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Samarco Fundão Dam Failure mode and effects analysis FMEA became the center of a recent article in the Brazilian media which described an exchange of messages by Samarco’s internal communication system, reportedly between the company president at the time of the breakup of the Fundão Dam, Ricardo Vescovi, and various directors. In the exchange they discussed the use of FMEA.
The newspaper Estado de São Paulo had reportedly access to the transcript, made with judicial authorization and presented in the final report of the Federal Police about the tragedy of November 5, which left 18 dead and 1 missing.
As a preamble we acknowledge that Mr. Vescovi’s lawyer, wrote in a note to the newspaper that “the Federal Police investigation report is a provisional document based on unilateral understanding”. “Ricardo Vescovi never received any notice or warning of possible impairment of safety Fundão Dam. He did not try to hide information of any sort. On the contrary, the information received about incidents, natural operation, indicated that the dam was within the safety standards. That was in accordance with statements by various specialists.”
From the transcripts it becomes apparent that management of the mining company knew of the problems already in August 2014. That was more than a year before the disaster. Top management stated to Brazilian Federal Police the instability problems were unknown to top management. They also stated operation’s managers dealt with them.
A discussion on the Fundão Dam reliability took place in 2011, following the same sources. Talking about the results of the FMEA (Failure Mode and Effect Analysis) of the Fundão Dam, Management asked whether “the likelihood of any problems happening had changed or just the severity (stiffness structure)? ”
Original Portuguese: Vescovi indaga se “mudou a probabilidade (de acontecer algum problema) ou apenas a severidade (a rigidez a estrutura)?”
We will pause here to note that, due to the arbitrary nature of FMEA (PIGs, risk matrix) cells limits, management would have the greatest difficulty to understand if the likelihood had really changed. We also note that the glossary was confused as the severity does not have, at first sight, any link with the “stiffness” of a structure, unless a lengthy explanation would state that the “stiffness” is related to the velocity of development of a breach…
The transcript continues. “I think this point is the most important of all. It allows to show that things have not got worse. We are just being more critical in the assessment of severity”.
Original Portuguese. “Acho esse ponto o mais relevante de todos, pois é o meio de mostrarmos que as coisas não pioraram, apenas estamos sendo mais críticos na avaliação de severidade”. (July 27, 2011, at 23h58 in response to a question from the mine).
FMEAs are performed periodically as a way to monitor physical conditions of dams, but they do not necessarily hep management focusing on relevant issues.
They could help defining operation strategy and tactical planning, but they lack finesse.
They should bring to light rational and unbiased prioritizations of risks, but, for a number of reasons explained elsewhere, they generally do not.
At Samarco management used them as a persuasion tool. “It is worth bringing up in the text something that corroborates a low probability of an event. An FMEA for example, beyond the opinion of ITBR”. ITBR was the internal committee formed by Samarco employees and also external experts. ITBR’s task was to evaluate the mining structures, with meetings every four months.
Original Portuguese. “Vale a pena abordarmos no texto algo que corrobore com uma baixa probabilidade de um evento. Como o FMEA por exemplo, além da própria opinião do ITBR”.
The Law will define who was legally at fault and liable in the case of the Samarco catastrophe. It is not to us to make any judgement or suggest any fault. That in particular to show respect to the victims, the families to all those involved in the accident.
At Riskope we have been claiming that ethics and rational thinking have to be fostered when dealing with critical infrastructures having potential to generate significant accidents.
We are continuously and relentlessly fostering better understanding of risk assessment methodologies, use of proper glossary and ways to better communicate risks via our courses and seminars.