Contributing human and organizational factors for the failure of balconies in Maastricht

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In 2003 five balconies of an apartment building in Maastricht, the Netherlands, collapsed, resulting in two fatalities. The building was just completed.
Forensic investigations showed that detailing of the reinforcement in the precast concrete slabs of the balconies was questionable. Several design changes hampered clear force flow through the structural elements. Inappropriate design fixes were made after discovery of some cracks that could not avoid failure of a lower concrete ridge, resulting in a progressive collapse of the 5 balconies.
Profound investigation of this case showed various human and organizational factors, that might have contributed to the failure. A complex process, with several design changes and many involved parties increased the probability of failure. Furthermore, insufficient communication, inadequate checking and inadequate follow up to warnings were present.
This paper will give insight in technical causes of the failure and of contributing human and organizational factors. These underlying factors will be systematically studied, by using a theoretical framework.