceedings of the Institution of Civil Engineers – Forensic Engineering 171(4): 171–178, Published online 10/06/2019
https://doi.org/10.1680/jfoen.19.00003
ICE Publishing: All rights reserved

Forensic Engineering

What lies hidden behind structural errors and


failures within the UK?
Paul A. Burrell PhD, CEng, FIStructE, FICE, FCABE, MAE
Associate, Mott MacDonald Ltd, Lingwood, UK (pa.burrell@btinternet.com)

Government figures from a House of Commons research briefing confirms that the components of the gross domestic
product by industry are accounted for by the service sector at 79%, production at 14%, construction at 6% and
agriculture at 1%. In its 2018 construction statistics, the Office for National Statistics (ONS) records that the construction
industry is worth c. £100 billion annually to the UK economy. However, the Get it Right Initiative suggested in 2017
that a minimum of 10% of this is lost in errors and litigation. According to the ONS figures there were 30 fatalities. To
investigate these errors and failures, this paper considers key areas in the education of chartered engineers, quality
management systems and knowledge sharing in order to gain experience. A series of open-ended, semi-structured
interviews was undertaken with senior professionals, including the judiciary, professors of engineering, global
consultants and professional indemnity insurers. Research findings revealed that technical knowledge is deliberately
withheld due to non-disclosure clauses in mediated settlements and through the practices of global professional
indemnity insurers. A study of pass rates for chartered membership of the Institution of Structural Engineers showed a
decrease despite an increase in academic requirements. Companies that promote corporate social responsibility
credentials often seek the best commercial deal regarding litigation settlement. This research concludes that there is a
sound business case for sharing knowledge, which would reduce claims, increase profits and save lives. Primary
legislation must be changed to compel a free exchange of technical knowledge regarding errors and structural failures.
A ‘no-blame’ repository needs to be established that should help reduce the adversarial nature of the construction
industry. Additionally, the suitability of the academic degree curriculum for structural engineers needs to be reassessed.

1. Introduction 2. Conceptual framework


The boundary conditions of education, both explicit and tacit,
The only real mistake is the one from which we learn nothing. quality management and experience are given in Figure 1.
(John Powell (1925–2009))
It is these boundary conditions that this paper seeks to explore to
In the aftermath following a significant structural error or improve the understanding of better experience, which should
failure, the causation as to how the error or failure occurred lead to a reduction in errors and failures. The outcome is
can generally be determined. However, the underlying question highlighted in Figure 2.
of what lies behind structural errors and failures occurring is a
more nebulous proposition. This paper seeks to determine why To understand the effect of these key factors and how they interact,
these errors and failures are seemingly repetitive and the lessons each was considered in turn. In order to provide context and a deeper
are not learnt. understanding, 14 semi-structured interviews, each approximately
80 min long, were undertaken with district judges, barristers,
Even with entrance requirements to become a chartered engineer arbitrators, mediators, the chief executive officer of a professional
ever increasing, continuing whole-career training through institution, an executive member of Confidential Reporting on
continued professional development and company integral quality Structural Safety (CROSS), professors of engineering, global insurers
management systems, there still remains an unacceptable level of and executives of global consulting companies. Each interviewee was
repetitive construction errors and failures. Therefore, what factors invited to participate on a voluntary basis, and anonymity of both the
are preventing the lessons from being learnt? interviewee and their employer was considered paramount. As an
integral part of the interview design, consideration of how the data
While there are numerous causes that lead to structural errors from the transcriptions could be extracted had to be established.
and failures, the author contends the main contributing factor to Bazeley (2013) helps the researcher in resolving qualitative data
be adequacy of education, which gives young aspiring engineers analysis using the NVivo software. Briefly, NVivo allows the
the building blocks that they will need for a career in engineering. researcher to convert qualitative data such as interviews into concepts
This education is acquired through being taught at university in by grouping words or phrases into order of significance or repetitive
the first instance and secondly gained post-university through themes that appear across the interviewees. This gives a high level of
professional knowledge. The third is through companies’ quality confidence through self-verification as they are direct statements by
management systems and how they are applied, and the fourth is the interviewees themselves, with themes and trends being easily
through the experience gained from the lessons learnt. identifiable across the groupings.

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Forensic Engineering What lies hidden behind structural errors
Volume 171 Issue FE4 and failures within the UK?
Burrell

70

60

50

Pass rate: %
Lack of
experience Professional 40
Education knowledge
30

Errors 20

10
Lack of Lack of 0
experience experience 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030
Time: years

Figure 3. UK trend line for Structural Engineers Chartered


Management Membership examination 1950–2018
systems

Since the advent of tuition fees following the publication of the


report by Dearing (1997), universities have sought to increase the
academic standard of lecturers to PhD. Table 1 details staff
Figure 1. The relationships between key issues that lead to errors
percentage taken from three randomly chosen universities that
provide civil engineering degrees. The results were based on the
numbers of academic staff listed on the individual universities’
websites within the appropriate faculty.

Barr (2008) reflects on the ever-widening gap between universities’


aspirations and industry’s expectations. He argues that successive
Experience Professional government education policies have aimed to improve secondary
Education knowledge education pass rates at the General Certificate of Secondary
Education and A levels. These changes in education policy have also
Free of seen a decline in the number of students taking mathematics, which
errors
then elicits more strain on the university to teach them to the normal
entrance quality that is expected. Figures obtained from the Bolton
Experience Experience report (Bolton, 2012) indicate there has also been an increase in
university entrants of 400% over the period 1990–2012 from 77 000
to 350 000, although the number of students opting to take
engineering degrees has remained reasonably constant over the same
Management period. Barr (2008) further contends that one of the outcomes of this
systems
trend is the significant increase in the number of non-scientific or
engineering degree scheme titles now on offer to prospective
engineering departments. Engineering education is expensive, as seen
by Barr (2008), since it requires a wide range of support facilities,
Figure 2. The relationships of key issues in reducing errors
Table 1. Comparison of academically qualified university staff
with those who have gained professional qualification through
3. Is education and lack of professional working within the industry
knowledge contributing to failures and
Number of
errors in construction? Number Number of academically
% of PhD
The academic requirements to become a chartered engineer have staff with
of academically qualified
University chartered
increased since the 1950s. This has seen a rise in ‘A’ level grade faculty qualified staff with
IStructE
passes to 98·1% for grades A* to E in 2016, from 68·2% in 1982. staff staff PhD chartered
status
Further, the minimum requirement to become a chartered engineer IStructE status
has risen from non-degree to an MEng. Yet, the pass rate of the A 24 23 2 8
chartered membership exam for the Institution of Structural B 37 36 1 3
C 72 63 6 10
Engineers (IStructE) has continued to fall, as shown in Figure 3.

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Forensic Engineering What lies hidden behind structural errors
Volume 171 Issue FE4 and failures within the UK?
Burrell

and vice chancellors would rather see the expansion in the more cost- entry competencies in basic mathematical skills have changed over
effective subject areas. He further avers that there should be closer the period 1991–2001. The data show that there has been a
ties between industry and academia, which the Joint Board of significant decline in many mathematical skills that are regarded by
Moderators (JBM) has taken to be a majorly significant, but higher education as essential for those undertaking degree courses
necessary, change in direction. Barr (2008) also contends that the gap with a significant mathematical content. As previously stated, all of
between employers’ expectations and academic institutions’ these concerns were, and continue to be, reported at the yearly
aspirations widened when the method of funding was changed by the academic conference held at the IStructE, with representatives from
Dearing (1997) report. This change saw the need to attract income many UK universities’ chairs of engineering (IStructE 2010–2016
from the private sector by providing and undertaking research by the inclusive). The author’s research has shown that the IStructE
universities. However, this has become something of a poisoned Chartered Membership examination pass rate has been in decline
chalice. Although income is welcomed as a cash cow, researchers since 1950. Indeed, Mustoe’s opinion (Mustoe, 2002) is shared by
have evolved and become detached from engineering per se and the Engineering Council report Measuring the Mathematical
have continued with a purely academic career to the detriment of Problem (EngC, 2000), which catalogues the decline in both the
belonging to a professional body. This point has not gone unnoticed standards achieved in mathematics and the quality of staff
by the JBM, where the chairman stated in his 2009 annual report teaching A level mathematics. This supports the author’s research,
(Parke, 2009: p. 4) the following. which concludes that, in mathematics, both the standard of the
undergraduate and the standard of education is poor. Mathematics
In July I wrote to you to outline the new JBM policy had been which is at the heart of engineering principles and design.
endorsed by the four JBM member Institutions that by 2015, 50% of
all academic staff designated as delivering the accredited degree The employers interviewed had become so concerned with the
programmes must be professionally qualified with one of the four standard of university education that they had introduced their
JBM member Institutions. own ‘in-house’ practice examinations when interviewing
prospective applicants, irrespective of the university that they had
The research data and analysis indicated disquiet on the current attended.
success of educational attainment at various levels. These
sentiments were expressed by both the university professors and There also seemed an over-reliance on the use of computer
all three of the employers. The reports by Chilver (1975) and software at the expense of understanding and knowledge of
Finniston (1980) were meant to raise standards of attainment for structural behaviour. This research shows that there has been no
engineers of the future. The university professors were unanimous increase in the pass rate for the Structural Engineers Chartered
in their opinion on the capability of A level students. They felt Membership Part 3 examination. The examination requires both
that the year-on-year increase in A* attainment did not reflect explicit and tacit knowledge. The candidate has to design and
positively on the candidates. Also, most students are provided draw two creditable structural solutions to a posed question. The
with standard formulae for their A level exams. In their majority of failures are due to a poor understanding of structural
experience, the depth, breadth and understanding of first-year behaviour, an inability to prepare their own handwritten
MEng undergraduates at deriving formulae from first principles calculations due to over-reliance on computer programs and poor
was poor. While both the academics and the employers embraced drawing skills needed to communicate their design. If
progress, particularly in the area of computer-aided design for examination results are to rise, then both employers and educators
both the production of drawings and analytical design software, have a significant role to play. Greater emphasis on mathematics
all agreed that students had an over-reliance on computers at the is required to improve the ability of graduates to produce
cost of derivation of formulae from first principles. The data handwritten calculations rather than place reliance on computers
analysis revealed how important the core skills of education were (which are not permitted within the examination). Employers
to the majority of the interviewees. Some of the comments must also engage more with their graduate engineers to help them
relating to the quality of education had a nostalgic undertone, understand and produce simple structures by hand. However,
‘well in my day ….’ even emanating from the academics. there has to be a leading force to take on this challenge. The
author would suggest that the JBM is best placed to bring about
Mustoe (2002) considers that the two main problems currently facing either direct change or recommendation to the government as it is
many teachers of mathematics to engineering undergraduates are the the body supported by the relevant institutions and accredits
diversity of the intake and the lack of basic skills in numeracy and university courses. Table 2 records the main areas of discussion
algebra among many of the student population, which severely and concerns.
hinders the exposition and development of mathematical ideas.
Engineering modules assume knowledge and skills which some 4. Quality management assurance and the
students do not have, nor do they have the ability to solve multistage construction industry
problems. Further research on students’ mathematical abilities was Quality assurance is an indicator or standard of compliance in
carried out by Lawson (2003). From his paper, data from diagnostic guaranteeing the consistency of a product or service. However, how
testing at Coventry University were used to illustrate how student does quality assurance sit within the construction industry, when

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Volume 171 Issue FE4 and failures within the UK?
Burrell

Table 2. State of education


From the research Suggested possible corrective actions required
Currently A level education and mathematical skills do not meet the Despite government figures, mathematics remains an area of
construction profession’s expectation. contested attainment. The JBM should review course content for
future accreditation.
Too many soft skills in university masters are being taught at the Since the reports by Finniston (1980) and Chilver (1975), there have
expense of structural analysis. been what are seen as soft subjects. Employers expressed a wish for
a return to core subjects.
Companies routinely test those being interviewed for employment for The JBM should consult with employers as to improvements required
core competencies. for future MEng courses.
There is failure to maintain professional membership examination pass The reports by Finniston (1980) and Chilver (1975) did raise results for a
rates. limited period. A new report into engineering education is overdue.
Universities have tended to focus on the academic skills of lecturers in Within engineering departments, there is a need to ensure that staff
construction engineering rather than on the core skills needed in the have appropriate professional experience in addition to academic
profession. There is a greater emphasis on employing engineering qualifications.
lecturing staff with doctorates rather than those with professional
experience. In the higher engineering education of engineers, there is
insufficient emphasis on understanding and knowledge of
engineering core skills.

Continuing errors and failures Reducing errors and failures

the service and product is predominantly individual to each Following the design phase of a project, a contractor is appointed
building that it is applied to? In contrast, due to the nature of their to construct the building. Again, the contractor could be different
business, the manufacturing, automotive, information technology on each and every project. Even with the same contractor, a
and pharmaceutical industries have an approach to quality control different construction team would be in place, depending on the
that is significantly different from that of the construction industry. location of the project. While a degree of quality control could be
maintained with certain items supplied due to them being
A product manufacturer produces a ‘widget’; this is then manufactured ‘off-site’ and hence subject to a management
replicated through a production process. There may be several system, the installation was site based with only commissioning
elements that need to come together in order to produce the final checking rather than a quality control. Indeed, most of the
widget. However, when one looks at the quality control to ensure construction processes are subject to either the local authority’s
that each widget is identical, the system relies on there being a building control or limited stage inspections. This situation, both
mass-repetitive production, a stable and fixed location and no in the author’s experience and included in the reports by Latham
external change control. (1994) and Egan (1998), is typical and not only shows a complete
dislocation between the design and construction phases, but can
In contrast, both Latham (1994) and Egan (1998) concluded that also be applied to all the individual parties involved in each and
the construction industry was wasteful, adversarial, nomadic and every project.
fragmented. This narrative echoes the author’s own experience.
Consider the first aspect of a construction project process: the This situation with a lack of coherence of an overarching quality
design. Even when working for a repeat client, the project can control system is made worse with smaller domestic-scale
never be the same. The client together with their cost consultants projects. The design phase could simply be a design calculation
knows within tolerable limits the cost of the structure above for a modest structural extension or alteration, which could be the
ground level. While it was accepted that the elevational treatment subject of an audit-style quality control only for the designer, as
would be subject to the local planning authority, this cost could be again each beam and each extension or alteration would be
allowed for. Of greater concern is the substructure, as this was different, in either span or loading; so, again, the quality control is
indeterminate, in terms of both scope and cost, as this would be for the benefit of the professional. Further, the production of a
entirely different for every site. Through investigations, this calculation sheet with the beam size would be, in probability, the
would eventually be resolved for each individual project. Thus, sole limit and involvement of the designer. The construction
each building was different; there was no stable and fixed location phase generally involves a modest local builder with no positive
and numerous external change controls. Therefore, when need or requirement for a quality assurance assessment. The scale
considering the quality assurance at the design stage, in reality of the project means that there is little engagement with the
this consisted of the individual professional advisors having their interested parties and no continuity of quality control. These were
own bespoke quality control systems with appropriate audit trails the very problems, particularly concerning defects, latent defects
for their benefit, rather than an integral system with the client’s and dispute resolution, that Latham (1994) and Egan (1998) tried
widget at its centre as for manufacturing. to address. Further, the Wolstenholme review, Never Waste a

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Burrell

Good Crisis (Wolstenholme, 2008), concluded that the 6. Lessons learnt through experience
construction industry had made little progress against the Latham
and Egan targets and identified a range of actions needed to drive The only source of knowledge is experience. (Albert Einstein
performance improvement. (1879–1955))

5. What did the research find regarding This paper has not sought to offer a single cure to rid the
management systems? profession of errors and failures, but to review current practice
All three of the companies interviewed had management systems in given that, despite significant advances in education and
place. They also considered that their systems were in fact better technology generally, there does not appear to be a reciprocal rise
than those deemed necessary to qualify for the ISO 9000:2015 in professional examinations, and there is a continuance of
requirements (ISO, 2015). None of their systems was able to repetitive errors costing the profession millions of pounds
predict errors or failures, and, while simple checking procedures annually, despite even more project quality systems being in place.
covered the most common of human computational errors, errors of
judgement could not be seen to be covered in practice. Even when The responses of the interviewees confirmed that information and
there had been a breakdown leading to an error, companies were knowledge, while collected by the judiciary, insurers and
left to their own devices to resolve and implement any remedial companies, was not communicated to other professionals. Wood
actions that were deemed necessary. Insurers had instances where (1998) contends that there is a natural human instinct to avoid
repetitive failures had occurred within the same practice, but neither association with failures and to seek to minimise their importance
the practice’s own management systems nor the checking and impact. Even within major construction organisations,
procedures within their own ISO 9000:2015 policy gave a coherent instances of failure are often hushed up, rather than being used to
opportunity to learn from the immediate problem or facilitate the highlight the organisational and technical causes so that all can
passing on of those lessons to be learnt. The companies were not learn from the failure and are then less likely to repeat it. Wood
required to review or revise their systems other than to record an (1998) also states that distorting the figures of failures or
audit trail for an annual inspection of their ISO 9000:2015 reoccurrences can lead to misinterpretation and false
accreditation. In the event of an error or failure, they only had to representation of the facts.
demonstrate a procedure for recording errors and failures and a
procedure for reviewing their protocol. Quality assurance Along with shipbuilding and aerospace, the construction industry
management as applied to the construction industry and professions is one of the oldest and most established project-based sectors
as a whole or to individual companies does not provide similar (Keegan and Turner, 2003). Indeed, the last 100 years has seen
results as those for manufacturing. This is because construction the industry evolve from a predominantly craft-based industry to a
sites, unlike most manufacturing ones, are not easily controlled multifaceted service, production and manufacturing sector.
environments. Both Latham (1994) and Egan (1998) were highly Because the industry has largely continued to construct in situ, the
critical of the number of latent defects, wastage and the amount of project-based approach has remained one of bringing together a
litigation in the construction industry. The research showed that, diverse collection of craft, professional and managerial staff to
despite this history, there is, as described by insurers, a certain different locations working collectively for short periods of time,
arrogance and over-reliance on in-house checking procedures rather before they disband to work on other ventures.
than getting the job done correctly in the first instance. Some
employers who were interviewed considered such systems were put Within the temporary organisation of the project, participants have a
in place only in order to satisfy pre-qualification on government range of objectives, not all of which will be complementary in
framework tenders as most quality system plans were a set of ‘tick nature. For many years, poor communication practices have been
boxes’ and paid little attention to the specific project. Table 3 recognised as a serious delimiting factor within the construction
records the key findings from the research. industry. Within the UK, a succession of government-commissioned

Table 3. Management systems


From the research Suggested possible corrective actions required
Over-reliance on checking procedures to capture Better preparation at the beginning of a project ensuring that relevant experiences are
errors available and learnt, rather than reacting to a situation having happened
Using management systems not suited for site- Introduction of building information modelling needs to be embraced across all of the
based construction construction industry
Systems are often used as a ‘Tick-boxing’ management systems should be discouraged, and real engagement employed
marketing/procurement platform only for realistic quality systems, including corrective actions
Tendency to regard in-house systems as better Insurers to provide claims data such that appropriate corrective actions can be incorporated
than ISO 9000:2015 (ISO, 2015) across the professions

Continuing errors and failures Reducing errors and failures

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reports has berated the industry for its apparent inability to mandatory, perhaps similar in context to the aviation profession.
communicate effectively, both internally and externally (Banwell, From a moral perspective, if knowledge of them was made public
1964; Egan, 1998; Emmerson, 1962; Latham, 1994). This lack of within the domain, this would help to not only reduce those errors
communication has been seen to lead to waste in terms of both and failures, but also remove the distress they cause to homeowners.
materials and delays, which as a result has led to adversarial conflicts This might lead to a potential reduction in household insurance
often ending in costly litigation. The interviews saw many instances premiums, and it would improve the general public’s perception of
where a breakdown in communication led to repetitive errors; these and confidence in the construction industry and professions.
often involved client expectation. This commonly evolved from what
a client had intended or understood from a drawing which was 7. Availability of knowledge and information
different when physically constructed on-site. Again, this emphasises and outcomes from the research
where the construction industry is different from others in that the The analysis of the qualitative data from the semi-structured
product (the building) is paid for during the construction process interviews revealed that there were copious amounts of valuable
rather than as a finished product. This payment during construction data held by insurers at both the national and global levels as well
applied to all clients in both the domestic and large commercial at the individual company level. However, both parties did not see
sectors. To increase their profit, contractors often substituted cheaper any ‘commercial benefit’ or incentive to make knowledge or
alternatives while citing that the alternative complies with the information available in a transparent manner. Both did agree there
specification. The author witnessed this first-hand under the auspice was a case for ethical and moral concession for the greater good of
of a design-and-build contract. For example, materials were routinely ‘all’ but were less inclined to have their data released into the public
substituted with a significant saving to the contractor. domain. All of this information and knowledge is a highly valuable
asset, which can be taught not only at the company level, but also at
In contrast to the construction industry, the aviation and maritime the university level in order to give graduates a better understanding
professions are governed by international treaties. International of both how structures work and the litigious nature of the
legislation has been put in place such that even the slightest error, construction industry and professions. There currently exist methods
fault or anything to do with the safeguard of the passengers must for reporting errors and failures within the structural and civil
be disclosed. Contrary to belief that this adds cost and therefore engineering community, these being the Standing Committee on
stifles competition, the additional cost of acting immediately is a Structural Safety (SCOSS) and CROSS. However, it was clear from
unit cost borne by all the companies. Collectively, the cost of safety the interviewees that these bodies were not known beyond a limited
far outweighs the cost of an international lawsuit for damages. audience consisting of the IStructE and the Institution of Civil
Where errors and failures in the construction have been Engineers. The judiciary had no knowledge of their existence, and
documented – for example, Ronan Point and Pipers Row car park – global insurers had limited knowledge of these bodies beyond the
significant changes have subsequently been made in the design of higher courts. SCOSS and CROSS need their profile to be elevated
buildings and structures. Arnold (2004) revisited the Ronan Point drastically, similar to that successfully operated by the aviation
partial collapse, which caused a fundamental change in structural profession, in order to be an effective body and for them to be
engineering design throughout the world. While building codes recognised and acknowledged by the judiciary and global insurers.
have been changed to prevent disproportionate and progressive
collapse, there remains an irony about the original explosion, which The Technology and Construction Court has in part been the
was caused by a broken gas main. In the immediate aftermath of victim of its own success. It has become so overwhelmed with
the failure, the gas supply was removed from the building and all construction cases that litigants have to declare that they have
similar tower blocks had their main gas supply removed. Arnold attempted to mediate or arbitrate the case, with court action being
(2004) found, as with corporate memory loss, that newer tenants the last resort. This process has seen a proliferation of ‘closed-
appear to be unaware of the significant history that exists and have door’ agreements which are then sealed with binding non-
been actively pursuing methods of reintroducing gas supplies, disclosure clauses, meaning access to technical data is severely
including bottled gas, to the high-rise block. Thus, although restricted to the litigants. In addition, global professional indemnity
information about the failure has resulted in changes to building insurers have significant amounts of claims data, which they use to
codes, the information regarding the danger of having a gas supply project premiums for their clients. These data, however, would
is not well known by those living in tower blocks. appear to be for their benefit only. Rarely are trends or risk areas
highlighted to their clients, in particular smaller clients, even
Within the construction industry, however, interviewees responded though these smaller clients may operate as a bespoke specialist in
that companies did wish to learn from their failures and errors, but it high-risk areas. The release of these data to a big-data repository
was information that was privileged to them and was regarded as too would help address the problems identified by Latham (1994) and
commercially sensitive to reveal or share with the professions as a Egan (1998) in reducing waste, latent defects and litigation. This
whole. Interestingly, some respondents were prepared to share would then reduce professional indemnity claims and should
knowledge gained from failures for the common good, but only if ultimately reduce both the need for remedial works and the
others adopted the same moral standing. This suggests that this fatalities that have costs in both economic and human terms. Table
release of knowledge about failures and errors would need to be 4 summarises the main findings from the interviews.

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Volume 171 Issue FE4 and failures within the UK?
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Table 4. The barriers to knowledge


From the interviews Suggested possible corrective actions required
There is ‘nothing in it for me’ in reporting on failures and errors Compulsory reporting
Cases go to mediation rather than the open court A ‘no-blame’ system that gives access to technical data
Non-disclosure clauses restrict data sharing Introduce a repository for big data (technical data)
Global professional indemnity insurers have much historical data, which can be used
to predict trends and high-risk areas
Lack of knowledge about existing current reporting systems SCOSS and CROSS need a higher profile throughout
the construction industry
Weak legislation regarding the sharing of knowledge surrounding failures and errors There is currently no legislation to share information
unless it is a criminal case

Continuing errors and failures Reducing errors and failures

8. Conclusions Everything we know in aviation, every rule in the rule book, every
Both the construction profession and industry are complex, more procedure we have, we know because someone somewhere has died.
so than most. However, there is much they can do to reduce errors We have purchased at great cost, lessons literally bought with blood
and failures that blight the industry. that we have to preserve as institutional knowledge to pass on to
succeeding generations. We cannot have the moral failures of
■ While mediated settlements can continue so as to protect the forgetting these lessons and have to relearn them. (Syed, 2015: p. 44)
names of the parties and any settlement reached, the valuable
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