On July 17, 1981 a suspended walkway collapsed in The Hyatt Regency Hotel in Kansas City, Missouri, killing 114 people and injuring 216 others during a tea dance. At the time, it was the deadliest structural collapse in U.S. history. This event and a subsequent series of other major incidents in the early and mid 1980′s began the formulative efforts towards defining the emerging field of Urban Heavy Rescue (UHR) that would transition into Urban Search and Rescue (USAR) in the late 1980′s and early 1990′s.
Another significant incident occurring in 1981 included the Harbor Cay Condominium Collapse (Cocoa Beach, Florida, 1981). This building was under construction at the time of collapse. Heavy floor and wall construction consisted of precast reinforced concrete slabs and cast-in-place concrete components. All five floors and the roof of the condominium collapsed in a pancake configuration, trapping a large number of construction workers. Eleven were killed and 23 injured. The incident involved more than 60 hours of continuous rescue operations and resources from 5 county fire districts; 16 municipal fire departments; and a response of Civil Defense, military, and private sector technical specialists.
Today marks the thirty year anniverary of the Kansas City event and the lessons learned that continue to be applied towards collapse rescue, urban search and rescue and techncial rescue operations, protocals, techniques, methodologies and preparedness.
On July 17, 1981, approximately 1,600 people gathered in the atrium to participate in and watch a dance competition. Dozens stood on the walkways. At 7:05 PM, the second-level walkway held approximately 40 people with more on the third and an additional 16 to 20 on the fourth level who watched the activities of crowd in the lobby below. The fourth floor bridge was suspended directly over the second floor bridge, with the third floor walkway offset several feet from the others.
Construction difficulties resulted in a subtle but flawed design change that doubled the load on the connection between the fourth floor walkway support beams and the tie rods carrying the weight of both walkways. This new design was barely adequate to support the dead load weight of the structure itself, much less the added weight of the spectators.
The connection failed and the fourth floor walkway collapsed onto the second floor and both walkways then fell to the lobby floor below, resulting in 111 immediate deaths and 216 injuries. Three additional victims died after being evacuated to hospitals making the total number of deaths 114 people.
The hotel had only been in operation for approximately one year at the time of the walkways collapse, and the ensuing investigation of the accident revealed some unsettling facts:
The high number of dead and injured, the location of the collapse, the size of the collapsed material, and the ineffectiveness of the typical emergency service tools created severe rescue limitations.
The incident required a large number of medical personnel working alongside the rescuers.
Twenty-nine live victims were removed from under the debris during the rescue operations. Heavy rigging and construction specialists and heavy equipment were needed to remove the debris during the rescue operations. large scale rescue operation soon unfolded. Heroes of the evening ranged from a husband who pulled his wife’s trapped foot from the wreckage, to a surgeon who performed an emergency amputation to save a trapped and bleeding victim, to construction crew workers who toiled throughout the night clearing the debris.
A local crane company arrived at the scene to remove sections of collapsed walkway. Dispatchers called in emergency vehicles from throughout the city. Outlying cities such as Belton and Lee’s Summit offered help within minutes of the dispatch calls. Victims were rushed to four nearby hospitals. Donors poured into the Greater Kansas City Community Blood Center. Local talk-show host Walt Bodine broadcast throughout the night. As late as midnight, excavators were trying to reach over a dozen people still trapped under the debris. At 5 a.m., workers uncovered the final 31 bodies from the last slab of concrete to be removed.
The rescue operation lasted well into the next morning and was carried out by a veritable army of emergency personnel, including 34 fire trucks, and paramedics and doctors from five area hospitals. Dr. Joseph Waeckerle directed the rescue effort setting up a makeshift morgue in the ruined lobby and turning the hotel’s taxi ring into a triage center, helping to organize the wounded by highest need for medical care. Those who could walk were instructed to leave the hotel to simplify the rescue effort, the fatally injured were told they were going to die and given morphine.
Workmen from a local construction company were also hired by the city fire department, bringing with them cranes, bulldozers, jackhammers and concrete-cutting power saws.
The biggest challenge to the rescue operation came when falling debris severed the hotel’s water pipes, flooding the lobby and putting trapped survivors at great risk of drowning. As the pipes were connected to water tanks, as opposed to a public source, the flow could not be shut off.
Eventually, Kansas City’s fire chief realized that the hotel’s front doors were trapping the water in the lobby. On his orders, a bulldozer was sent in to rip out the doors, which allowed the water to pour out of the lobby and thus eliminated the danger to survivors.
Check out the following books about the Hyatt Regency disaster held by the Kansas City Public Library:
Continue researching the Hyatt Regency disaster using material held by the Missouri Valley Special Collections:
NBS BSS 143; May 1982. An investigation into the collapse of two suspended walkways within the atrium area of the Hyatt Regency Hotel in Kansas City, Mo., is presented in this report. The investigation included on-site inspections, laboratory tests and analytical studies. Three suspended walkways spanned the atrium at the second, third, and fourth floor levels. The second floor walkway was suspended from the forth floor walkway which was directly above it. In turn, this fourth floor walkway was suspended from the atrium roof framing by a set of six hanger rods. The third floor walkway was offset from the other two and was independently suspended from the roof framing by another set of hanger rods. In the collapse, the second and fourth floor walkways fell to the atrium floor with the fourth floor walkway coming to rest on top of the lower walkway.
- Early 1976: Crown Center Redevelopment Corporation (owner) commences project to design and build a Hyatt Regency Hotel in Kansas City, Missouri.
- July 1976: Gillum-Colaco, Inc. (G.C.E. International, Inc., 1983), a Texas corporation, selected as the consulting structural engineer for the Hyatt project.
- July 1976- Hyatt project in schematic design development.
- Summer 1977: G.C.E. assisted owner and architect (PBNDML Architects, Planners, Inc.) with developing various plans for hotel project, and decided on basic design.
- Late 1977- Bid set of structural drawings and specifications
- Early 1978: Project prepared, using standard Kansas City, Missouri, Building Codes.
- April 4, 1978: Actual contract entered into by G.C.E. and the architect, PBNDML Architects, Planners, Inc. G.C.E. agreed to provide “all structural engineering services for a 750-room hotel project located at 2345 McGee Street, Kansas City, Missouri.”
- Spring 1978: Construction on hotel begins.
- August 28, 1978: Specifications on project issued for construction, based on the American Institute of Steel Construction (AISC) standards used by fabricators.
- December 1978: Eldridge Construction Company, general contractor on the Hyatt project, enters into subcontract with Havens Steel Company. Havens agrees to fabricate and erect the atrium steel for the Hyatt project.
- January 1979: Events and communications between G.C.E. and Havens.
- February 1979: Havens makes design change from a single to a double hanger rod box beam connection for use at the fourth floor walkways. Telephone calls disputed; however, because of alleged communications between engineer and fabricator, Shop Drawing 30 and Erection Drawing E3 are changed.
- February 1979: G.C.E. receives 42 shop drawings (including Shop Drawing 30 and Erection Drawing E-3) on February 16, and returns them to Havens stamped with engineering review stamp approval on February 26.
- October 14, 1979: Part of the atrium roof collapses while the hotel is under construction. Inspection team called in, whose contract dealt primarily with the investigation of the cause of the roof collapse and created no obligation to check any engineering or design work beyond the scope of their investigation and contract.
- October 16, 1979: Owner retains an independent engineering firm, Seiden-Page, to investigate the cause of the atrium roof collapse.
- October 20, 1979: Gillum writes owner, stating he is undertaking both an atrium collapse investigation as well as a thorough design check of all the members comprising the atrium roof.
- October- Reports and meetings from engineer to clients
- November 1979: owner/architect assures clients of overall safety of the entire atrium.
- July 1980: Construction of hotel complete, and the Kansas City Hyatt Regency Hotel opens for business.
- July 17, 1981: Connections supporting the rods from the ceiling that held up the 2nd and 4th floor walkways across the atrium of the Hyatt Regency Hotel collapse, killing 114 and injuring in excess of 200 others.
- February 3, 1984: Missouri Board of Architects, Professional Engineers and Land Surveyors files complaint against Daniel M. Duncan, Jack D. Gillum and G.C.E. International Inc., charging gross negligence, incompetence, misconduct and unprofessional conduct in the practice of engineering in connection with their performance of engineering services in the design and construction of the Hyatt Regency Hotel in Kansas City, Missouri.
- November, 1984: Duncan, Gillum, and G.C.E. International, Inc. found guilty of gross negligence, misconduct and unprofessional conduct in the practice of engineering. Subsequently, Duncan and Gillum lost their licenses to practice engineering in the State of Missouri, and G.C.E. had its certificate of authority as an engineering firm revoked. American Society of Civil Engineering (ASCE) adopts report that states structural engineers have full responsibility for design projects. Duncan and Gillum now practicing engineers in states other than Missouri.
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Investigators, including David Tonneman (a respected engineering critic), concluded that the basic problem was a lack of proper communication between Jack D. Gillum and Associates, Christopher Willoughby (a University of Michigan engineering student at the time), and Havens Steel.
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In particular, the drawings prepared by Jack D. Gillum and Associates were only preliminary sketches but were interpreted by Havens as finalized drawings.
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Jack D. Gillum and Associates failed to review the initial design thoroughly, and accepted Havens’ proposed plan without performing basic calculations that would have revealed its serious intrinsic flaws — in particular, the doubling of the load on the fourth-floor beams.
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The engineers employed by Jack D. Gillum and Associates who had approved the final drawings were convicted by the Missouri Board of Architects, Professional Engineers, and Land Surveyors of gross negligence, misconduct and unprofessional conduct in the practice of engineering; they all lost their engineering licenses in the states of Missouri and Texas and their membership with ASCE.
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While Jack D. Gillum and Associates itself was discharged of criminal negligence, it lost its license to be an engineering firm
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The Following is a direct reference to ENGINEERING ETHICS The Kansas City Hyatt Regency Walkways Collapse pubished by theDepartment of Philosophy and Department of Mechanical Engineering Texas A&M University through NSF Grant Number DIR-9012252 Direct Link: http://ethics.tamu.edu/ethics/hyatt/hyatt1.htm
Structural Failure During the Atrium Tea Dance
In 1976, Crown Center Redevelopment Corporation initiated a project for designing and building a Hyatt Regency Hotel in Kansas City Missouri. In July of 1976, Gillum-Colaco, Inc., a Texas corporation, was selected as the consulting structural engineer for the project. A schematic design development phase for the project was undertaken from July 1976 through the summer of 1977. During that time, Jack D. Gillum (the supervisor of the professional engineering activities of Gillum-Colaco, Inc.) and Daniel M. Duncan (working under the direct supervision of Gillum, the engineer responsible for the actual structural engineering work on the Hyatt project) assisted Crown Center Redevelopment Corporation (the owner) and PBNDML Architects, Planners, Inc. (the architect on the project) in developing plans for the hotel project and deciding on its basic design. A bid set of structural drawings and specifications for the project were prepared in late 1977 and early 1978, and construction began on the hotel in the spring of 1978. The specifications on the project were issued for construction on August 28, 1978.
On April 4, 1978, the actual written contract was entered into by Gillum-Colaco, Inc. and PBNDML Architects, Planners, Inc. The contract was standard in nature, and Gillum-Colaco, Inc. agreed to provide all the structural engineering services for the Hyatt Regency project. The firm Gillum-Colaco, Inc. did not actually perform the structural engineering services on the project; instead, they subcontracted the responsibility for performing all of the structural engineering services for the Hyatt Regency Hotel project to their subsidiary firm, Jack D. Gillum & Associates, Ltd. (hereinafter referenced as G.C.E.).7 According to the specifications for the project, no work could start until the shop drawings for the work had been approved by the structural engineer.
Three teams, with particular roles to play in the construction system employed in building the Hyatt Regency Hotel, were contracted for the project: PBNDML and G.C.E. made up the “design team,” and were authorized to control the entire project on behalf of the owner; Eldridge Construction Co., as the “construction team,” was responsible for general contracting; and the “inspection team,” made up of two inspecting agencies (H&R Inspection and General Testing), a quality control official, a construction manager, and an investigating engineer (Seiden and Page).
On December 19, 1978, Eldridge Construction Company, as general contractor, entered into a subcontract with Havens Steel Company, who agreed to fabricate and erect the atrium steel for the Hyatt project.
G.C.E. was responsible for preparing structural engineering drawings for the Hyatt project: three walkways spanning the atrium area of the hotel. Wide flange beams with 16-inch depths (W16x26) were used along either side of the walkway and hung from a box beam (made from two MC8x8.5 rectangular channels, welded toe-to-toe). A clip angle welded to the top of the box beam connected these beams by bolts to the W section. This joint carried virtually no moment, and therefore was modeled as a hinge. One end of the walkway was welded to a fixed plate and would be a fixed support, but for simplicity, it could be modeled as a hinge. This only makes a difference on the hanger rod nearest this support (it would carry less load than the others and would not govern design). The other end of the walkway support was a sliding bearing modeled by a roller. The original design for the hanger rod connection to the fourth floor walkway was a continuous rod through both walkway box beams (Figure 1 below).
Events and disputed communications between G.C.E. engineers and Havens resulted in a design change from a single to a double hanger rod box beam connection for use at the fourth floor walkways. The fabricator requested this change to avoid threading the entire rod. They made the change, and the contract’s Shop Drawing 30 and Erection Drawing E-3 were changed (Figure 2 shows the hanger rod as built).
On February 16, 1979, G.C.E. received 42 shop drawings (including the revised Shop Drawing 30 and Erection Drawing E-3). On February 26, 1979, G.C.E. returned the drawings to Havens, stamped with Gillum’s engineering review seal, authorizing construction. The fabricator (Havens) built the walkways in compliance with the directions contained in the structural drawings, as interpreted by the shop drawings, with regard to these hangers. In addition, Havens followed the American Institute of Steel Construction (AISC) guidelines and standards for the actual design of steel-to-steel connections by steel fabricators.
As a precedent for the Hyatt case, the Guide to Investigation of Structural Failure‘s Section 4.5, “Failure Causes Classified by Connection Type,” states that:
Overall collapses resulting from connection failures have occurred only in structures with few or no redundancies. Where low strength connections have been repeated, the failure of one has lead to failure of neighboring connections and a progressive collapse has occurred. The primary causes of connection failures are:
- Improper design due to lack of consideration of all forces acting on a connection, especially those associated with volume changes.
- Improper design utilizing abrupt section changes resulting in stress concentrations.
- Insufficient provisions for rotation and movement.
- Improper preparation of mating surfaces and installation of connections.
- Degradation of materials in a connection.
- Lack of consideration of large residual stresses resulting from manufacture or fabrication.
On October 14, 1979, part of the atrium roof collapsed while the hotel was under construction. As a result, the owner called in the inspection team. The inspection team’s contract dealt primarily with the investigation of the cause of the roof collapse and created no obligation to check any engineering or design work beyond the scope of their investigation and contract. In addition to the inspection team, the owner retained, on October 16, 1979, an independent engineering firm, Seiden-Page, to investigate the cause of the atrium roof collapse. On October 20, 1979, G.C.E.’s Gillum wrote the owner, stating that he was undertaking both an atrium collapse investigation as well as a thorough design check of all the members comprising the atrium roof. G.C.E. promised to check all steel connections in the structures, not just those found in the roof.
From October-November, 1979, various reports were sent from G.C.E. to the owner and architect, assuring the overall safety of the entire atrium. In addition to the reports, meetings were held between the owner, architect and G.C.E.
In July of 1980, the construction was complete, and the Kansas City Hyatt Regency Hotel was opened for business.
Just one year later, on July 17, 1981, the box beams resting on the supporting rod nuts and washers were deformed, so that the box beam resting on the nuts and washers on the rods could no longer hold up the load. The box beams (and walkways) separated from the ceiling rods and the fourth and second floor walkways across the atrium of the Hyatt Regency Hotel collapsed, killing 114 and injuring in excess of 200 others.
One investigation report gave the following summary:
The Hyatt Regency consists of three main sections: a 40-story tower section, a function block, and a connecting atrium. The atrium is a large open area, approximately 117 ft (36 m) by 145 ft (44 m) in plan and 50 ft (15 m) high. Three suspended walkways spanned the atrium at the second, third and fourth floor levels [see Figure 3 on following page]. These walkways connected the tower section and the function block. The third floor walkway was independently suspended from the atrium roof trusses while the second floor walkway was suspended from the fourth floor walkway, which in turn was suspended from the roof framing.
In the collapse, the second and fourth floor walkways fell to the atrium first floor with the fourth floor walkway coming to rest on top of the second. Most of those killed or injured were either on the atrium first floor level or on the second floor walkway. The third floor walkway was not involved in the collapse.
Following the accident investigations, on February 3, 1984, the Missouri Board of Architects, Professional Engineers and Land Surveyors filed a complaint against Daniel M. Duncan, Jack D. Gillum, and G.C.E. International, Inc., charging gross negligence, incompetence, misconduct and unprofessional conduct in the practice of engineering in connection with their performance of engineering services in the design and construction of the Hyatt Regency Hotel. The NBS report noted that:
The hanger rod detail actually used in the construction of the second and fourth floor walkways is a departure from the detail shown on the contract drawings. In the original arrangement each hanger rod was to be continuous from the second floor walkway to the hanger rod bracket attached to the atrium roof framing. The design load to be transferred to each hanger rod at the second floor walkway would have been 20.3 kips (90 kN). An essentially identical load would have been transferred to each hanger rod at the fourth floor walkway. Thus the design load acting on the upper portion of a continuous hanger rod would have been twice that acting on the lower portion, but the required design load for the box beam hanger rod connections would have been the same for both walkways (20.3 kips (90 kN)).11
The hanger rod configuration actually used consisted of two hanger rods: the fourth floor to ceiling hanger rod segment as originally detailed on the second to fourth floor segment which was offset 4 in. (102 mm) inward along the axis of the box beam. With this modification the design load to be transferred by each second floor box beam-hanger rod connection was unchanged, as were the loads in the upper and lower hanger rod segments. However, the load to be transferred from the fourth floor box beam to the upper hanger rod under this arrangement was essentially doubled, thus compounding an already critical condition. The design load for a fourth floor box beam-hanger rod connection would be 40.7 kips (181 kN) for this configuration. …
Had this change in hanger rod detail not been made, the ultimate capacity of the box beam-hanger rod connection still would have been far short of that expected of a connection designed in accordance with the Kansas City Building Code, which is based on the AISC Specification. In terms of ultimate load capacity of the connection, the minimum value should have been 1.67 times 20.3, or 33.9 kips (151 kN). Based on test results the mean ultimate capacity of a single-rod connection is approximately 20.5 kips (91 kN), depending on the weld area. Thus the ultimate capacity actually available using the original connection detail would have been approximately 60% of that expected of a connection designed in accordance with AISC Specifications.12
During the 26-week administrative law trial that ensued, G.C.E. representatives denied ever receiving the call about the design change. Yet, Gillum affixed his seal of approval to the revised engineering design drawings.
Results of the hearing concluded that G.C.E., in preparation of their structural detail drawings, “depicting the box beam hanger rod connection for the Hyatt atrium walkways, failed to conform to acceptable engineering practice. [This is based] upon evidence of a number of mistakes, errors, omissions and inadequacies contained on this section detail itself and of [G.C.E.'s] alleged failure to conform to the accepted custom and practice of engineering for proper communication of the engineer’s design intent.”13 Evidence showed that neither due care during the design phase, nor appropriate investigations following the atrium roof collapse were undertaken by G.C.E. In addition, G.C.E. was found responsible for the change from a one-rod to a two-rod system. Further, it was found that even if Havens failed to review the shop drawings or to specifically note the box beam hanger rod connections, the engineers were still responsible for the final check. Evidence showed that G.C.E. engineers did not “spot check” the connection or the atrium roof collapse, and that they placed too much reliance on Havens.
Due to evidence supplied at the Hearings, a number of principals involved lost their engineering licenses, a number of firms went bankrupt, and many expensive legal suits were settled out of court. In November, 1984, Duncan, Gillum, and G.C.E. International, Inc. were found guilty of gross negligence, misconduct and unprofessional conduct in the practice of engineering. Subsequently, Duncan and Gillum lost their licenses to practice engineering in the State of Missouri (and later, Texas), and G.C.E. had its certificate of authority as an engineering firm revoked.
As a result of the Hyatt Regency Walkways Collapse, the American Society of Civil Engineering (ASCE) adopted a report that states structural engineers have full responsibility for design projects.
Both Duncan and Gillum are now practicing engineers in states other than Missouri and Texas.
The responsibility for and obligation to design steel-to-steel connections in construction lies at the heart of the Hyatt Regency Hotel project controversy. To understand the issues of negligence and the engineer’s design responsibility, we must examine some key elements associated with professional obligations to protect the public. This will be discussed in class from three perspectives: the implicit social contract between engineers and society; the issue of public risk and informed consent; and negligence and codes of ethics of professional societies.
Annotated Bibliography
Davis, Michael, “Thinking Like An Engineer: The Place of a Code of Ethics in the Practice of a Profession,” Philosophy & Public Affairs, Vol. 20, No. 2, Spring 1991, pp. 150-167. (see also, “Explaining Wrongdoing,” Journal of Social Philosophy, Vol. 20, Numbers 1&2, Spring/Fall 1989, pp. 74-90.
In these lucid essays, Davis argues that “a code of professional ethics is central to advising individual engineers how to conduct themselves, to judging their conduct, and ultimately to understanding engineering as a profession.” Using the now infamous Challenger disaster as his model, Davis discusses both the evolution of engineering ethics as well as why engineers should obey their professional codes of ethics, from both a pragmatic and ethically-responsible point of view. Essential reading for any graduating engineering student.
Engineering News Report.
Throughout the hearings, Engineering News Report, published by the National Society of Professional Engineers (NSPE), kept vigilant watch over the case. Of particular interest are their following articles:
- “Hyatt Walkway Design Switched,” July 30, 1981.
- “Hyatt Hearing Traces Design Change,” July 26, 1984.
- “Difference of Opinion: Hyatt Structural Engineer Gillum Disputes NBS Collapse Report,” September 6, 1984.
- “Weld Aided Collapse, Witness Says,” September 13, 1984.
- “Judge Bars Hyatt Tests,” September 20, 1984.
- “Hyatt Engineers Found Guilty of Negligence,” November 21, 1985.
- “Hyatt Ruling Rocks Engineers,” November 28, 1985.
- “Construction Rescuers Sue,” August 7, 1986.
Glickman, Theodore S., and Michael Gough (eds.), Readings in Risk, Washington, D.C.: Resources for the Future, 1990.
This is an excellent collection of essays on managing technology-induced risk. As a starting-off point, of particular worth to the engineers are the essays: “Probing the Question of Technology-Induced Risk” and “Choosing and Managing Technology-Induced Risk,” by M. Granger Morgan; “Defining Risk,” by Baruch Fischhoff, Stephen R. Watson, and Chris Hope; “Risk Analysis: Understanding ‘How Safe is Safe Enough?’,” by Stephen L. Derby and Ralph L. Keeney; “Social Benefit Versus Technological Risk,” by Chauncey Starr; and “The Application of Probabilistic Risk Assessment Techniques to Energy Technologies,” by Norman C. Rasmussen.
Gibble, Kenneth (ed.), Management Lessons from Engineering Failures, Proceedings of a symposium sponsored by the Engineering Management Division of the American Society of Civil Engineers in conjunction with the ASCE Convention in Boston, October 28, 1986, New York: American Society of Civil Engineers, 1986.
This short work examines a variety of engineering failures, including those involving individual planning, and project failures. In particular see Irvin M. Fogel’s essay, “Avoiding ‘Failures’ Caused by Lack of Management,” and Gerald W. Farquhar’s “Lessons to be Learned in the Management of Change Orders in Shop Drawings,” both excellent illustrations for use with the Hyatt case.
Hall, John C., “Acts and Omissions,” The Philosophical Quarterly, Vol. 39, No. 157, October 1989, pp. 399-408.
This article is a discussion of the legal and ethical ramifications of professional choices and activities, both active and passive.
“Hyatt Notebook: Parts I and II,” Kansas City, October 1984 and November 1984.
These are two articles written by a Kansas City television reporter for the local magazine, Kansas City, detailing highlights from the 26-week Hyatt Regency Walkways Collapse hearings.
Janney, Jack R. (ed.), Guide to Investigation of Structural Failures, prepared for the American Society of Civil Engineers’ Research Council on Performance of Structures, sponsored by the Federal Highway Administration, U.S. Department of Transportation, Contract No. DOTFH118843, 1979.
This short volume gives an excellent overview of structural failure investigation procedures, and discusses failure causes by project type, structural type, and material, connection and foundation type. In addition, discussions on field operations, project management, and data analysis and reports are offered. Of particular interest to those studying the Hyatt case are sections 4.5-4.7, “Failure Causes Classified by Connection Type,” and “Steel to Steel Connections.”
Martin, Mike W. and Roland Schinzinger, Ethics in Engineering (2nd ed.), New York: McGraw-Hill Book Company, 1989.
An excellent text-book treatment of ethical issues in engineering. Of particular interest to this case is Part Two, “The Experimental Nature of Engineering,” and Part Three, “Engineers, Management and Organizations.”
McK Norrie, Kenneth, “Reasonable: The Keystone of Negligence,” Journal of Medical Ethics, Vol. 13, No. 2, June 1987, pp. 92-94.
This article is a brief discussion of legal liability for professional actions. “The more knowledge, skill and experience a person has, the higher standard the law subjects that person to” (p. 92).
PDF version: Missouri Board for Architects, Professional Engineers and Land Surveyors vs. Daniel M. Duncan, Jack D. Gillum and G.C.E. International, Inc., before the Administrative Hearing Commission, State of Missouri, Case No. AR840239, Statement of the Case, Findings of Fact, Conclusions of Law and Decision rendered by Judge James B. Deutsch, November 14, 1985, 442 pp. Note this is a BIG file – 20 Mb!
Word version: Missouri Board for Architects, Professional Engineers and Land Surveyors vs. Daniel M. Duncan, Jack D. Gillum and G.C.E. International, Inc., before the Administrative Hearing Commission, State of Missouri, Case No. AR840239, Statement of the Case, Findings of Fact, Conclusions of Law and Decision rendered by Judge James B. Deutsch, November 14, 1985, 442 pp. This has been changed to Word format, without any checking. Many errors are found when the scanner attempted to transcribe the pdf file to Word, but no one has found the time to correct the conversion
This volume contains the findings, conclusions of law and the final decision of the Hyatt Regency Walkways Collapse case, as rendered by Judge James B. Deutsch. The volume contains both the findings of the case and an excellent general discussion of responsibilities of the professional engineer.
Pfrang, Edward O. and Richard Marshall, “Collapse of the Kansas City Hyatt Regency Walkways,” Civil Engineering-ASCE, July 1982, pp. 65-68.
Official findings of the failure investigation conducted by the National Bureau of Standards, U.S. Department of Commerce. Among its conclusions was this: “Even if the now-notorious design shift in the hanger rod details had not been made, the entire design of all three walkways, including the one which did not collapse, was a significant violation of the Kansas City Building Code.”

Lobby Area

June 1981

Post Collapse

MCI Triage Operations
National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program
No commentsVideo Clip recorded live by Fire Department Network News TV (FDNNTV) at the 50th IAFF Fire Fighter Convention in San Diego, CA on August 23, 2010.
The National Institute for Occupational Safety and Health, also known as NIOSH, is a federal agency that is part of the Centers for Disease Control. NIOSH has a mission of generating new knowledge in the occupational safety and health field and to transfer that knowledge into practice for the advancement of workers, including firefighters and emergency responders.
In 1998, the International Association of Fire Fighters (IAFF) requested that Congress fund NIOSH to start a firefighter safety initiative called the NIOSH Fire Fighter Fatality Investigation and Prevention Program. “We investigate fatalities to learn from the mistakes the others made and to try to prevent future fatalities and injuries from occurring in similar events,” stated Project Officer Tim Merinar with the NIOSH Fire Fighter Fatality Investigation and Prevention Program. According to NIOSH, the Fire Fighter Fatality Investigation Program has made over 1,000 recommendations arising from over 300 investigations since its inception in 1998.
Merinar claimed that some do not fully understand who NIOSH is and what their goals are, often being confused with OSHA. However, the National Institute for Occupational Safety and Health is not an enforcement agency, they are a research and education agency. Merinar added, “We’re not looking to find fault or place blame on the fire departments or the individual firefighters in the incidents.”
As soon as possible after an incident, a NIOSH investigator will meet with the fire department. “Oftentimes, we have to explain who we are, why we’re there, what we’re trying to accomplish,” added Merinar. NIOSH investigates as many firefighter fatalities as possible involving structure fires, deaths from cardiovascular disease, as well as deaths during non-fireground incidents.
NIOSH offers many different publications to firefighters, including their newest one about risk management at structure fires. This literature is distributed to the fire service free of charge. Another publication offered to firefighters deals with floor joists and the risk of falling through fire-damaged floors. “They work very well for the construction industry, but when they’re exposed to fire they also fail very rapidly. Which leads to early building collapses,” explained Merinar. “Many firefighters have been injured and killed in these collapses.”
NIOSH FFFIPP
Trends such as this uncovered during their investigations and spread to the fire service, could help prevent future deaths. Another trend found several years ago by NIOSH involved PASS devices not sounding on firefighters who died. According to Merinar, NIOSH worked with the National Fire Protection Association to have the standard changed to make the PASS devices more reliable and more effective for firefighters. Currently, they are working with the NFPA on the thermal degradation characteristics of face piece lenses.
Fire Fighter Fatality Investigation and Prevention Program
For more information on the NIOSH Fire Fighter Fatality Investigation and Prevention Program, incident reports or fire fighter publications, visit www.cdc.gov/niosh/fire/.
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Stakeholder Comment on the National Institute for Occupational Safety and Health (NIOSH) Fire Fighter Fatality Investigation and Prevention Program (FFFIPP)-2011
The National Institute for Occupational Safety and Health (NIOSH) is seeking stakeholder input on the progress and future directions of the Fire Fighter Fatality Investigation and Prevention Program (FFFIPP). Since its initiation in 1998, NIOSH has sought public input to help plan and direct the goals and objectives of the FFFIPP. NIOSH received public comments on the FFFIPP in 1998, March 2006, and November 2008. NIOSH is again seeking input on the progress and future directions of the FFFIPP to ensure that the program is meeting the needs and expectations of the U.S. fire service and to identify ways in which the program can improve its impact on the safety and health of fire fighters across the United States. NIOSH will compile and consider all comments received and use them in making decisions on how to proceed with the FFFIPP.
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Related Dockets
NIOSH Docket number 063NIOSH Docket number 063-A
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Robert A. Taft Lab.
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Cincinnati, Ohio 45226
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4676 Columbia Parkway, Room 111
Cincinnati, Ohio 45226.
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Contact persons for technical information
Chief, Fatality Investigations Team
NIOSH/CDC
1095 Willowdale Road
Mailstop H-1808
Morgantown, WV 26505
304/285-6016
Recent NIOSH Fire Fighter Safety Publications
Preventing Deaths and Injuries of Fire Fighters Operating Modified Excess/Surplus Vehicles
DHHS (NIOSH) Publication No. 2011-125
Fire fighters may be at risk for crash-related injuries while operating excess and other surplus vehicles that have been modified for fire service use. Fire departments with limited resources often craft fire apparatus out of excess/surplus military and other vehicles as an affordable alternative to purchasing new or used apparatus. NIOSH urges fire departments to take precautions and actions to minimize the hazards and risks to fire fighters when using modified excess/surplus vehicles.
Evaluation of Chemical and Particle Exposures During Vehicle Fire Suppression Training (2010)
(56 pages, 4.85 MB)
Health Hazard Evaluation Report, HETA 2008-0241-3113
In September 2008 and July 2009, NIOSH researchers collected area and personal breathing zone air samples during a Health Hazard Evaluation (HHE) to evaluate firefighters’ exposures to airborne chemicals during vehicle fire suppression training. Several hazardous chemicals were found on the area samples, including respiratory toxicants and potential carcinogens. Of the chemicals measured in the personal breathing zones, levels of formaldehyde, carbon monoxide, and isocyanates were near or above short term exposure limits or ceiling limits. In addition, the number of particles and mass of the particles in the air increased during knockdown and remained elevated throughout the fire overhaul. Based on this evaluation, the levels of gases and particles released during vehicle fires have the potential to cause acute health effects to firefighters who do not wear self-contained breathing apparatus.
NIOSH Alert: Preventing Deaths and Injuries of Fire Fighters using Risk Management Principles at Structure Fires
DHHS (NIOSH) Publication No. 2010-153
Fire fighters are often killed or injured when fighting fires in abandoned, vacant, and unoccupied structures. These structures pose additional and sometimes unique risks due to the potential for fire fighters to encounter unexpected and unsafe building conditions such as dilapidation, decay, damage from previous fires and vandals, and other factors such as uncertain occupancy status. Risk management principles must be applied at all structure fires to ensure the appropriate strategy and tactics are used based on the fireground conditions encountered.
Preventing Exposures to Bloodborne Pathogens among Paramedics
DHHS (NIOSH) Publication No. 2010-139
Patient care puts paramedics at risk of exposure to blood. These exposures carry the risk of infection from bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), which causes AIDS. A national survey of 2,664 paramedics contributed new information about their risk of exposure to blood and identified opportunities to control exposures and prevent infections.
Preventing Deaths and Injuries of Fire Fighters Working Above Fire-Damaged Floors
DHHS (NIOSH) Publication No. 2009-114
Fire fighters are at risk of falling through fire-damaged floors.
Fire Fighter Fatality Investigation and Prevention Program: Leading Recommendations for Preventing Fire Fighter Fatalities, 1998–2005
DHHS (NIOSH) Publication No. 2009-100
This document is a synthesis of the 1,286 individual recommendations from the 335 FFFIPP investigations conducted from 1998 to 2005.
Fire Fighter Fatality Investigation and Prevention Program Evaluation
NIOSH report of findings from its national survey of U.S. fire departments.
Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events
DHHS (NIOSH) Publication No. 2007-133
Fire fighters are at risk of dying on the job from preventable cardiovascular conditions.
FDA AND NIOSH Public Health Notification: Oxygen Regulator Fires Resulting from Incorrect Use of CGA 870 Seals
This document provides information on the danger of fires at the interface of oxygen regulators and cylinder valves because of incorrect use of CGA 870 seals, and identifies measures to prevent such fires.
NIOSH Alert: Preventing Injuries and Deaths of Fire Fighters due to Truss System Failures
DHHS (NIOSH) Publication No. 2005-132
Fire fighters may be injured and killed when fire-damaged roof and floor truss systems collapse, sometimes without warning.
NIOSH Workplace Solutions—Preventing Deaths and Injuries to Fire Fighters During Live-Fire Training in Acquired Structures
DHHS (NIOSH) Publication No. 2005-102
Fire fighters are subjected to many hazards when participating in live-fire training. Training facilities with approved burn buildings should be used for live-fire training whenever possible. However, when acquired structures are used for live-fire training, NIOSH strongly recommends that fire departments follow the national consensus guidelines in NFPA 1403, standard on live-fire training evolutions [NFPA 2002a] to reduce the risk of injury and death. These guidelines are summarized in the recommendations in this document.
Radio Communication
The past few decades have seen major advancements in the communication industry. These advancements have improved radio frequency spectrum efficiency, but also have added complexity to the expansion of existing systems and the design of new systems. The U.S. Fire Administration in conjunction with the International Association of Fire Fighters has released the report Voice Radio Communications Guide for the Fire Service
3.85 MB (77 pages) This report is designed to help fire service leaders and members understand new communication and radio system issues in order to remain informed players in the process.
Current Status, Knowledge Gaps, and Research Needs Pertaining to Firefighter Radio Communication Systems
The National Institute for Occupational Safety and Health (NIOSH) commissioned this study to identify and address specific deficiencies in firefighter radio communications and to identify technologies that may address these deficiencies. Specifically to be addressed were current and emerging technologies that improve, or hold promise to improve, firefighter radio communications and provide firefighter location in structures.
The National Institute of Standards and Technology, Building and Fire Research Laboratory publication “Testing of Portable Radios in a Fire Fighting Environment”
265 KB (24 pages)
focuses on the thermal environment that radios would be expected to withstand while being used in structural fire fighting operations. Current NFPA standards for radios are reviewed and recommendations for establishing performance standards are presented. The need for providing additional protection from the thermal environment is documented.