68
6 Justifying the Need for New Approaches
A second observation concerns the complexities related to the design and operation of the dam. The possibility of lack of adherence to procedures and quality
control cannot be ignored and must be examined as part of a risk assessment process
that takes a rigorous approach to hazard identification and an understanding of the
uncertainties. Reports in the Brazilian press made reference to the use of FMEA in
support of the design changes but, in whatever manner was used, it failed to identify
the hazards created.
Given the complexities that have to be considered in the determination of the failure mode and its trigger(s), the Fundão Panel employed fault tree analysis to portray
the many possible events and conditions as well as the various trigger mechanisms to
guide its deliberations. The figure they display in their report provides an excellent
example not only of the complex failure modes but also domino effects and long
chains of events.
We can now focus on some legal and societal aspects starting with the common
practice risk assessment and the decisions it stirred internally. The Samarco Fundão
Dam failure mode and effects analysis (FMEA) (https://www.riskope.com/2015/01/
15/failure-modes-and-effects-analysis-fmea-risk-methodology/) became the centre
of an article in the Gazeta Online (2016) 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. Another newspaper, the
Folha de São Paulo (2016) reportedly had 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 (our
trans).
However, from the transcripts it becomes apparent that management of the mining
company knew of the problems already in August 2014, more than a year before
the disaster. Top management stated to Brazilian Federal Police that the instability
problems were unknown to them. 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 of the Fundão Dam, Management
asked whether “the likelihood of any problems happening had changed or just the
severity (stiffness structure)?”.
1
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
1 Original Portuguese: Vescovi indaga se “mudou a probabilidade (de acontecer algum problema)
ou apenas a severidade (a rigidez a estrutura)?”.
6 Justifying the Need for New Approaches
A second observation concerns the complexities related to the design and operation of the dam. The possibility of lack of adherence to procedures and quality
control cannot be ignored and must be examined as part of a risk assessment process
that takes a rigorous approach to hazard identification and an understanding of the
uncertainties. Reports in the Brazilian press made reference to the use of FMEA in
support of the design changes but, in whatever manner was used, it failed to identify
the hazards created.
Given the complexities that have to be considered in the determination of the failure mode and its trigger(s), the Fundão Panel employed fault tree analysis to portray
the many possible events and conditions as well as the various trigger mechanisms to
guide its deliberations. The figure they display in their report provides an excellent
example not only of the complex failure modes but also domino effects and long
chains of events.
We can now focus on some legal and societal aspects starting with the common
practice risk assessment and the decisions it stirred internally. The Samarco Fundão
Dam failure mode and effects analysis (FMEA) (https://www.riskope.com/2015/01/
15/failure-modes-and-effects-analysis-fmea-risk-methodology/) became the centre
of an article in the Gazeta Online (2016) 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. Another newspaper, the
Folha de São Paulo (2016) reportedly had 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 (our
trans).
However, from the transcripts it becomes apparent that management of the mining
company knew of the problems already in August 2014, more than a year before
the disaster. Top management stated to Brazilian Federal Police that the instability
problems were unknown to them. 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 of the Fundão Dam, Management
asked whether “the likelihood of any problems happening had changed or just the
severity (stiffness structure)?”.
1
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
1 Original Portuguese: Vescovi indaga se “mudou a probabilidade (de acontecer algum problema)
ou apenas a severidade (a rigidez a estrutura)?”.