No failure no accident in man-made disasters in construction

. Construction is an industry that carries the risk of causing human death, and the destruction of assets and the environment. Several cases such as girder collapse, crane overturning, formwork collapse, and material landslides have occurred recently in large-scale infrastructure projects in Indonesia. Currently, construction accident theory describes active and latent failures in management, and human as well as technical issues. The purpose of this paper is to propose the theory of no failure no accident in any man-made disaster. A further review of literature studies is used to outline current research findings on management, technical, and human failures leading to catastrophic events. Evidence-based reasoning from 5 cases of catastrophic events in construction is described to reveal failure modes that lead to incidents and accidents. In this paper, firstly the failure modes and their effects are described based on the literature review, and secondly, empirical evidence of failure modes is presented using selected disaster cases recorded by the Construction Safety Committee, Ministry of Public Works, and Public Housing. Finally, this paper concludes that failure modes represent the quality of systems, services, procedures, goods, and personnel that is defective to contribute to a catastrophic event that causes damage to people, the public, property, and the environment.


Introduction
The construction industry not only plays an important role in increasing economic growth [1] but carries high risk of human death both workers and public, and destruction of properties and built assets as well as environmental damages.Several cases such as girder collapse, crane overturning, formwork collapse, and material landslides have occurred recently in large-scale infrastructure projects in Indonesia.Construction accidents result in an increase in direct and indirect costs.Direct costs include insurance costs, worker's medical expenses, and costs for property loss or damage, while indirect costs include increased transportation costs and time delay penalties [1][2][3].
In 2021, the number of general accidents in Indonesia is 234,270 cases.The number increased by 5.65% from the previous year which was 221,740 cases (BPJS, 2021).Some construction accidents occuring in many infrastructure projects in Indonesia were catastrophic dangerour occurrence.Aamong others were the collapse of a girder on the Pasuruan Toll Flyover Bridge Construction Project in Probolinggo in 2017.This catastrophic events was caused by a crane lifting operation for a erecting PCI girders and bumping installed girders.Another dangerous occurrence was shifting heavy equipment portal gentry cranes which caused the crane to overturn in the Kelapa Gading Light Rail Transit (LRT) project area, North Jakarta in 2017.Evidences on site show some suspected causes were improper equipment operating methods.A case of overturning of a mobile crane when it was about to install a digital sign weighing six tons on the Jakarta-Cikampek KM 15 Toll Road Section in 2017.The suspected cause was the competency of the operator.A case of collapse of the Becakayu Toll Pier Head formwork in Jakarta in 2018 has suspected cause was the pier head formwork being cast was not strong enough to withstand the load.The gondola in the Hospital Building Expansion Project Islam (RSI) Unisma Malang fell down in 2020.It was investigated that the cause was its steel rope broken down due to an overload carried by the gondola.Last year (2021) the catastrophic accident of three workers in the Pacal Dam Land Retaining Wall (TPT) Construction Project in Bojonegoro Regency hit by a concrete retaining iron.It was allegedly due to several workers doing work on iron rams for TPT construction, but suddenly the soil of the embankment adjacent to the project being carried out were facing a landslide.The landslide pushed the concrete iron that was being rammed to collapse and hitting the three victims who were working nearby.
The objective of this paper is to propose the theory of no failure no accident in any man-made disaster.A further review of literature studies is used to outline current research findings on management, technical, and human failures leading to catastrophic events.Evidence-based reasoning from 5 cases of catastrophic events in construction is described to reveal failure modes that lead to incidents and accidents.In this paper, firstly the failure modes and their effects are described based on the literature review, and secondly, empirical evidence of failure modes is presented using selected catastrophic accident cases which were investigated.Finally, this paper concludes that failure modes represent the quality of systems, services, procedures, goods, and personnel that is defective to contribute to a catastrophic event that causes damage to people, the public, property, and the environment.

Construction accident
The National Safety Council (NSC) defines an accident as an incident or a sequence of incidents that results in injury, death, or unwanted property damage.Accident refers to the event, not to the outcome of the event.Pure Chance Theory considers accidents to be fate.Human factors are not considered the cause of construction accidents but incidents or accidents occur because of God's will.Then the accident theory further states that the main factors causing accidents are humans such as The Biased Liability Theory, The Unequal Initial Liability, The Stress Theory, and The Alertness Theory [2] with several perspectives respectively.Meanwhile, the Ergonomic Theory states that accidents occur when individuals interact with tools/machines in their work environment.This theory also considers external barriers from operators such as other personnel factors, methods, and work environment as factors that also contribute to accidents [4].
So far, accident investigations have adopted the theory of accident-causing mechanisms proposed by Heinrich (1930) in domino theory.Heinrich (1930) postulated that accidents are analogous to five dominoes that are arranged vertically close together which describes the causal process of how accidents occur.Each domino represents the element causing the accident.The first three dominoes describe environmental and social factors resulting in human error or disability, resulting in unsafe acts, while the last two dominoes describe accidents and injuries.If one of the first three dominoes is removed there is a potential for accidents and injuries.However, when the domino in the center is removed, an accident may not occur because the chain is broken.That is, the factor of human error or disability is the dominant cause of accidents or injuries [2,4,5].The domino theory was modified by Bird (1974) who expressed that the role of management, origin, and unsafe conditions are the causes of accidents.The role of management is considered to be the root cause of accidents.Originating factors and unsafe conditions are prerequisites for accidents and are triggered by a lack of management control.Lack of management control causes a decrease in operational and technical system performance standards which can increase the probability of the risk of accidents [2,4,6] in the tripod theory made an analogy that latent failures in the system are directly likened to pathogens that stick to the human body, coupled with triggering factors such as stress, chemical toxins, bad weather conditions, and the like defeating the immune system and causing disease.Diseases arise because of the role of pathogens in the organ systems of the human body.The more pathogens developed, the greater the chance of disease emergence.The more complex a system, the more likely it is that more pathogens enter the system.Accidents occur due to "pathogens that persist in the human body system" or what can be called failure then spread to lowerlevel organizations to higher levels and then lead to unsafe conditions and behavior, for example, workers commit violations and then enter dangerous areas and allows accidents to occur if there is neglect or no protection.This theory also proposes a series of accident events that is similar to a domino sequence, where fallible decisions, defects in management functions, and psychological aspects of operators are latent failures as causes of accidents resulting in unsafe actions but if there is no proper protection then accidents could happen.Furthermore, this theory was further developed by Groeneweg (1994) also postulating that accidents are a direct result of violations caused by disturbances in the work area that occur due to behavioral mechanisms that do not meet standards, and under certain conditions, this behavior is produced by sources of failure in the workplace outside the work area such as design, machinery/equipment, procedures, training, mismatched objectives, communication, organization, maintenance, and protection management could also be the root cause of accidents [4].
Bellamy and Geyer (1992) in the sociotechnical theory explain that the chronology of accident events is described as a pyramid, with several levels initiated from level 5 to level 1, where level 5 is failures originating from technological knowledge, technical standards, and codes.corporate practices (legislation and regulation systems, public opinion and pressure, and political climate), availability of resources i.e. people and equipment, economic climate, population, and natural disasters.At the fourth level, sources from the organization and management include organizational objectives, standards of maintenance and improvement, team formation and organization, resource allocation, data collection systems, performance monitoring, the definition of lines of responsibility, and accountability.Then the third level comes from communication, information, and feedback control, which discusses the ways that occur within the organization and processes related to appropriate feedback, deviations from the system's goals are communicated, and then at the second and the first level relates to the duties/responsibilities of operators and systems engineering covering hardware, software as well as systems and operating techniques.If you don't have a proper protection system, accidents can happen.Whittington et al (1992) in The Failure Initiation Theory stated that in detail the failures initiated the occurrence of accidents.This theory assumes that accidents in construction projects result from failures initiated by individuals, field management, project management, and organizational policies [4].
In Constraint-Response Theory which also adheres to Heinrich's Domino Theory (1930) stated that each individual in the project organization introduces factors that lead directly or indirectly to the occurrence of accidents [4].Each participant in the project organization has limitations or constraints in certain situations in the project environment.The response of one of the project participants will affect a construction activity on the project.The construction process that begins with construction planning, implementation, control, and inadequate working environment conditions can trigger the formation of latent failures.Departing from the accident theory above which explains the source of failure as the cause of an incident or accident, further discusses active and latent failures which include management failures, technical failures, and human failures.

Construction failures
Claimed structural failure during construction is related to the unsuitability of the work carried out during the construction process [7].Revealed that one of the main reasons for structural collapse is the failure to adequately consider construction loads which may actually be greater than the service load of the building [8].Also defined failure as the inability of a constructed facility or its components to perform as specified in the design and construction requirements [9].Such collapse or failure may not result in death or injury.However, it can result in significant losses in the economic aspect, as it is known that usually, the main factor of failure is in the method, model, and mechanism of work accidents [10].Further literature study is described in this paper to outline the current research findings on management, technical, and human failures that lead to accidents.

Management failures
Project management is the application of knowledge, skills, tools, and techniques to project activities in order to meet project requirements.And all must be managed expertly to deliver the results on time, within budget, and learning and integration required by the organization.According to experts, an organization is defined as the process of determining and grouping the work to be done, assigning and delegating authority and responsibility with a view to enabling people to work together effectively in achieving goals.The project organization consists of project participants who are accompanied by their respective roles and responsibilities in achieving the success of a project, especially in implementing construction safety with a "zero accident" commitment.All infrastructure project participants including clients, main contractors, subcontractors, designers, and suppliers are required to be able to commit to construction safety.In this case, the client has an interest in realizing a "fit and purpose" construction, assisted by the designer in terms of minimizing the risk of planning failure that may exist and the contractor as the builder is obliged to carry out the requirements set out in the contract.Misinterpretations, unclear contract clauses, and incomplete ones have the potential to be the cause of contractor failure in executing the construction process [11].
Investors as owners and sources of capital from an infrastructure project already have a strategy for making a decision on whether the project is feasible or not.Generally, infrastructure projects in Indonesia require a financial feasibility analysis [12] with large budgets and even foreign assistance such as infrastructure projects for dams, weirs, bridges, irrigation, ports, airports, monorails, coastal reclamation, toll roads, housing, and so on.has a large potential risk to project financial, environmental, social and technical problems in the field.In terms of construction activities in the field, it seems that the contractors and subcontractors are fully responsible for this.In this case, there is a "gap" between duties and responsibilities.Sometimes, subcontractors do not have the knowledge or experience in implementing a similar project, nor do they provide an adequate safety program or a "rough" safety cost plan, requiring a review of the procurement mechanism.It is often suspected that the cause of project failure is the practice of collusion in the procurement of service providers [13][14][15].Bid competition from bidders and the traditional lump sum contract type can be said to be a latent failure in construction projects [16].
Failure also arises due to fallible decisions [15,17,18] made by parties who do not have the right knowledge or understanding to make decisions, especially related to technical issues.This lack of knowledge has two indications.One of them is depth of knowledge, where an engineer who is skilled in overall decision-making has no specific knowledge for a particular task.While the second indication is ignorance it involves interdisciplinary decision-making without extensive knowledge [19] Whereas problems that arise regarding structural and construction failures are associated with technical and management errors made during the construction phase of the construction process caused by inadequate coordination and communication procedures between engineers, designers, and contractors [11], lack of control over behavior workers in the project, time pressure and new types of work unfamiliar to the work team (Winge et al, 2019).[11], [13], B.Amade (2015) Lack of communication (among project team or to workers) [11], [15], [20], [23], [26][27][28][29][30] Poor site management [11], [31], [32], B. Amade (2015) Inappropriate project risk management B. Amade (2015)

Technical failures
Technical failures are related to problems with materials, tools, supporting structures, construction processes, and environmental factors at the project site.Based on cases of structural failures that occur in infrastructure projects such as girder collapse, crane overturning, or material landslides, it is inseparable from technical errors in project implementation.Failure is the main and most serious consequence of structural failure, but overstress is also seen in the early stages through the development of deformation and fracture.If a structure is properly designed and constructed according to the design, the overstress indicates several other failures, such as the use of inappropriate materials [11,22,27,33].Most of the construction uses local materials [22] because they are easily available such as cement, wood, stone, brick, and sand.In material management, it is necessary to understand material properties and diagnose defects or non-conformances to the specified specifications.Therefore, the preventive efforts made by designers, contractors, and engineers involved in the material selection must be familiar with commonly used materials and have a deeper understanding of their transport and storage techniques [15], [33][34][35][36].
Structural failures often arise due to human errors made during the design process.Errors in the design process when viewed from personnel factors are caused by the level of ability, experience, accountability, or personality type of the designer.Meanwhile, if viewed from organizational factors, it is caused by lack of education or training, lack of resources, lack of professionalism, absence of technology use, and if viewed from project-related factors, errors are caused due to inaccuracies in determining the scope of work and there is no integration between design and other considering factors [11].Lack of workability in construction can result in defects resulting in changes in appearance due to lack of attention to foundation design can cause ground motion indicated by cracks in brick walls, construction changes; perhaps also with a sagging roof, and changes in shape (Ashley, 1985).Defective work can be described as work that fails to meet the description or contract requirements, including particularly the drawings or specifications, along with all that is implied, quality, workmanship, performance, or design [26].Failures can also occur during the expected service life of a structure, for example, the catastrophic collapse of bridges and other structures due to a lack of maintenance after many years of construction [35].

Controlling
Lack of quality control [39] Lack of project audit [26]

Human errors
In the theory of construction accidents which is based on the causal model of safety behavior, humans are the main cause of injury or fatality.The human error arises because of activities carried out beyond their capabilities (Ferrel et al, 1997 cited by DeCamp, Whitney et al, 2015).This is related to the competencies possessed by workers including knowledge, experience, and age, although there are humans who have innate traits that are prone to accidents.Workers will feel comfortable working if the work environment is comfortable and familiar to them.The incompetence of project managers, staff, foremen, and workers is a factor causing the human error which is discussed in several studies [20,35,28] quoted by J Yates, 2002, [22,44,14,45,39,15].Bentley (1981) cited by Atkinson (1999) has investigated the causes of declining building quality due to lack of skills, lack of maintenance, lack of knowledge of field operators, poor construction skills, low design quality, and unclear project information based on observations on 27 building constructions.Managerial influences underlie many errors that cause construction defects such as "pathogens" that persist in a system, giving rise to a series of errors that result in what the operator did [26].For example, defects in building structures such as dampness in plastering on walls, improper foundation design due to soil movement cause cracks in brick walls, and structural changes such as sagging roofs, changes in the shape of building components, and so on (Ashley, 1985 cited by Hasan M et al. 2016).
Table 3. Literature review on human failures.

Unsafe Acts
Error/omission by workers [26] Disobedience/violation [14] Lack of worker's awareness of the importance of safety [14], [27] Refusal to accept knowledge and technology for operations [13]

Findings & discussion
Findings from those literature reviews assist to uncover existing failures modes whether technical failures, management or organizational failures or human operative failures of any catastrophic accidents in construction.In this paper, evidential failures in two catastrophic accidents were analysed according to fact findings of investigation and/ or forensic engineering.The first accident involved a mobile crane collapse during lifting operation in a toll road project.
The second accident involved one heavy truck and one minibus belong to public have overtuned in an excavation work of underpass road project.The constraint-response theory of accident causation [4] was employed to present the causal structure of those two catastrophic accidents.The following figures describe evidences of failure modes and causal structure of the two catastrophic accidents.
The following figure 1 identifies various failure modes covering technical failures, human failures dan management failures leading to boom crane collapse which cause damage to properties and traffic congestion.It can be seen that technical failures mostly occurred in the first place, then human failures and finally management or organizational failure s respectively.Using the constraintresponse theory of construction accident causation, figure 2 describes identified causal structure of boon crane collapse.The structure shows that deficient construction process such as inappropriate site condition, inappropriate construction operation or method statement and inappropriate construction plan and control are preconditioning events instigating to any failure.
Figure 3 and 4 also present the same issues of existing failure modes to lead to trench collapse in a underpass project.Instability of trench slope under excavation works was the failure.However, there is no single failure mode of ground condition but it shows that multiple failure modes also happened.The case also figures out that many defective system, services, procedure, goods and personel are contributing factors toward the failure.All those defects are actually substandard acts or non-conformance to standards.It reflects any failure to potentially lead to any accident.For instance, sling broken, reduced lifting capacity ratio and unsuitable temporary retaining wall are of important evidences showing substandard acts.Looking at those defective evidences, it can be explained that defects lead to failure modes lead to incidents lead to accidents.Therefore, the preposition of no failure no accident is valid.The preposition conveys that preventing accident must deal with preventing any failures while preventing any defects.Preventing any defects within all aspect of construction process means compliance to norm, standard, code and criteria of project management requirements including technical and non-technical aspects.The figure 1 shows that broken of sling is technical failures due to technical defect of 50% reduced lifting capacity.The figure 3 also describes trench collapse to lead to truck and minibus overtuned.There are many technical defects, managerial defects and operasional defects leading to the active failure.The figure 1 also addresses defective lifting equipment, ground condition, lifting procedure, lifting plan and operation, project planning, and also construction hazard assessment.[4] categorised those defects under substandard, inadequate, inappropriate, unsuitable, improper, deficiencies of site condition, operative action, construction operation, construction control and construction plan.The figure 2 and figure presents causal structure of boom crane collapse and trench collapse.Learning from the case as described in figure 2 and  4, there are many contributory factors leading to actives failures.Those contributing factors lie dormant within contractor's project management, designer's project management and client's project management.Those factors reflect latent failures leading to defective or deficient construction and instigating active failures and finally accidents.Gibbs, et al (2005) found permanent work design, projecst management and risk management are originating factors to lead to accident causation.Symbersky (1995) called conceptual design and detail design have higher ability to influence safety.

Conclusions
This paper addresses the no failure no accident theory.This theory reflects that the more failures the most likely of accidents.The findings of the literature reviews show that many failure modes and they can be categorised into technical failures, management and organisational failures and human operative failures.Empirical evidences from accident analysis found that those various failures stem from defective or deficient construction process such as improper materials, inappropriate equipments, unstable ground, unsuitable workplaces, inadequate site condition, and also improper construction operation, lack of construction control and inappropriate contruction plan.The causal structures of failure modes to lead to accident show that any constraint and improper respond to the constraints may result in latent failures lie dorman within project conception and project planning & design.It can be concluded that defects or substandard acts contribute to failure modes and finally to lead to accidents.This paper recommends that preventing catastrophic accidents in construction should address elimination, reduction or avoidance of any potential defects within every stage of project life cycle from preproject up to commissioning.Further researches cover investigation of number and various type of defects contributing to vulnerability of construction industry.

Table 1 .
Literature review on management failures.

Table 2 .
Literature review on technical failures.