6.3 Samarco Panel: Lesson Learned
69
the likelihood had really changed. We also note that the glossary was confusing 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”.
2
FMEAs are performed periodically as a way to monitor physical conditions of dams, but they do not necessarily hep management focusing on relevant issues (https://www.riskope.com/2016/02/24/80-20-rule-in-risk-managementpractice-a-way-out-of-the-overwhelming-syndrome/#_blank). They could help
defining operation strategy and tactical planning, but they lack the required
finesse. They should also bring to light rational and unbiased prioritizations of
risks, but, for a number of reasons explained elsewhere (https://www.riskope.com/
wp-content/uploads/Can-We-Stop-Misrepresenting-Reality-to-the-Public.pdf), 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. 3
The 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.
The courts will define who was legally at fault and liable in the case of the Samarco
catastrophe. It is not to us to make any judgment or suggest any fault. That in particular
to show respect to the victims, the families and all those involved in the accident.
6.4 Oroville IFT Lesson Learned
The IFT (Sect. 3.1) is commended on the scope and depth of their work. In particular,
the IFT’s detailed examination of the non-physical or, human, organizational, and
industry factors that led to the failure of the spillway systems adds significantly to
the understanding as to how risks are created and what has to be done to overcome
the challenges or barriers related to the identification of hazards and their effective
management.
2 The original response in 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 23h 58 in response to a question from the mine).
3 The original text in 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.
69
the likelihood had really changed. We also note that the glossary was confusing 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”.
2
FMEAs are performed periodically as a way to monitor physical conditions of dams, but they do not necessarily hep management focusing on relevant issues (https://www.riskope.com/2016/02/24/80-20-rule-in-risk-managementpractice-a-way-out-of-the-overwhelming-syndrome/#_blank). They could help
defining operation strategy and tactical planning, but they lack the required
finesse. They should also bring to light rational and unbiased prioritizations of
risks, but, for a number of reasons explained elsewhere (https://www.riskope.com/
wp-content/uploads/Can-We-Stop-Misrepresenting-Reality-to-the-Public.pdf), 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. 3
The 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.
The courts will define who was legally at fault and liable in the case of the Samarco
catastrophe. It is not to us to make any judgment or suggest any fault. That in particular
to show respect to the victims, the families and all those involved in the accident.
6.4 Oroville IFT Lesson Learned
The IFT (Sect. 3.1) is commended on the scope and depth of their work. In particular,
the IFT’s detailed examination of the non-physical or, human, organizational, and
industry factors that led to the failure of the spillway systems adds significantly to
the understanding as to how risks are created and what has to be done to overcome
the challenges or barriers related to the identification of hazards and their effective
management.
2 The original response in 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 23h 58 in response to a question from the mine).
3 The original text in 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.