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Index

• DISASTROUS FAILURES

Structural Robustness • STRUCTURAL ROBUSTNESS IN THE NARROW SENSE


• STRUCTURAL ROBUSTNESS IN A GENERAL SENSE
of Bridges and Viaducts • HUMAN ERROR
• MANAGING THE UNEXPECTED
Franco Bontempi - Unexpected events
Professore Ordinario di Tecnica delle Costruzioni - HRO
Facoltà di Ingegneria Civile e Industriale
- HRO principles
UNIVERSITÀ DEGLI STUDI DI ROMA LA SAPIENZA
Via Eudossiana 18 - 00184 Roma – ITALIA
- People
franco.bontempi@uniroma1.it - Culture

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NTC 2018 NTC 2018

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La scoperta dell’acqua calda 1846

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2005

https://www.slideshare.net/FrancoBontempi/robustezza-strutturale-113343022
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1
Can an airplane crash because it
DISASTROUS FAILURES punctured a tire?

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1. During takeoff from runway 26 right at Roissy
Charles de Gaulle Airport, shortly before
rotation, the front right tyre (tyre No 2) of the
left landing gear ran over a strip of metal, which
had fallen from another aircraft, and was
damaged.
2. Debris was thrown against the wing structure
leading to a rupture of tank 5.
3. A major fire, fuelled by the leak, broke out
almost immediately under the left wing.
4. Problems appeared shortly afterwards on engine
2 and for a brief period on engine 1.
5. The aircraft took off. The crew shut down engine
2, then only operating at near idle power,
following an engine fire alarm.
6. They noticed that the landing gear would not
retract.
7. The aircraft flew for around a minute at a speed
of 200 kt and at a radio altitude of 200 feet, but
was unable to gain height or speed. Engine 1
then lost thrust, the aircraftªs angle of attack
and bank increased sharply. The thrust on
engines 3 and 4 fell suddenly.
26/03/2022 Structural Robustness of Bridges and Viaducts 21 8. The aircraft crashed onto aStructural
26/03/2022 hotel. Robustness of Bridges and Viaducts 22

2
3
2
1
How will this bridge die?

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Es.: genetics

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https://en.wikipedia.org/wiki/Alm%C3%B6_Bridge

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The Almö Bridge (inaugurated in 1960), that connected the island of
Tjörn (Sweden's 7th largest island) to the mainland. The bridge collapsed
January 18th 1980, when the bulk carrier MS Star Clipper struck the
bridge arch. Eight people died that night as they drove over the edge
until the road on the Tjörn side was closed 40 minutes after the
accident. A new cable-stayed bridge, Tjörn Bridge, was built and
inaugurated in 1981.

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3
Minnesota I-35W Bridge

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I-35W Bridge

Downtown
District

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Source: Google Earth
Structural Robustness of Bridges and Viaducts 44

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Bridge Scheme (1)

DNA - INTRINSIC NATURE OF THE BRIDGE STRUCTURE:


Load Path – Redundancy – Robustness – Survaivability
Reliability - Availability – Maintenability - Safety

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Bridge Scheme (2)

The fixed bearing assemblies were located at piers 1, 3, 7, 9, 12, and 13.
Expansion (sliding) bearings were used at the south and north abutments and at piers 2,
4, 10, and 11.
Expansion Structural
roller bearings were used at piers 5, 6, and 8.
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Bridge Scheme (3) Roller #5

+
The fixed bearing assemblies were located at piers 1, 3, 7, 9, 12, and 13.
Expansion (sliding) bearings were used at the south and north abutments and at piers 2,
4, 10, and 11.
ExpansionStructural
roller bearings were used at piers 5, 6, and 8.
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Structural Integrity Roller #4


• Structural integrity is the term used for the performance 1
characteristic applied to a component, a single structure,
or a structure consisting of different components.

• Structural integrity is the ability of an item to hold


together under a load, including its own weight, resisting
breakage or bending. It assures that the construction will
perform its designed function, during reasonable use, for
as long as the designed life of the structure.

• Items are constructed with structural integrity to ensure


that catastrophic failure does not occur, which can result
in injuries, severe damage, death, or monetary losses.
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Bridge Scheme (3) Bridge Scheme (4)

+ -
The fixed bearing assemblies were located at piers 1, 3, 7, 9, 12, and 13.
Expansion (sliding) bearings were used at the south and north abutments and at piers 2,
4, 10, and 11.
ExpansionStructural
roller bearings were used at piers 5, 6, and 8.
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Crossing the Threshold of Failure
Precise moment
3 of failure

Failure
level

2007
1998 modification

Critical load (not scaled)


1977 modification modification

Original
design
Upper bound of load

Instantaneous load

Lower bound of load

Time (not scaled)


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Dead Load of Original 1967 Bridge After 1977 and 1998 Modifications
Orange and red shading: Orange and red shading:
exceeds yield stress exceeds yield stress

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GLDJRQDO 65 26/03/2022 GLDJRQDO Structural Robustness of Bridges and Viaducts
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Loads at Time of Accident


Orange and red shading:
exceeds yield stress

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GLDJRQDO 67 26/03/2022 Structural Robustness of Bridges and Viaducts 68

5
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Failure Logic
HAZARD

HOLES DUE TO
ACTIVE ERRORS

E
NC
FE
DE
TH
EP
-D
IN
HOLES DUE TO
HIDDEN ERRORS
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NTSB

TT
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15/67

Sub-structured model

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Forensic Engineering
COSE – STRUTTURE - SISTEMI COSA
FORWARD THINGS – STRUCTURES - SYSTEMS WHAT
ANALYSIS
PERSONE – COMPORTAMENTI CHI
PEOPLE – HUMAN BEHAVIOR WHO

BACK ROTTURA – COLLASSO - CRISI


CONOSCENZA
KONWLEDGE

FAILURES – COLLPASE - CRISIS


ANALYSIS
SPIEGAZIONE – CAUSE PERCHE’
REASONS - DISCLOSURE WHY
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26/67

Knowledge Development FHWA GUIDELINES, (2009)

RESISTANCE OF GUSSET PLATES:

üGUSSET PLATES SUBJECT TO SHEAR

üGUSSET PLATES IN COMPRESSION

üGUSSET PLATES IN TENSION

RESISTANCE OF FASTENERS

üSHEAR RESISTANCE OF FASTENERS

üPLATE BEARING RESISTANCE AT FASTENERS

http://bridges.transportation.org/Documents/FHWA-IF-09
014LoadRatingGuidanceandExamplesforGussetsFebruary2009rev3.pdf

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After this tragedy, the Federal Highway Administration (FHWA) focused its attention on all the I-35W SAINT ANTHONY FALLS BRIDGE (September 2008)
465 steel deck truss bridges present in the National Bridge Inventory [NTSB, 2008].
There are 323 sensors that regularly measure bridge conditions
such as deck movement, stress, and temperature

“The term “fracture critical” indicates that if one main component of a bridge fails, the entire
structure could collapse. Therefore, a fracture critical bridge is a steel structure that is designed
with little or no load path redundancy. Load path redundancy is a characteristic of the design that
allows the bridge to redistribute load to other structural members on the bridge if any one member
loses capacity. “
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http://www.startribune.com/new-35w-bridge-already-is-
aging/268746561/
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4
Examples

Opening day was six years ago, and the I-35W bridge is needing repairs — some that come
from our harsh winters, but some from improper installations.
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Es.

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For six days in January 1998, freezing rain coated


Ontario, Quebec and New Brunswick with 7-11
cm (3-4 in) of ice. Trees and hydro wires fell and
utility poles and transmission towers came
down causing massive power outages, some for
as long as a month. It was the most expensive
natural disaster in Canada. According to
Environment Canada, the ice storm of 1998
directly affected more people than any other
previous weather event in Canadian history.

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Es.

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https://californiawaterblog.com/2
016/05/01/the-collapse-of-water-
exports-los-angeles-1914/

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Es. Es.

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http://urbanplanet.info/architecture/par
is-air-terminal-collapse-report-france/

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Es.

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http://www.wise-uranium.org/img/stavaa.gif
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Es. System Complexity (Perrow)

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Seismic Action
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Structure / Infrastructure

FAR FIELD ZONE


Structural
OBJECT EXCHAGE ZONE System
STRUCTURE
Also if artificial,
Local / Punctual these systems
Scale need to have
necessarily
evolutive soundness,
ecological coherence
Global / Regional and sustainability
Scale characteristics

Critical Node
Infrastructural
NET INFRASTRUCTURE System

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(0,62) (28.5,62)

(53,56)
(0,54)

(63,45)

(92,34)

(92,32)
(0,29)
(92,29)

(0,0) (92,0)

Node Congestion System with Element connected in Series


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System with Element connected in Parallel


Structural System Degradation
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Damage at Local Level

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Damage at Element Level


Damage at Structural Level
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Es.

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STRUCTURAL ROBUSTNESS
IN THE NARROW SENSE

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Performance, Safety and Integrity Levels Structural Integrity


f(D) Service Limit States
OBJECT
USE Ultimate Limit States • Structural integrity is the ability of an item—either a
Structural Integrity Limit States
structural component or a structure consisting of many
System components—to hold together under a load, including its
D own weight, without breaking or deforming excessively.
Black Swan Events

SAFETY Mean • It assures that the construction will perform its designed
Frequent function during reasonable use, for as long as its intended
life span.
NET Maximum • Items are constructed with structural integrity to prevent
Infrastructural INTEGRITY
Rare
catastrophic failure, which can result in injuries, severe
System damage, death, and/or monetary losses.
Accidental
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Structural Robustness Structural Robustness: Intensity Feature


less robust
• Capacity of a structure (structural system) to show regular RELIABILITY
STRUCTURAL QUALITY

decrease of its structural quality (integrity) due to negative AVAILABILITY


causes. MAINTAINABILITY
ATTRIBUTES
• It implies: SAFETY

a) some smoothness of the decrease of structural SECURITY more robust


performance due to negative events
configuration

INTEGRITY
Damaged

(intensive feature); NEGATIVE CAUSE

a) some limited spatial spread of the ruptures Nominal it is a defect and represents a

(extensive feature). configuration THREATS


FAULT potential cause of error, active or dormant

the system is in an incorrect state:


ERROR it may or may not cause failure

permanent interruption of a system ability


FAILURE to perform a required function
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150
Level of Structural Failures Bad vs Good Collapse: Extensive Feature
STRUCTURE Collapse
& LOADS Mechanism

Verification Format
Usual ULS & SLS
“IMPLOSION”
1st level: OF THE
Material STRUCTURE
Point
NO SWAY is a process in which
objects are destroyed by
collapsing on themselves
3rd level: 2nd level:
Structural Element
Element Section

“EXPLOSION”
OF THE
4th level:
SWAY STRUCTURE
Structural
Structural Robustness
System Assessment is a process
NOT CONFINED
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Fail-Safe (ITA) Fail-Safe (ENG)


• Nella tecnica, denominazione dei sistemi (apparati, • A fail-safe in engineering is a design feature or practice that
componenti, strutture ecc.) progettati in modo da evitare in the event of a specific type of failure, inherently
che eventuali avarie arrechino danni a persone o ad altri responds in a way that will cause no or minimal harm to
sistemi a loro interconnessi od operanti in prossimità. other equipment, the environment or to people.
• In particolare, nelle costruzioni meccaniche, e specialmente • Unlike inherent safety to a particular hazard, a system being
in quelle aeronautiche, sono così chiamate le strutture "fail-safe" does not mean that failure is impossible or
capaci ancora di notevole resistenza, benché affette da improbable, but rather that the system's design prevents or
incrinature o rotture di qualche parte o elemento (anche di mitigates unsafe consequences of the system's failure. That
parti nascoste o non immediatamente visibili). Le incrinature is, if and when a "fail-safe" system "fails", it is "safe" or at
e rotture vengono riparate o rimosse in occasione delle least no less safe than when it was operating correctly.
ispezioni e delle revisioni obbligatorie periodiche.
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Synonym: Damage Tolerance Synonym: Graceful Degradation

• Property of a structure relating to its ability to sustain • Ability of a computer, machine, electronic system or network
defects safely until repair can be effected. to maintain limited functionality even when a large portion
• The approach to engineering design to account for damage of it has been destroyed or rendered inoperative. The
tolerance is based on the assumption that flaws can exist in purpose of graceful degradation is to prevent catastrophic
any structure and such flaws propagate with usage. failure.
• In engineering, structure is considered to be damage tolerant • Ideally, even the simultaneous loss of multiple components
if a maintenance program has been implemented that will does not cause downtime in a system with this feature.
result in the detection and repair of accidental damage, • In graceful degradation, the operating efficiency or speed
corrosion and fatigue cracking before such damage reduces declines gradually as an increasing number of components
the residual strength of the structure below an acceptable fail.
limit.
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5
Design for Robustness

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Design Strategy #1: CONTINUITY Nipigon River Bridge

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New Haengju Bridge

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Design Strategy #2: SEGMENTATION Es.

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Es.

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The collision of Esso Maracaibo

https://www.venezuelatu
ya.com/occidente/puente
rafaelurdanetaeng.htm

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http://www.aukevisser.nl/others/id1337.htm

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Cascade Effect / Chain Reaction

6 • A cascade effect is an inevitable and sometimes unforeseen


chain of events due to an act affecting a system.
• In biology, the term cascade refers to a process that, once
started, proceeds stepwise to its full, seemingly inevitable,
conclusion.
Progressive collapse • A chain reaction is the cumulative effect produced when
one event sets off a chain of similar events.
• It typically refers to a linked sequence of events where the
time between successive events is relatively small.

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Runaway: Progressive Collapse

effect

decomposability
course predictability

time
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Pancake Type Collapse

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Domino Like Collapse
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Tauern Superhighway Bridge, Austria 1975

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Zipping Like Collapse

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Long span suspension bridges Progressive collapse

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2002

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1) Minimum number of removed hangers and most sensitive location for


the triggering of the progressive collapse: the bridge results to be more
sensible to the damage at mid-span, where the removal of just 5 hanger
for the symmetrical rupture and 7 hangers for the asymmetrical rupture is
needed in order to trigger the collapse propagation. 2) Preferential direction for the collapse propagation: to the higher damage sensibility of
Shifting the initial damage location aside (about at 1/3 of the span) the the bridge central zone counterpoises a lower acceleration of the collapse progression
asymmetrical rupture of 9 hangers is required for the collapse propagation, triggered by central ruptures, with respect to that one triggered by lateral ruptures.
while moving the initial damage near the tower even the asymmetrical This effect is due to the particular configuration of the structural system that requires a
removal of 12 hangers has no global effects on the structure and very 7 growing hanger length from the centre to the sides of the bridge: when a chain rupture
hangers must be symmetrically removed on both sides in order to trigger trigger, the ultimate elongation required to the hangers adjoining the failed ones increases
the propagation of the ruptures on the adjoining hangers. as the collapse propagates (because the unsupported deck length also increases).
If the initial damage occurs at mid-span, it involves the shortest hangers and the collapse
propagation is partially slowed down from the growing element ductility of sideward
hangers. On the contrary, a more intense initial damage is required sideways to trigger
chain ruptures, but then the hanger breakdowns speeds up when moving toward the
centre, where the hanger length decreases.
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4) Sensibility to modality of damage (asymmetrical or
4) Sensibility to modalityfailure):
symmetrical of damage (asymmetrical
another or symmetrical
consideration about the failure): another
consideration about thecollapse
possible possiblestandstill
collapse concerns
standstill the
concerns
higherthe higher susceptibility of
susceptibility
the bridge to anofunsymmetrical hanger
the bridge to an failure thanhanger
unsymmetrical to a symmetrical
failure thanone:
to a in the last case
the symmetrical hinge formations
symmetrical one: indetermines
the last casea the
symmetrical
symmetricalmoment
hingeincrement on the
deck box-girders,formations
thus possibly allowing for an early deck segment
determines a symmetrical moment increment detachment that would
arrestthus
on the deck box-girders, the collapse
possibly allowing for an early
deck segment detachment that would arrest the collapse

3) Qualitative measure that could possibly lead the collapse to an halt: in the case of a
3) Qualitative
central rupture ameasure that could
closer increment in possibly leadofthe
the section thecollapse
hangersto(that
an halt: in the
remain case the
instead of a
central
same forrupture a closer
about 5/6 increment
of the in the
span length) section
could of the
possibly hangers
provide for(that remainstandstill.
a collapse instead theIn
the case of a chain rupture triggered in a lateral zone the preferential direction showedIn
same for about 5/6 of the span length) could possibly provide for a collapse standstill.
the caseprogressive
by the of a chain rupture
collapsetriggered in a lateral
would probably make zone
lessthe preferential
effective such adirection
measure.showed by
the progressive collapse would probably make less effective such a measure.
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Es.

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https://www.tuhh.de/sdb/starossek/Ver
oeffentlichungen/Dateien/Progressive%2
0collapse%20of%20bridges%20(Uwe%20
Starossek).pdf

http://www.confederationbridge.com/ab
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out/confederation-bridge/design.html 216

Threat from continuity

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Need of discontinuity

https://www.tuhh.de/sdb/starossek/Veroeffentlichungen/Dateien/Progressive%20collapse%20of%20bridges%20(Uwe%20Starossek).pdf

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Design as Foresight

STRUCTURAL ROBUSTNESS
IN THE GENERAL SENSE

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Design as Decision and Synthesis Evolutive vs Innovative Design (1)

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Evolutive vs Innovative Design (2) Es.: design clima

design
clima

Il principio di precauzione si applica


non a pericoli già identificati, ma a
pericoli potenziali, di cui non si ha
ancora conoscenza certa.

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Ponte sul Rio Sinigo

L’industria Italiana del L’industria Italiana del


Cemento 1983;12:759–72. Cemento 1983;12:759–72.

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L’industria Italiana del


Cemento 1983;12:759–72.

L’industria Italiana del


Cemento 1983;12:759–72.

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Drucker Beam Model

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ATTUALE
Verifiche di sicurezza agli Stati Limite
Stati limite di esercizio Stati limite ultimi

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ALZATO ACCOPPIATO

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ACCOPPIATO ACCOPPIATO

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ACCOPPIATO ACCOPPIATO

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ACCOPPIATO CONTROVENTATO

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HUMAN ERROR

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Causes of System Failure Eccesso di Norme Tecniche


• «Ma un numero di regole eccessivo comporta vari degli inconvenienti
Research level Design code level
dianzi citati e in particolare:
100% C - l'impoverimento dell'autonomia e della creatività, in quanto l'opera
Unknown phenomena del progettista è irretita dalle norme;
- la difficoltà di discernere ciò che veramente conta;
% of failure

B B B
- la sensazione di avere, al riparo delle norme, responsabilità assai
Human errors

Known phenomena
alleviate;
A - la difficoltà non infrequente di rendersi conto dei ragionamenti che
giustificano certe regole, rischiando di considerare queste alla stregua
di algoritmi, ossia di schemi operativi che, una volta appresi, il
pensiero non è più chiamato a giustificare.»
past present future -
Time Proliferazione delle normative e tecnicismo. Ultima lezione ufficiale del corso di Tecnica delle costruzioni tenuta dal prof.Piero Pozzati
- nell'a.a. 1991-'92, presso la Facoltà di Ingegneria dell'Università di Bologna (3 giugno 1992).

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Errors by Reason
conoscenza
esecuzione valutazione

scelta
decisione scelta
decisione
conoscenza
valutazione

esecuzione
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conoscenza
valutazione

conoscenza
valutazione scelta
decisione

scelta
decisione
esecuzione

esecuzione
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Factors (1) Factors (2)

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Errors by Rasmussen

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Sharp Criteria vs. Fuzzy Criteria Judgement Errors
• Context dependence • Conformity
• Contrast effect • The representativeness heuristic
• Recency effect • Law of small numbers
• Halo effect • Hot hand
• Plasticity • Neglecting base rates
• Order effects • Nonregressive prediction
• Pseudo-opinions • Synchronicity
• Vividness • Causalation
• Wishful thinking • Salience
• Anchoring • Minority influence
• Social loafing • Groupthink

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The effect of context

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MANAGING
THE UNEXPECTED

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Unexpected events

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Brutal audit Small events


• Small events have large consequences.
• Small discrepancies give off small clues that are hard to spot
• The ability to deal with a crisis is largely dependent on the but easy to treat if they are spotted.
structures that have been developed before chaos arrives. • When clues become much more visible, they are that much
• The event can in some ways be considered as an abrupt and harder to treat.
brutal audit: at a moment’s notice, everything that was left • Managing the unexpected often means that people have to
unprepared becomes a complex problem, and every make strong responses to weak signals, something that is
weakness comes rushing to the forefront. counterintuitive and not very heroic.
• Normally, we make weak responses to weak signals and
strong responses to strong signals.
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Sensitivity to initial conditions Butterfly Effect

• The meteorologist Edward Lorenz discovered that a simple


model of heat convection possesses intrinsic unpredictability,
a circumstance he called the “butterfly effect,” suggesting
that the mere flapping of a butterfly’s wing can change the
weather.
• A more homely example is the pinball machine: the ball’s
movements are precisely governed by laws of gravitational
rolling and elastic collisions—both fully understood—yet the
final outcome is unpredictable.

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Chaos Theory (1) Chaos Theory (2)


• Chaos theory concerns deterministic systems whose
behavior can in principle be predicted. Chaotic systems are • In chaotic systems, the uncertainty in a forecast increases
predictable for a while and then 'appear' to become random. exponentially with elapsed time. Hence, mathematically,
• The amount of time that the behavior of a chaotic system doubling the forecast time more than squares the
can be effectively predicted depends on three things: proportional uncertainty in the forecast. This means, in
qhow much uncertainty can be tolerated in the forecast, practice, a meaningful prediction cannot be made over an
interval of more than two or three times the Lyapunov time.
qhow accurately its current state can be measured,
• When meaningful predictions cannot be made, the system
qand a time scale depending on the dynamics of the system, appears random.
called the Lyapunov time.

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http://abyss.uoregon.edu/~js/21st_century_science/lectures/lec08.html http://abyss.uoregon.edu/~js/21st_century_science/lectures/lec08.html
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Authorities vs Experts

• Systems that mismanage the unexpected tend to


ignore small failures, accept simple diagnoses, take
frontline operations for granted, neglect capabilities
for resilience, and defer to authorities rather than
experts

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How to handle unexpected events

1. Tracks small failures


2. Resists oversimplification
3. Remains sensitive to operations
4. Maintains capabilities for resilience HRO
5. Takes advantage of shifting locations of
expertise

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High Reliability Organization (HRO)
• A high reliability organization (HRO) is an organization that
has succeeded in avoiding catastrophes in an environment
where normal accidents can be expected due to risk factors
and complexity.
• Important case studies in HRO research include both studies
of disasters (e.g., Three Mile Island nuclear incident, the
Challenger explosion and Columbia explosion, the Bhopal
chemical leak, the Tenerife air crash, the Mann Gulch forest
fire, the Black Hawk friendly fire incident in Iraq) and cases
like the air traffic control system, naval aircraft carriers, and
nuclear power operations.
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2 - Resists
oversimplification 4 - Maintains capabilities for
resilience

1 - Tracks small failures

5 - Takes advantage of
shifting locations of
expertise

3 - Remains sensitive to operations

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Mindfulness (1) Mindfulness (2)

• Mindfulness – a rich awareness of discriminatory • The big difference between functioning in HROs and in other
detail and an enhanced ability to discover and correct organizations is often most evident in the early stages when
errors that could escalate into a crisis. the unexpected gives off only weak signals of trouble.
• By mindful, one also means striving to maintain an • The overwhelming tendency is to respond to weak signals
underlying style of mental functioning that is with a weak response. Mindfulness preserves the capability
distinguished by continuous updating and deepening to see the significance of weak signals and to respond
of increasingly plausible interpretations of the vigorously.
context, what problems define it, and what remedies
it contains.

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Mindfulness Defined Detection, Containment, Resilience


1. combination of ongoing scrutiny of existing expectations, • One attributes the success of HROs in managing the
2. continuous refinement and differentiation of expectations unexpected to their determined efforts to act mindfully.
based on newer experiences, 1) By this one means that they organize themselves in such a
3. willingness and capability to invent new expectations that way that they are better able to notice the unexpected in
make sense of unprecedented events, the making and halt its development.
4. a more nuanced appreciation of context and ways to deal 2) If they have difficulty halting the development of the
with it, unexpected, they focus on containing it.
5. and identification of new dimensions of context that 3) And if the unexpected breaks through the containment,
improve foresight and current functioning. they focus on resilience and swift restoration of system
functioning.

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Resilience Note
• To be resilient is to be mindful about errors that have • Mindfulness also involves preferences that are diverse; close
already occurred and to correct them before they worsen attention to situations; resilience in the face of events; sensemaking
and cause more serious harm. that shows whether a decision is necessary; people with diverse
interests who debate, speak up, and listen to one another; and
• Resilience encourages people to act while thinking or to act designs that are malleable rather than fixed.
in order to think more clearly. • When you try to move toward mindfulness, there is resistance, partly
• Resilience is about bouncing back from errors and about because of threats to psychology safety.
coping with surprises in the moment. • After all, it’s a whole lot easier to bask in success, keep it simple,
• Achieved through an extensive action repertoire and skills follow routines, avoid trouble, and do an adequate job. I know how to
do those things. But dwell on failure? Question my assumptions?
with improvisation. Linger over details? Fight fires creatively? Ask for help? No thanks. Or
more likely, “You first!”

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Mindlessness (1)
• When people function mindlessly, they don’t understand
either themselves or their environments, but they feel as
though they do.
• A silent contributor to mindlessness is the zeal found in most
firms for planning. Plans act the same way as expectations.
They guide people to search narrowly for confirmation that
the plan is correct.
• Mindlessness is more likely when people are distracted,
hurried, or overloaded.

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Mindlessness (2) Mindless Control Systems

• A tendency toward mindlessness is characterized by a style • It is impossible to manage any organization solely by means
of mental functioning in which people follow recipes, impose of mindless control systems that depend on rules, plans,
old categories to classify what they see, act with some routines, stable categories, and fixed criteria for correct
rigidity, operate on automatic pilot, and mislabel unfamiliar performance.
new contexts as familiar old ones. • No one knows enough to design such a system so that it can
• A mindless mental style works to conceal problems that are cope with a dynamic environment.
worsening. • Instead, designers who want to hold dynamic systems
together must organize in ways that evoke mindful work.

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Plans, visions and forecast Mindless/Mindful Investments


• Plans and visions and forecasts are inaccurate and gain much
of their power from efforts to avoid disconfirmation.
• You’ll also discover that plans and visions and forecasts
create blind spots. • To manage the unexpected is to be reliably mindful, not
reliably mindless.
• Corrections to those inaccuracies lie in the hands of those
who have a deeper grasp of how things really work. And that • Obvious as that may sound, those who invest heavily in
grasp comes from mindfulness. plans, standard operating procedures, protocols, recipes, and
• People who act mindfully notice and pursue that rich, routines tend to invest more heavily in mindlessness than in
neglected remainder of information that mindless actors mindfulness.
leave unnoticed and untouched. Mindful people hold
complex projects together because they understand what is
happening.
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John Boyd

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HRO Principle 1: Preoccupation with failure.

• HROs are distinctive because they are preoccupied


with failure.
• They treat any lapse as a symptom that something
may be wrong with the system, something that could
Principles of HRO have severe consequences if several separate small
errors happened to coincide.

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Note HRO Principle 2: Reluctance to simplify.

• HROs encourage reporting of errors, they elaborate • Another way HROs manage for the unexpected is by
experiences of a near miss for what can be learned, and they being reluctant to accept simplifications.
are wary of the potential liabilities of success, including • It is certainly true that success in any coordinated
complacency, the temptation to reduce margins of safety, activity requires that people simplify in order to stay
and the drift into automatic processing. focused on a handful of key issues and key indicators.
• They also make a continuing effort to articulate mistakes But it is also true that less simplification allows you to
they don’t want to make and assess the likelihood that see more. HROs take deliberate steps to create more
strategies increase the risk of triggering these mistakes. complete and nuanced pictures of what they face and
who they are as they face it.

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Note HRO Principle 3: Sensitivity to operations.


• Knowing that the world they face is complex, unstable,
unknowable, and unpredictable, HROs position themselves to • HROs are sensitive to operations.
see as much as possible.
• They welcome diverse experience, skepticism toward received
• They are attentive to the front line, where the real
wisdom, and negotiating tactics that reconcile differences of work gets done. The “big picture” in HROs is less
opinion without destroying the nuances that diverse people strategic and more situational than is true of most
detect. other organizations.
• When they “recognize” an event as something they have • When people have well-developed situational
experienced before and understood, that recognition is a source awareness, they can make the continuous
of concern rather than comfort. The concern is that superficial adjustments that prevent errors from accumulating
similarities between the present and the past mask deeper and enlarging.
differences that could prove fatal.
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Note HRO Principle 4: Commitment to resilience.


• Anomalies are noticed while they are still tractable and can
still be isolated.
• All of this is made possible because HROs are aware of the
• No system is perfect. HROs know this as well as
close ties between sensitivity to operations and sensitivity to anyone.
relationships. • This is why they complement their anticipatory
• People who refuse to speak up out of fear undermine the activities of learning from failure, complicating their
system, which knows less than it needs to know to work
effectively. perceptions, and remaining sensitive to operations
• People in HROs know that you can’t develop a big picture of
with a commitment to resilience.
operations if the symptoms of those operations are
withheld.

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Note Note

• The essence of resilience is therefore the intrinsic ability of • Resilience is a combination of keeping errors small and of
an organization (system) to maintain or regain a dynamically improvising workarounds that allow the system to keep
stable state, which allows it to continue operations after a functioning.
major mishap and/or in the presence of a continuous stress. • Both pathways to resilience demand deep knowledge of the
technology, the system, one’s coworkers, and most of all,
• HROs develop capabilities to detect, contain, and bounce oneself.
back from those inevitable errors that are part of an • HROs put a premium on training, personnel with deep and
indeterminate world. varied experience, and skills of recombination and making do
• The hallmark of an HRO is not that it is error-free but that with whatever is at hand. They imagine worst-case
errors don’t disable it. conditions and practice their own equivalent of fire drills.

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HRO Principle 5: Deference to Expertise. Note
• HROs is deferent to expertise. • Decisions are made on the front line, and authority migrates
to the people with the most expertise, regardless of their
• HROs cultivate diversity, not just because it helps rank. This is not simply a case of people deferring to the
them notice more in complex environments, but also person with the “most experience.”
because it helps them do more with the complexities.
• Experience by itself is no guarantee of expertise, since all too
• Rigid hierarchies have their own special vulnerability often people have the same experience over and over and
to error. Errors at higher levels tend to pick up and do little to elaborate those repetitions. The pattern of
combine with errors at lower levels, thereby making decisions “migrating” to expertise is found in flight
the resulting problem bigger, harder to comprehend, operations on aircraft carriers, where “uniqueness coupled
and more prone to escalation. with the need for accurate decisions leads to decisions that
‘search’ for the expert and migrate around the organization.
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Error is pervasive. The unexpected is pervasive.

• Nowhere one finds any mention of perfection, zero errors,


flawless performance, or infallible humans.
• Error is pervasive.
• The unexpected is pervasive.
• By now that message should be clear. What is not pervasive
People are well-developed skills to detect and contain these errors
at their early stages.

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Expectations (1) Expectations (2)


• The basic argument is that expectations are built into • To have an expectation is to envision something, usually for
organizational roles, routines, and strategies. These good reasons, that is reasonably certain to come about.
expectations create the orderliness and predictability that • To expect something is to be mentally ready for it. Every
count on when one organizes. deliberate action you take is based on assumptions about
how the world will react to what you do.
• Expectations, however, are a mixed blessing because they
create blind spots. • Expectancies form the basis for virtually all deliberate actions
because expectancies about how the world operates serve as
• Blind spots sometimes take the form of belated recognition implicit assumptions that guide behavioral choices.
of unexpected threatening events. And frequently blind • Expectations provide a significant infrastructure for everyday
spots get larger simply because one does a biased search for life. They are like a planning function that suggests the likely
evidence that confirms the accuracy of original expectations. course of events…

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Blind spots Detection / Not Error-Free


• The problem with blind spots is that they often conceal small • It is the failure both to articulate important mistakes that
errors that are getting bigger and can produce disabling must not occur and to organize in order to detect them that
brutal audits. allows unexpected events to spin out of control.
• To counteract these blind spots, organizations try to develop • HROs develop capabilities to detect, contain, and bounce
a greater awareness of discriminatory detail.
back from those inevitable errors that are part of an
• This enriched awareness, which we call mindfulness, indeterminate world.
uncovers early signs that expectations are inadequate, that
unexpected events are unfolding, and that recovery needs to • The signature of an HRO is not that it is error-free, but that
be implemented. errors don’t disable it.
• Recovery requires updating both of one’s understanding of • Resilience is a combination of keeping errors small and of
what is happening and of the lines of action that were tied to improvising workarounds that keep the system functioning.
the earlier expectations.
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Error Reporting Assumptions


• Every deliberate action you take is based on assumptions
• A necessary component of an incident review is the about how the world will react to what you do.
reporting of an incident. And research shows that people • Expectancies form the basis for virtually all deliberate actions
need to feel safe to report incidents or they will ignore them because expectancies about how the world operates serve as
or cover them up. implicit assumptions that guide behavioral choices.
• HROs increase their knowledge base by encouraging and • Expectations provide a significant infrastructure for everyday
rewarding error reporting. life. They are like a routine that suggests the probable course
of events. They direct your attention to certain features of
events, which means that they affect what you notice, mull
over, and remember. When you expect that something will
happen, that is a lot like testing a hypothesis.
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Self-fulfilling prophecy (1) Self-fulfilling prophecy (2)
• A self-fulfilling prophecy is the sociopsychological • American sociologist William Isaac Thomas was the first to
phenomenon of someone "predicting" or expecting discover this phenomenon. In 1928 he developed the
something, and this "prediction" or expectation coming true Thomas theorem (also known as the Thomas dictum), stating
simply because the person believes it will and the person's that,
resulting behaviors aligning to fulfill the belief. If men define situations as real,
• This suggests that people's beliefs influence their actions. they are real in their consequences.
• The principle behind this phenomenon is that people create • In other words, the consequence will come to fruition based
consequences regarding people or events, based on previous on how one interprets the situation. Using Thomas' idea,
knowledge of the subject. another American sociologist, Robert K. Merton, coined the
• A self-fulfilling prophecy is applicable to either negative or term "self-fulfilling prophecy", popularizing the idea that “a
positive outcomes. belief or expectation, correct or incorrect, could bring about
a desired or expected outcome.”
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Note Confirmations
• Self-fulfilling theory can be divided into two behaviors, one would be the • Many of expectations are reasonably accurate. They tend to
Pygmalion effect which is when “one person has expectations of another, changes
her behavior in accordance with these expectations, and the object of the be confirmed, partly because they are based on experience
expectations then also changes her behavior as a result.” and partly because one corrects those that have negative
• Additionally, philosopher Karl Popper called the self-fulfilling prophecy the consequences.
Oedipus effect:
• One of the ideas I had discussed in The Poverty of Historicism was the influence • The tricky part is that all of us tend to be awfully generous in
of a prediction upon the event predicted. I had called this the "Oedipus effect", what we accept as evidence that our expectations are
because the oracle played a most important role in the sequence of events which
led to the fulfilment of its prophecy. [...] For a time I thought that the existence of confirmed.
the Oedipus effect distinguished the social from the natural sciences. But in
biology, too—even in molecular biology—expectations often play a role in • Furthermore, we actively seek out evidence that confirms
bringing about what has been expected. our expectations and avoid evidence that disconfirms them.
• An early precursor of the concept appears in Edward Gibbon’s Decline and Fall of
the Roman Empire: "During many ages, the prediction, as it is usual, contributed
to its own accomplishment" (chapter I, part II).
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Unpleasant Feelings

• Evidence shows that when something unexpected happens,


this is an unpleasant experience. Part of managing the
unexpected involves anticipating these feelings of
unpleasantness and taking steps to minimize their impact.

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Cognitive dissonance Routines and planes


• A person who experiences internal inconsistency tends to • People also search for confirmation in other forms of
become psychologically uncomfortable and is motivated to expecting such as routines and plans.
reduce the cognitive dissonance. They tend to make changes to
• Organizations often presume that because they have
justify the stressful behavior, either by adding new parts to the
cognition causing the psychological dissonance or by avoiding routines to deal with problems, this proves that they
circumstances and contradictory information likely to increase understand those problems.
the magnitude of the cognitive dissonance. • Although there is a grain of truth to that inference, what
• Coping with the nuances of contradictory ideas or experiences is they fail to see is that their routines are also expectations
mentally stressful. It requires energy and effort to sit with those that are subject to the very same traps as any other
seemingly opposite things that all seem true. Festinger argued expectations.
that some people would inevitably resolve dissonance by blindly
believing whatever they wanted to believe.
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Kahneman and Tversky Updating


• Whenever a routine is activated, people assume that the
• We actively seek out evidence that confirms our world today is pretty much like the world that existed at the
expectations and avoid evidence that disconfirms them. time the routine was first learned.
• We tend to overestimate the validity of expectations • Furthermore, people tend to look for confirmation that their
currently held. existing routines are correct. And over time, they come to
see more and more confirmation based on fewer and fewer
• The continuing search for confirming evidence postpones data.
your realization that something unexpected is developing.
• What is missing are continuing efforts to update the routines
and expectations and to act in ways that would compel such
updating.

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Plans Counteract to seek confirmation
• This same pattern of confirmation seeking is associated with
plans. • People in HROs work hard to counteract the tendency to
• Plans guide people to search narrowly for confirmation that seek confirmation by designing practices that incorporate
the plans are correct. the five principles.
• Disconfirming evidence is avoided, and plans lure you into • They understand that their expectations are incomplete and
overlooking a buildup of the unexpected. that they can come closer to getting it right if they doubt
• This is not surprising since much of the imagery used to those expectations that seem to be confirmed most often.
describe plans is like the imagery people use when they talk
about expectations.

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Alertness Expectations and Planning

• The tendencies to seek confirmation and avoid • If you understand the problems that expectations create, you
disconfirmation are well-honed, well-practiced human understand the problems that plans create. And you may
tendencies. begin to understand why a preoccupation with plans and
• That’s why HROs have to work so hard and so continuously planning makes it that much harder for you to act mindfully.
to override these tendencies and remain alert. And that’s • By contrast, mindfulness is essentially a preoccupation with
why you may have to work just as hard. updating. It is grounded in an understanding that knowledge
• All of us face an ongoing struggle for alertness because we and ignorance grow together.
face an ongoing preference for information that confirms.

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Redirecting Attention Believing is Seeing

• Trouble starts when I fail to notice that I see only whatever


• The power of a mindful orientation is that it redirects confirms my categories and expectations but nothing else.
attention from the expected to the irrelevant, from the The trouble deepens even further if I kid myself that seeing is
confirming to the disconfirming, from the pleasant to the believing. That’s wrong. It’s the other way around. Believing
unpleasant, from the more certain to the less certain, from is seeing. You see what you expect to see. You see what you
the explicit to the implicit, from the factual to the probable, have the labels to see. You see what you have the skills to
and from the consensual to the contested. manage.

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Occhio clinico Forms of unexpected

I. The first form of the unexpected occurs when an


L'occhio vede solo ciò event that was expected to happen fails to occur.
che la mente è preparata II. A second form of the unexpected occurs when an
event that was not expected to happen does
a comprendere happen.
(Henri Bergson) III. The third form of the unexpected occurs when an
event that was simply unthought of happens.
Henri-Louis Bergson (Parigi, 18 ottobre 1859 – Parigi, 4 gennaio 1941) è stato un filosofo francese. La sua opera superò le tradizioni ottocentesche dello Spiritualismo e
del Positivismo ed ebbe una forte influenza nei campi della psicologia, della biologia, dell'arte, della letteratura e della teologia. Fu insignito del Premio Nobel per la
letteratura nel 1927 sia «per le sue ricche e feconde idee» sia «per la brillante abilità con cui ha saputo presentarle».

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Start Finally
• In each of these three cases, the surprise starts with an
expectation. • If you are slow to realize that things are not the way you
• Presumably, if you hold these expectations, you look for expected them to be, the problem worsens and becomes
evidence that confirms them rather than evidence that harder to solve and gets entangled with other problems.
disconfirms them. • When it finally becomes clear that your expectation is
• If you find confirming evidence, this “proves” that your wrong, there may be few options left to resolve the problem.
hunches about the world are accurate, that you are in • In the meantime, efficiency and effectiveness have declined,
control, that you know what’s up, and that you are safe. the system is now vulnerable to further collapse, and safety,
• The continuing search for confirming evidence postpones reputations, and production are in jeopardy.
your realization that your model has its limits.

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Imaginations WTC
• A significant goal of HROs is to increase their understanding
of the third form of the unexpected and to expand
knowledge of “the imagined deemed possible.”
• The commission’s report contains this striking
assertion:
• HRO principles steer people toward mindful practices that
encourage imagination. “Imagination is not a gift usually associated with
• The crucial nature of imagination is reflected in the report of bureaucracies. ... It is therefore crucial to find a way of
the commission investigating the terrorist attacks on routinizing, even bureaucratizing the exercise of
September 11, 2001. It found shortfalls in imagination prior imagination. Doing so requires more than finding an
to the collapse of the twin towers. expert who can imagine that aircraft could be used as
weapons.”

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Alertness Trivialize

• It takes more than a shrewd expert to forestall the • People sometimes inadvertently trivialize the importance of
unexpected in most situations. imagination. For example, these days we keep hearing the
• It takes mindful practices that encourage imagination, foster hollow maxim “Expect the unexpected.” That well-meaning
enriched expectations, raise doubts about all expectations, sentiment assumes that people can live their lives while
increase the ability to make novel sense of small assuming that their expectations are misleading.
interruptions in expectations, and facilitate learning that • The problem is, they can’t afford to. They live, instead, as if
intensifies and deepens alertness. their expectations are basically correct and as if there is little
that can surprise them. To do otherwise would be to forgo
any feeling of control or predictability.

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Virginity Leemers
• You’ll probably know when something unexpected happens
• Once you’ve accepted an anomaly or something less than because you’ll feel surprised, puzzled, or anxious. Aviators
perfect, you know, you’ve given up your virginity. You can’t call these feelings leemers (probably derived from leery), the
go back. You’re at the point that it’s very hard to draw the feeling that something is not quite right, but you can’t put
line. You know, next time they say it’s the same problem, it’s your finger on it. Trust those feelings. They are a solid clue
just eroded 5 mils more. Once you accepted it, where do you that your model of the world is in error.
draw the line? Once you’ve done it, it’s very difficult to go • More important, try to hold on to those feelings and resist
back now and get very hard-nosed and say I’m not going to the temptation to gloss over what has just happened and
accept that. treat it as normal. In that brief interval between surprise and
successful normalizing lies one of your few opportunities to
discover what you don’t know.
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Learning moment Sustained High Performance

• This is one of those rare moments when you can significantly • If you update and differentiate the labels you impose on the
improve your understanding. world, the unexpected will be spotted earlier and dealt with
• If you wait too long, normalizing will take over, and you’ll be more fully, and sustained high performance will be more
convinced that there is nothing to learn. assured.
• Most opportunities for learning come in the form of brief • Reliability is a dynamic event and gets compromised by
moments. distraction and ignorance.
• And one of the best moments for learning, a moment of the • Mindfulness is about staying attuned to what is happening
unexpected, is also one of the shortest-lived moments. and about a deepening grasp of what those events mean.

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Importance of Doctrine
• When you think about mindful culture as a means to manage
the unexpected, keep the following picture of culture in front
of you.
• Culture is about the assumptions that influence the people
who manage the unexpected. Culture can hold large systems
together. Culture is unspoken, implicit, taken for granted. You
feel culture when what you do feels appropriate or
Culture inappropriate. You feel the unexpected when something
surprises you.
• Culture produces simultaneous centralization-
decentralization by binding people to a small set of core
values and allowing them discretion over everything else.
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Churchill’s Audit Culture

•Why didn’t I know? •Perché non lo sapevo?


•Why didn’t my •Perché i miei • Culture is a pattern of shared beliefs and expectations that
advisors know? consulenti non lo shape how individuals and groups act.
• Descriptions of safety culture often read like lists of banal
sapevano? injunctions to “do good.”
•Why wasn’t I told? •Perché non me l'hanno • Culture will affect what you see and how you interpret it.
detto? • Culture change takes a long time.

•Why didn’t I ask? •Perché non l'ho


chiesto?
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Culture - Schein Building on strengths


• Culture is defined by six formal properties:
(1) shared basic assumptions that are
(2) invented, discovered, or developed by a given group as it • Never start with the idea of changing culture.
(3) learns to cope with its problem of external adaptation and • Try to build on existing cultural strengths rather than
internal integration in ways that
attempting to change those elements that may be
(4) have worked well enough to be considered valid and, weaknesses.
therefore,
(5) can be taught to new members of the group as the
(6) correct way to perceive, think, and feel in relation to those
problems.

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Four Subcultures Reason (James)


• Reason (James) argues that it takes four subcultures to ensure an
informed culture. Assumptions, values, and artifacts must line up
• The problem is that candid reporting of errors takes trust and consistently around the issues of
trustworthiness. Both are hard to develop, easy to destroy, 1. What gets reported when people make errors or experience near
and hard to institutionalize. misses (reporting culture)
1. Reporting Culture 2. How people apportion blame when something goes wrong (just
culture)
2. Just Culture 3. How readily people can adapt to sudden and radical increments in
pressure, pacing, and intensity (flexible culture)
3. Flexible Culture 4. How adequately people can convert the lessons that they have
4. Learning Culture learned into reconfigurations of assumptions, frameworks, and
action (learning culture).

James Reason
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1 - Reporting Culture 2 - Just Culture

• Since safety cultures are dependent on the knowledge


gained from rare incidents, mistakes, near misses, and other
“free lessons,” they need to be structured so that people feel
willing to “confess” their own errors. • An organization is defined by how it handles blame and
punishment, and that in turn can affect what gets reported
• A reporting culture is about protection of people who report. in the first place.
• It is also about what kinds of reports are trusted.

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3 - Flexible Culture 4 - Learning Culture


• An informed culture learns by means of ongoing debates
• Adapts to changing demands about constantly shifting discrepancies. These debates
promote learning because they identify new sources of
• Deference to expertise – decisions migrate to expertise hazard and danger and new ways to cope.
during periods of high-tempo activity
• Culture shapes actions largely without people being aware of
• Collect multiple signals from a variety of sources how little they see and how many options they overlook.
• HROs assume that the system is endangered until there is • When people are drawn into a culture that is partly of their
conclusive proof that it is not own making, it is very hard for them to see that what they
take for granted hides the beginnings of trouble.

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Mindful Culture

• To be mindful is to become susceptible to learning anxiety.


And anxious people need what Edgar Schein calls
“psychological safety.”
• Mindfulness requires continuous ongoing activity.
• We are not talking about a “safety war” that ends in victory.
We are talking instead about an endless guerilla conflict.

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Index Robustezza strutturale


• DISASTROUS FAILURES
• STRUCTURAL ROBUSTNESS IN THE NARROW SENSE
• STRUCTURAL ROBUSTNESS IN A GENERAL SENSE
• HUMAN ERROR
• MANAGING THE UNEXPECTED
- Unexpected events
- HRO
- HRO principles
- People https://www.stradeeautostrade.it/ponti-e-viadotti/i- https://www.stradeeautostrade.it/ponti-e-viadotti/i-
concetti-elementari-alla-base-della-robustezza-strutturale- concetti-elementari-alla-base-della-robustezza-strutturale-
- Culture di-ponti-e-viadotti-prima-parte/ di-ponti-e-viadotti-seconda-parte/

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Structural Robustness of Bridges and Viaducts 390
Structural Robustness
of Bridges and Viaducts
Franco Bontempi
Professore Ordinario di Tecnica delle Costruzioni
Facoltà di Ingegneria Civile e Industriale
UNIVERSITÀ DEGLI STUDI DI ROMA LA SAPIENZA
Via Eudossiana 18 - 00184 Roma – ITALIA
franco.bontempi@uniroma1.it

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