Archives For Psychology

Human psychology and the role it plays in decision making under uncertainty.

787 Battery after fire (Image source: NTSB)

The NTSB have released their final report on the Boeing 787 Dreamliner Li-Ion battery fires. The report makes interesting reading, but for me the most telling point is summarised in conclusion seven, which I quote below.

Conclusion 7. Boeing’s electrical power system safety assessment did not consider the most severe effects of a cell internal short circuit and include requirements to mitigate related risks, and the review of the assessment by Boeing authorized representatives and Federal Aviation Administration certification engineers did not reveal this deficiency.

NTSB/AIR-14/01  (p78 )

In other words Boeing got themselves into a position with their safety assessment where their ‘assumed worst case’ was much less worse case than the reality. This failure to imagine the worst ensured that when they aggressively weight optimised the battery design instead of thermally optimising it, the risks they were actually running were unwittingly so much higher.

The first principal is that you must not fool yourself, and that you are the easiest person to fool

Richard P. Feynman

I’m also thinking that the behaviour of Boeing is consistent with what McDermid et al, calls probative blindness. That is, the safety activities that were conducted were intended to comply with regulatory requirements rather than actually determine what hazards existed and their risk.

… there is a high level of corporate confidence in the safety of the [Nimrod aircraft]. However, the lack of structured evidence to support this confidence clearly requires rectifying, in order to meet forthcoming legislation and to achieve compliance.

Nimrod Safety Management Plan 2002 (1)

As the quote from the Nimrod program deftly illustrates, often (2) safety analyses are conducted simply to confirm what we already ‘know’ that the system is safe, non-probative if you will. In these circumstances the objective is compliance with the regulations rather than to generate evidence that our system is unsafe. In such circumstances doing more or better safety analysis is unlikely to prevent an accident because the evidence will not cause beliefs to change, belief it seems is a powerful thing.

The Boeing battery saga also illustrates how much regulators like the FAA actually rely on the technical competence of those being regulated, and how fragile that regulatory relationship is when it comes to dealing with the safety of emerging technologies.

Notes

1. As quoted in Probative Blindness: How Safety Activity can fail to Update Beliefs about Safety, A J Rae*, J A McDermid, R D Alexander, M Nicholson (IET SSCS Conference 2014).

2. Actually in aerospace I’d assert that it’s normal practice to carry out hazard analyses simply to comply with a regulatory requirement. As far as the organisation commissioning them is concerned the results are going to tell them what they know already, that the system is safe.

Finding MH370

26/08/2014 — 1 Comment

MH370 underwater search area map (Image source- Australian Govt)

Finding MH370 is going to be a bitch

The aircraft has gone down in an area which is the undersea equivalent of the eastern slopes of the Rockies, well before anyone mapped them. Add to that a search area of thousands of square kilometres in about an isolated a spot as you can imagine, a search zone interpolated from satellite pings and you can see that it’s going to be tough.

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Yours truly

I’ve just finished reading an interesting post by Andrew Rae on the missing aspects of engineering education (Mind the Feynman gap) which parallels my more specific concerns, and possibly unkinder comments, about the lack of professionalism in the software community.

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As I was asked a question on risk homeostasis at the course I’m teaching, here without further ado is John Adam’s tour de force on The failure of seat belt legislation. Collectively, the group of countries that had not passed seat belt laws experienced a greater decrease than the group that had passed laws. Now John doesn’t directly draw the conclusion, but I will, that the seat belt laws kill more people than they save.

And it gets worse, in 1989 the British Government made seat belt wearing compulsory for children under 14 years old in the rear seats of cars, the result? In the year after there was an increase of almost 10% in the numbers of children killed in rear seats, and of almost 12% in the numbers injured (both above background increases). If not enacted there would be young adults now walking around today enjoying their lives, but of course the legislation was passed and we have to live with the consequences.

Now I could forgive the well intentioned who passed these laws, if when it became apparent that they were having a completely contrary effect they repealed them. But what I can’t forgive is the blind persistence, in practices that clearly kill more than they save. What can we make of this depraved indifference, other than people and organisations will sacrifice almost anything and anyone rather than admit they’re wrong?

Well I can’t believe I’m saying this but those happy clappers of the software development world, the proponents of Agile, Scrum and the like might (grits teeth), actually, have a point. At least when it comes to the development of novel software systems in circumstances of uncertainty, and possibly even for high assurance systems.

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Deepwater horizon (Image source NY Times)

Mindfulness and paying attention to the wrong things

As I talked about in a previous post on the Deepwater Horizon disaster, I believe one of the underlying reasons, perhaps the reason, for Deepwater’s problems escalating to into a catastrophe was the attentional blindness of management to the indicators of problems on the rig, and that this blindness was due in large part to a corporate focus on individual worker injury rates at the expense of thinking about those rare but catastrophic risks that James Reason calls organisational accidents. And, in a coincidence to end all coincidences there was actually a high level management team visiting just prior to the disaster to congratulate the crew as to their seven years of injury free operations.

So it was kind of interesting to read in James Reason’s latest work ‘A Life in Error‘ his conclusion that the road to epic organisational accidents, is paved with declining or low Lost Time Injury Frequency Rates (LTIFR). He goes on to give the following examples in support:

  • Westray mining disaster (1992), Canada. 26 miners died, but the company had received an award for reducing the LTIFR,
  • Moura mining disaster (1994), Queensland. 11 miners died. The company had halved its LTIFR in the four years preceding the accident.
  • Longford gas plant explosion (1998), Victoria. Two died, eight injured. Safety was directed to reducing LTIFR rather than identifying and fixing the major hazards of un-repaired equipment.
  • Texas City explosion (2005), Texas. The Independent Safety Review panel identified that BP relied on injury rates to evaluate safety performance.

As Reason concludes, the causes of accidents that result in a direct (and individual injury) are very different to those that result in what he calls an organisational accident, that is one that is both rare and truly catastrophic. Therefore data gathered on LTIFR tells you nothing about the likelihood of such a catastrophic event, and as it turns out can be quite misleading. My belief is that not only is such data misleading, it’s salience actively channelises management attention, thereby ensuring the organisation is effectively unable to see the indications of impending disaster.

So if you see an organisation whose operations can go catastrophically wrong, but all you hear from management is proud pronouncements as to how they’re reducing their loss time injury rate then you might want to consider maintaining a safe, perhaps very safe, distance.

Reason’s A Life in Error is an excellent read by the way, I give if four omitted critical procedural steps out of five. :)

One of the trophes I’ve noticed in design projects over the years is the tendency of engineers to instinctively jump from need to a singular conceptual solution. Unfortunately that initial solution rarely stands the test of time, and inevitably at some crisis point there’s a recognition that this will not work and the engineers go back to change the concept, often junking it completely.

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