Dressed to Kill: The 130 Liberty Street/ Fire – Lessons Learned in Complexity, Leadership and Performance Agenda

• Project & Incident Description

• Construction projects as complex systems

• System conditions in place that “dressed to kill”

• Conclusions/outcomes project & incident description Deutsche Bank Building • 130 Liberty Street, NY, NY • Original Name: Bankers Trust • Original Cost: $76 M • Completed: 1977 • 40 stories, 536 ft. high (136 m) • 1.4 million sq. ft. (130,000 sq. meters) • Floor plate: 43,000 sq. ft. (4046 sq. meters)

Deutsche Bank Building - 2004

• Deutsche Bank and insurance company dispute resolved • LMDC (NY State) assumes ownership • Structurally repaired • Contamination includes: , dioxin, lead, quartz, polycyclic aromatic hydrocarbons, and manganese

• FDNY Abatement & Deconstruction Plan

• Clean (abate) five floors working from top • Maintain a 5 floor buffer zone • Deconstruct floors above buffer zone concurrent with lower floor abatement • Abate 3 floors at a time inside of containment (negative pressure environment) • Perimeter air monitoring on scaffolding around the building and adjacent buildings • Major premise: All porous building materials will be treated as ACM (i.e., everything except steel and concrete – non-porous materials) August 18, 2007 • Building is deconstructed down to 24th floor and cleaned down to 19th • Deconstruction contractor has $20 million in outstanding invoices • Time frame for cleaning a floor is 8 weeks vs. 2 week estimate (note: dispute and resolution*) • Discovery of 785 pieces of victim remains in building delay progress • Excessive pressure from Port Authority NY/NJ – “this project is holding up the redevelopment of the WTC complex” • Fire department has not visited the site for over a year vs. every 15 days as required • Standpipe system in building has not been tested for 6 months – meets code requirements. • Workers are smoking in designated areas on site – some compliance issues

* Governor administration struck a deal to pay the contractors up front and negotiate or litigate over cost later

August 18, 2007 – Fire • Fire discovered by hoist operator • End of shift on Saturday • All personnel in building successfully evacuated • Fire believed to be started by someone smoking • Fire standpipe system non- operational • Negative pressure system in operation at the time

construction projects as complex socio-technical systems Construction Projects

• Exists across a time horizon with discrete phases (life cycle): Conceptual – Design – Planning – Procure – Construction – Operate – Deconstruct

• Multiple-0rganizational project structure (30-40 companies) each executing a piece of the scope of work

• Changing work environment

• Transient workforce

• Aggressive schedules with integrated penalty/reward criteria

• Highly competitive bid structure Construction Projects

• A complex, dynamic, resourced-constrained environment

• Teams must reconcile multiple opposing goals using local rationale

• Constantly hunting for efficiencies • Productivity gains by borrowing against safety margins in ways that are not measured or outcomes predicted

• All normal things to do

• Most safety tools in place are designed for simple, linear systems NYC 10 year -Construction Fatalities 35

30 32 29 25

20 22 21 15 18

10 12 8 7 7 5 6 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 system conditions in place that “dressed to kill” System conditions

• Largest abatement project in NYC history

• Largest demolition/deconstruction project in NYC history

• Simultaneous abatement & deconstruction operations

• Significant cost and schedule pressure (over budget and behind schedule prior to start)

• 11th hour change in project team entities System conditions

• Unprecedented regulatory oversight and presence

• Significant community involvement and outrage

• Political pressure – New York City (Mayor) vs. New York State (Governor)

• Hints of organized crime affiliation amongst some companies System conditions

• Overlapping regulatory jurisdictions with little analysis of the effects of simultaneous compliance outcomes

• Adjacent buildings with similar levels of contamination not being approached the same

• Ambiguity associated with levels of contamination and what it meant to worker and community safety/health

• Lingering emotional trauma from the events of 9/11 as a context outcomes & conclusions Outcomes • City claimed sovereign immunity to prosecution

• Fire Department & Building Department admitted failures

• Three individuals indicted on 4 counts each (two counts of manslaughter, one count of criminally negligent homicide and one count reckless endangerment).

• New standards created for construction, demolition and abatement

• Project would eventually restart and be completed in 2010 (without incident)

• Project cost would escalate from the original $90 million to ~$400 million conclusions • Complex vs. simple

• Making something so safe that it becomes dangerous

• Good intentions colliding with a paralyzing fear of making mistakes

• Leadership ?? Objective Subjective Technical Safety Challenges/ Adaptive Challenges/ Incremental Improvement Breakthrough Performance

Focus: Focus: • Safety Systems/ • Beliefs, values and culture Process/Procedure • Possibilities for • Technology the Future • Training • Accountability/ • Rules Commitment Mode: Mode: • Identify Issues • Authentic Listening • Set Priorities • Shared Commitment • Solve/Fix • Think/Create • Get Right Back into Action • Engage/Collaborate • Input/Output • Identify Prevailing View (Context) • Prediction/Control • Create New View (Context) Nature: Nature: • Linear • Multi-Dimensional • Local View • Strategic • Tactical • Future Focused • Past-Based • Leadership • Management Management Leadership Technical Safety Challenges/ Adaptive Challenges/ Incremental Improvement Breakthrough Performance

Focus: Focus: • Safety Systems/ • People Process/Procedure • Possibilities for • Technology the Future • Training • Accountability/ • Rules Commitment Mode: Mode: • Identify Issues • Authentic Listening • Set Priorities • Shared Commitment • Solve/Fix • Think/Create • Get Right Back into Action • Engage/Collaborate • Input/Output • Identify Prevailing View (Context) • Prediction/Control • Create New View (Context) Nature: Nature: • Linear • Multi-Dimensional • Local View • Strategic • Tactical • Future Focused • Past-Based • Leadership • Management

“If you really want to change the city, or want a real struggle, a real fight, then it would require re-engaging with things like public planning for example, or re-engaging with government, or re-engaging with a large-scale institutionalised developers. I think that’s where the real struggles lie, that we re-engage with these structures and these institutions, this horribly complex ‘dark matter.’ That’s where it becomes really interesting.”

Wouter Vanstiphout, Dutch architectural historian thank you