MANAGEMENT SYSTEM PITFALLS ARE THE ONES THAT LOOK “SUCCESSFUL” ON PAPER

 

(Based on True Experience Consulting and Assessing Companies - by Nik Zafri)

The pattern I’ve seen behind most corporate failures is simple:

1) Truth is punished

2) Appearances are rewarded

3) Leadership becomes disconnected from reality 

A good management system doesn’t just control people, it listens, learns, and responds before small problems become disasters.

Systems don’t fail overnight - They fail quietly, until one day they fail publicly.

Company disasters rarely start with bad people. They start with bad management systems.

 Not to be blunt, but do take a moment to review what I’ve summarized in the diagram (Some may sound or feel extremely familiar to you)

PROPOSAL FOR ARCHITECTURAL RISK ASSESSMENT - BY NIK ZAFRI

Note on Format and Use

The structure, layout, and presentation format reflected herein originated from my contribution to a proposal prepared for the extension of a hospital project. As the original author, I am declassifying this format, which remains part of my professional work.

Should a similar format or approach appear elsewhere, it may reasonably be understood as deriving from this contribution, which was intended to be integrated into the full hospital extension proposal. The format reflects an established methodology and professional practice developed through prior experience.

The original author and proposer, together with the original project team, remains available to provide clarification or explanation to relevant stakeholders, should the need arise.

Reference and Use Notice

Parties who wish to adopt or refer to this material or format are encouraged to seek prior consent, as its application and interpretation may require appropriate professional judgment and contextual understanding.

Accordingly, no responsibility or liability is assumed for any outcomes or decisions arising from its use outside the original proposal context.

1. Objective

To identify, assess, and mitigate design-derived architectural risks for the proposed hospital extension, ensuring compliance with The Ministry of Health Malaysia (MOH), Joint Commission International (JCI), and CKAPS standards. The assessment excludes generic project risks (budget, staffing, site safety, etc.) and focuses solely on design-related risks.

2. Methodology

3. References

• ISO 31000:2018 – Risk Management – Guidelines (primary framework for identifying, analyzing, and mitigating risks),
• ISO 22301:2019 – Business Continuity Management (important for healthcare facilities that cannot afford downtime),
• ISO 45001:2018 – Occupational Health and Safety Management (relevant to safety-by-design considerations),
• ISO/IEC 27001:2022 – Information Security Management Systems (ISMS) (for HIS, patient data, IoT medical devices),
• ISO/IEC 27701:2019 – Privacy Information Management (relevant to patient confidentiality and compliance with Personal Data Protection Act in Malaysia)
• MOH Telemedicine Blueprint (for digital health and medical IoT alignment),
• Ministry of Health (MOH) Malaysia Guidelines – e.g., Fire Safety, Hospital Planning, Engineering Services.
• CKAPS Requirements – Pusat Perubatan Swasta (Private Healthcare Facilities and Services Act 1998),
• JCI Standards – International accreditation framework for healthcare quality and patient safety,
• ASHRAE Standards (e.g., ASHRAE 170-2021) – Ventilation for healthcare facilities (especially for OTs, ICUs, isolation wards),
• NFPA 101 (Life Safety Code) – Patient egress and fire safety requirements,
• Uniform Building By-Laws (UBBL) Malaysia 1984 (amended 2021) – Fire safety, accessibility, structural requirements,
• MS 1184:2014 – Universal design and accessibility in built environment,
• MS 1525:2019 – Energy efficiency in non-residential buildings (aligns with ESG requirements).
• BS 9999:2017 – Fire safety in building design and management,
• MS IEC 60364 – Electrical installations of buildings,
• MS 830 – Code of practice for air-conditioning and mechanical ventilation,
• MS 1910:2006 – Medical gas pipeline systems (very relevant for hospital extensions),
• BS EN 1822 – HEPA filter standards for critical hospital spaces (e.g., OTs, ICUs),
• DOE Malaysia Environmental Quality Regulations (effluent discharge limits for STP),
• WHO Water, Sanitation and Hygiene (WASH) Standards (hospital water safety),
• ISO 14001:2015 – Environmental Management Systems (relevant for sustainability and ESG),

4. Architectural Risk Categories

5. Financial Risk

6. Strategic Risk

7. Regulatory/Design Risks

8. Architect’s Reporting Obligations

9. Submission and Evaluation Compliance

Appendix 1 - Risk Register: Architectural Risks - Project: .........Hospital Extension (Phase ....... & ............)

Appendix 2 - Stage-Specific Risk Matrix - Project: ............Hospital Extension (Phase ... & .....)

Appendix 3 - Technical Mitigations with Architecture Artifacts - Project: ................. Hospital Extension (Phase .... & .....)

Appendix 4 - Exclusions (Generic Project Risks) - Project: ............ Hospital Extension (Phase .... & ...)

Note : 

Certain “umbrella” risks as mentioned above will be excluded from the site-specific risk register, as they fall under broader project governance

These aspects are typically recognized in the Project Execution Plan (PEP) but excluded from the Hospital Engineering Risk Register

NCR - CROOKED/MISALIGNED BEAM

Case Study 2022 - Somewhere in Johor

Non-Conformance Report (NCR), Class : Major, Subject: Crooked/Misaligned Beam Installation - Housing Project

1) Description of Non-Conformance - During site inspection, it was observed that a reinforced concrete beam has been installed out of alignment (crooked) and does not conform to the approved construction drawings, specifications, and tolerances.

2) Reference Documents

• Approved Structural Drawings No.: ___

• Project Specifications,

• MS EN 1990 1991, 1992-1-1 (Eurocode), BS 5606, MS EN 13670, MS EN 206, CIRIA C660 & C766, CIDB Qlassic or CONQUAS w/a, JKR Standard Specs

• Method Statement for RC Works

Note :

Engineer’s Rule of Thumb (Quietly Used on Site)

• ≤10 mm = BS 5606 tolerable deviation (with PE acceptance)

• >10 mm = Structural justification mandatory

• >25 mm = Eurocode eccentricity risk = rebuild or strengthen

3) Potential Risks

The deviation may affect :

• structural load transfer,

• alignment of slabs/walls above,

• architectural finishes and services installation

4) Possible Root Causes

• Incorrect setting-out or survey control,

• Formwork not properly braced or checked before concreting,

• Movement of formwork during concreting,

• Inadequate supervision and quality checks

5) Immediate Action

• Stop further works affecting or supported by the affected beam,

• Barricade the area if necessary for safety,

• Submit as-built measurements showing the extent of misalignment

6) Assessment Criteria

The Contractor shall assess:

• Degree of deviation (mm offset and rotation),

• Structural adequacy under design loads,

• Impact on adjoining elements (slab, column, wall, finishes)

Assessment to be endorsed by the Professional Engineer (PE/C&S)*

Note : Within ..... days, the Contractor shall submit the following for Engineer’s review:

Accurate as-built survey measurement indicating:

1. Structural assessment endorsed by the Professional Engineer (C&S), addressing:

2. Proposed rectification method statement, if required

Failure to submit the above within the stipulated timeframe may result in instruction for demolition and reconstruction at Contractor’s cost.

*Note : Engineer’s Conditional Acceptance Clause (If Applicable) Conditional acceptance may only be considered subject to all of the following being satisfied:

• The measured deviation does not exceed 10 mm from the designed beam axis,

Structural analysis confirms no adverse effect on:

• Load path

• Structural capacity,

• Durability and cover requirements,

• The deviation does not induce eccentric loading on columns, walls, or slabs

Written confirmation is issued by the Professional Engineer stating that:

• The structure remains fully compliant with design intent,

• Long-term performance and safety are not compromised

In the absence of such written confirmation, the beam shall be deemed non-compliant and unacceptable.

7) Rectification Methods (Subject to Engineer’s Approval)

Note : 6. Rectification Requirement (If Conditional Acceptance Is Not Granted)

Where the deviation:

• Exceeds 10 mm, or

• Cannot be justified structurally, or

• Affects architectural alignment, finishes, or future services

The Contractor shall, at no additional cost to the Employer:

• Carry out approved structural strengthening, or

• Demolish and reconstruct the affected beam in accordance with approved drawings,

The selection of rectification method shall be at the sole discretion of the Professional Engineer.

7.1 Option 1: Minor Deviation (Within Structural Tolerance)

If confirmed structurally acceptable: Engineer to issue formal acceptance with conditions

Localized:

• Non-shrink grout,

• Structural repair mortar,

• Adjustments in non-structural elements (plaster, finishes)

Note: Acceptance must be in writing.

7.2 Option 2: Moderate Deviation (Structurally Safe but Non-Compliant)

Structural strengthening such as:

• RC jacketing,

• Steel plate bonding,

• FRP wrapping (if approved)

Repair method statement to be submitted and load testing may be required

7.3 Option 3: Major Deviation (Structurally Unsafe/Excessive Misalignment)

Demolition and reconstruction of the affected beam

Works to follow approved:

• Demolition method statement,

• Temporary support/propping design,

• Recasting procedure

8. Preventive Action

• Reverification of setting-out points before formwork installation,

• Mandatory formwork inspection checklist,

• Surveyor confirmation prior to concreting

• Increased supervision during concrete pour

9. NCR Closure Requirement

• Approved Engineer’s rectification proposal,

• Photographic records before, during, and after repair,

• Updated as-built drawings

• Engineer’s written confirmation of compliance

• Risk Register Updates - See 10.

10. Risk Register Update

This non-conformance involves a primary structural element and has potential implications on structural integrity, construction sequencing, and downstream works. Accordingly, the Contractor shall update the Project Risk Register to reflect this non-conformance as a live structural risk, including:

• Description of the risk arising from beam misalignment,

• Risk rating prior to corrective action,

• Mitigation and control measures,

• Residual risk after rectification,

10.1 Responsible party and monitoring actions

The updated Risk Register shall be submitted together with the engineering assessment and rectification proposal.

The NCR shall not be closed until the Risk Register update is reviewed and accepted.

Sample Risk Register Update

Legend :

• 🟢 Low Severity : No impact on structural safety or design intent; acceptable with monitoring.

• 🟡 Medium Severity : Limited impact - requires engineering review and mitigation.

• 🔴 High Severity : Affects structural safety, load path, or compliance with approved drawings; immediate action required.