Hyatt-Regency Walkway Bridge Collapse

A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page.

July 17, 1981

Kansas City, MO
Wanted to use
standard parts

On July 17, 1981, the second and fourth floor suspended walkways collapsed at the newly opened Hyatt Regency of Kansas City,
Missouri. A dance contest had attracted a crowd and the atrium under the walkway was filled with people. This accident killed 113
people and injured 186.

Evidence:
Statement by
fabricator, cheaper to
use standard parts.

The hotel was newly constructed and the walkways were well maintained. So how did this happen?
A root cause analysis of this accident shows that there were a number of causes that contributed to the walkways collapsing.
Investigation into the accident shows that the structural design of the walkway was inadequate. A weld failed which allowed a support
rod to pull through the box beam and the walkways fell.

AND

Additionally, the weld had greater stress than normal on it at the time of the failure because a large crowd had gathered to watch a
danced content. About 20 people were on second floor walkway and about 40 were on the fourth floor walkway at the time of the
accident. The higher loading combined to the walkway collapse.
Identifying the failure mechanism is important during an investigation, but a thorough root cause analysis needs to take the analysis
farther to really understand the causes. The reason that an inadequate design was built needs to be determined.

113 fatalities,
186 injuries

Evidence:
Eye witnesses

Walkways
collapsed

AND

Customer Goal
Impacted

Severe negative
impact

Customer Goal
Impacted

Evidence:
Eye witnesses

Fall

Hotel closed for

three months

Possible Solutions:
Make weld stronger

Longitudinal
weld wasn't
strong enough

Crushed by
structure

Safety Goals
Impacted

Fabricator
changed design

Evidence:
Eye witnesses

Support rod
pulled through
box beam
Evidence:
Examination of
structural post
accident

Evidence:
Examination of
structural post
accident

Evidence:
NSTB findings

AND

Higher stress
than usual on
walkways
Evidence:
Eye witnesses

Repair of Hotel

Inadequate
design

More people on
walkways than
usual

Unapproved
design changes
Evidence: Final
design was not
approved by
structural
engineer
Evidence: Final
design was
different from
design concept
at contract

Evidence:
Statement by
fabricator. Review of
documentation.
AND

Possible Solutions:
Create formal
design review
process
Design review
process
ineffective

Drawings
allowed
"fabricators
judgment"
Evidence:
Project engineer
assumed
fabricator would
do the design
AND

Original design
difficult to
implement
Evidence:
Long portion of rod
was threaded. Nonstandard parts
required.

Evidence:
Eye witnesses

In this case, it appears that the design was changed without approval of the structural engineer. This resulted from a communication
error between the fabricator and the structural engineer. The structural engineer sent a sketch of a proposed walkway design to the
fabricator, assuming that the fabricator would work the details of the design himself. The fabricator assumed the sketch was a
finalized drawing.

Production Goal
Impacted

The fabricator then picked standard parts to fit the sketch. This resulted in a significant change from the original design and
dramatically decreased the load bearing capacity of the walkways.
The original design called for continuous hanger rods (a non-standard part that would have needed to be manufactured) that passed
through the fourth floor walkway beam box to the second floor walkway, resulting in the ceiling connecting supporting the weight of
both walkways. The fabricator changed the design to use two shorter rods (standard parts) which resulted in the fourth floor walkway
supporting the weight of the second floor walkway, which it wasnt designed to handle.

Cause Map
Intermediate Level

Why?
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Effect

Cause

NOTE: Read the Cause Map from left to right

with the phrase "Was Caused By" in place of
each arrow.

Its important to investigate beyond the point of inadequate design to learn what failed in the design process to prevent future
accidents from occurring.