Thursday, 28 April 2011

Risks for engineers

The Engineering Council recently published guidance on risk.

The Working Group has packed a great deal of wisdom into eight pages. Proposing sensible wisdom as formal guidance to engineers constitutes a major change from risk management as currently practised in many places. If the outcome is successful implementation of the guidance, then that will represent real progress. However, the publication represents a major step that is itself fraught with risk and unintended consequences. This post examines some of them.

Delightfully, it includes the word 'ergonomics', for which many thanks are due to Reg Sell. The particular wording "consider the role that ergonomics can play in mitigating the risk of human error" is a compromise many ergonomists would accept only with considerable reluctance, since it reflects an outdated and negative view of how accidents happen (e.g. see Sidney Dekker's writings). The clause also highlights the difficulties of writing well-intentioned guidance, since there are many sectors of engineering with mandatory (or effectively mandatory) requirements to use (rather than consider) ergonomics. In my experience of talking to engineeers, most of them are blissfully unaware of their obligations e.g. under the Machinery Safety directive.

My reading of the scope of the guidance is that it goes well beyond engineering competence thresholds such as E3, C3. Indeed, asking a technically-based engineer to meet these guidelines seems well beyond reasonable for the engineer, for her employer, or for society. It is hard to see 'addressing human, organizational and cultural perspectives' as an engineering competence or responsibility [such perspectives are already in BS31100:2008. It is not obvious why they have been put on the engineer's desk]. Given the engineer also appears to be responsible for monitoring the Twitter feed (as part of principle 6), she is going to be a busy girl. A footnote saying THESE GUIDELINES CAN BE MET ONLY WITH THE FULL INVOLVEMENT OF HUMAN SCIENCES IN A MULTI-DISCIPLINARY TEAM would probably be enough. Or is this supposed to be a move to post-normal engineering (cf. post-normal science)?

There is the risk that the existence of these guidelines, in the absence of more specific material on implementation, puts the responsible engineer at risk in a post-accident situation. How is an engineer supposed to reconcile an obligation to ALARP with John Adams' evidence-based rants and Lord Young's idea of common sense? 'Challenging'. Courtroom hindsight will leave plenty of room for debate e.g. when are procedures 'over-elaborate'?

High-level management gets a mention - just. Governance does not. The word 'business' does not., nor does anything to do with finance. The references to open reporting and culture are fine, but these are often unlikely to be within the purview of an engineer - for example, one looking at a $100M shortfall in maintenance on a petro-chemical plant. What support is the Engineering Council going to give in such situations? My reading of the guidance is that it is putting the engineer in harms' way, rather than out of it. How are Vince Weldon situations to be addressed?

At a more mundane level, the principles should toll the death knell of the clerical approach to tending risk management databases. Given the scale of vested interest behind such an approach, engineers trying to end the atomised treatment of risk registers will need some serious back-up, and it is not obvious that the standards and regulations cited will do that.

The list of useful references is a single page, and I am sure there is a long wish-list on the cutting-room floor. My wish-list item would have been IRGC material - in particular, their Risk Governance (.pdf). Firstly, what is being asked for in the Engineering Council guidance is more at the level of governance than management. Secondly, the IRGC knowledge characterisation of types of risk problems seems very powerful, and could be readily implemented using the Cynefin framework.

The document is a missed opportunity to support lost opportunity risk and innovation. It would not really have helped the Nokia smartphone team in 2004 when their anticipation of the iPhone was turned down. The 'safe' option of high-level management doing nothing needs to be changed. This is discussed at the Argenta blog here.

Finally, it is as well to remember that “The Engineering Method is the use of heuristics to cause the best change in a poorly understood situation within the available resources”. Billy V. Koen

Saturday, 16 April 2011

Government and the web - Order and Complexity

Events at Fukushima have highlighted the interface between government bureaucracy and web-enabled networks. Alexis Madrigal has raised the question of trust and access to information, pointing out that crowdsourced data could act as a useful resource. He has highlighted the Kickstarter project for crowdsourced radiation monitoring

In the same time-frame but a different context, Alberto Cottica's resignation post talks of the difficult interface between bureaucracies and networks.

"Kublai’s story seems to be representative of a tough problem in public policy: administrations find it hard to manage the interface with the online communities they collaborate with – even if they originate them ." He talks of the mismatch between Weber bureaucracies and web-based networks.

This mismatch is usefully seen within the Cynefin framework as the need to move between the complicated domain and the complex domain.

Lee Clarke discusses the interface in 'Worst Cases'. He doesn't use Cynefin, but the mapping is pretty clear:
"Concentrated, high-technology systems are more prone to catastrophic failures than others. Charles Perrow's book 'Normal Accidents' shows that many of our most dangerous technologies actually require centralized organizations to function properly. Nuclear power plants, for example, simply can't be run by anything other than a highly secretive bureaucracy that's utterly dependent on expert knowledge. That's fine when everything is going well, but when things start to go badly people in highly centralized organizations have a hard time recovering from cascading failures, they have a hard time learning from their mistakes, and society has a hard time looking inside of them to regulate them properly.
An estimated five hundred thousand people left Manhattan on 9/11 in one of the largest water-borne evacuations in history. How did that happen? Barges, fishing boats, pleasure boats, ferries, all manner of watercraft carried people to safety. It wasn't driven by an official plan. No one was in charge. Ordinary people, though terrified, boarded the vessels in an orderly way.As a rescue system, it was flexible, decentralized, and massively effective.
What does this mean we ought to do? It means we should eschew the centralization of disaster resources in large bureaucracies. Such centralization actually increases vulnerabilities, because centralization is more likely to create systems that don't fail gracefully. It means officials should see the public as an asset in disaster planning and response, rather than as a hindrance. People can generally handle bad news if they believe they are being dealt with honestly and with fealty. It means that local citizens groups should be involved in setting policies. Above all, it means that important choices should be made in a more open and transparent manner. This will necessarily entail inefficiencies and irrationalities, but that is of little consequence in the larger scheme of things.
I'm recommending that we foster preemptive resilience. "

Amanda Ripley has stressed the value of some training for the ordinary citizen rather than putting all training effort into specialist emergency services.

Another viewpoint, compatible with Cynefin, is the Competing Values Framework. Value Based gives a good summary .

Competing values and reforming public management (.pdf) by the Work Foundation introduces the Competing Values Framework (with some unnecessary modification) in a public management context and has a helpful discussion of UK public sector reforms using the framework.
The government-network interface is between the inward-looking control oriented Internal Process values and the outward-looking adhocracy of Open Systems. These fundamentally different value sets are at the root of issues around 'Big Society' and much else.

Several of the Fukushima resources have been built using social networking technology aimed at supporting people during a crisis. For example, a general site for people developing crisis-related internet resources is and Google have developed . Example sites related to crowdsourcing Fukushima-related information include:

Optimistic update: There have always been government hierarchies with operating procedures that can cope with complexity. For example.

If you think that reporting during incidents should be left to 'professionals' and crowdsourcing might be irresponsible, try this.

Second optimistic update: the story of safecast is well worth reading.

Patrice Cloutier has a good piece called Capability Based Planning: the Canadian perspective and my reaction.

Great graphic from Gerald Baron. (Click on it to see it properly).

And last of all as usual, the end-user. Chief Bill Boyd has an excellent blog.