Comments about technological history, system fractures, and human resilience from James R. Chiles, the author of Inviting Disaster: Lessons from the Edge of Technology (HarperBusiness 2001; paperback 2002) and The God Machine: From Boomerangs to Black Hawks, the Story of the Helicopter (Random House, 2007, paperback 2008)

Thursday, January 14, 2016

Institutional Memory and the Silver Tsunami, Part 2

How to forge a long-lasting, collective memory that leads to safer operations? That's the subject of this followup post to Part 1.

Physical markers can be valuable memory aids. Old stone monuments on hillsides in Japan, erected following long-ago tsunami, warn those who look for them (photo, CBS News): 

Even better are functional monuments, like this building in Banda Aceh that held up against the 2004 event (photo, Daily Telegraph):

Even temporary markers like lockout tags save lives if in conjunction with physical barriers like locks that prevent a valve wheel from being turned, or a blind being unbolted.

The New London explosion – the worst school catastrophe in US history – illustrates the most costly method to build a memory: high-profile, landmark cases that resonates strongly with the public and lawmakers. Soon after, laws were passed requiring odorants in natural gas for sale, and the registration of professional engineers. Also influential were the gas leak at Bhopal, the collapse of the Quebec Bridge in 1907, the Chernobyl reactor explosion, and the Northeast Blackout of 1965.

But even the most vivid memories fade, and the ranks turn over. How to keep them fresh? On July 6, 1988, Steve Rae was an electrical technician aboard the Piper Alpha rig at the time a chain of mistakes led to a natural-gas leak from a high-pressure pipe. 

The chain of events promptly killed 167 men. Twenty years later he took the podium in front of 130 students at a petroleum technician's school to relive the day, its aftermath, and its costly lessons like the importance of a safety-case approach to prevention. "I attended three funerals on the same day,” he told the newly minted graduates, “and that will never leave me.”

Assuming that institutional memory is important, we have to consider this tough question: Will it always make the critical difference? Not alone, it won't. The loss of Challenger seared across NASA and its contractors and made another solid-rocket booster failure very unlikely, it didn't prevent the loss of Columbia seventeen years later.

A common objection to proposals that would fire up a major effort to gather and preserve an institutional memory is that the effort will drain thousands of hours of otherwise productive time, in additional to consultant costs. And once it's done, who'll have the time to go through a mass of recollections that seems less relevant by the year? Won't the competition take advantage of our hard-won knowledge? That's short-sighted, according to Trevor Kletz: “If we tell other people about our accidents, then in return they may tell us about theirs, and we shall be able to prevent them from happening to us.”

I think two broad types of collective memory are achievable and worthwhile in high-risk industries, each in its way. And they don't have to be a time-burner.

The two types are motivational memory and working memory.

A motivational memory is less about technical details and more about remembering the need to work cooperatively and safely. 

Why do newly graduating structural engineers in Canada join in the ritual of the Iron Ring? It's not a refresher on statics and dynamics, it's a reminder that people die in collapses if experts don't sweat the details. Jack Gillum has given speeches about the catastrophic collapse of walkways at Kansas City's Hyatt Regency Hotel in 1981. Gillum, as the engineer of record, was found negligent in not catching a fatal flaw in revised shop drawings. He lost his Missouri license over it and 114 people lost their lives that night. Many more were injured in the collapse. A firefighter had to perform an amputation with a chain saw. I heard Gillum speak at an engineers' forensic convention fourteen years ago, and what he said that day remains with me. Further, I believe that when employees are injured on the job, managers who controlled the job site are obligated to visit them in the hospital, and attend funerals too.

Working memory: rather than taking aside all employees for long recorded interviews as they approach retirement, consider strengthening the day to day, functional memory as held in the minds of high-performance teams. Confronted with the need to design a new line of cars from scratch, Chrysler split the job among one hundred “tech-clubs,” each responsible for a key component or assembly. By forcing early companionship between design engineers, marketers and suppliers, Chrysler found it could speed development and cut costs. One advantage of a team approach is that expertise is broadly distributed, lowering the risk that a single employee's departure could cripple a critical operation. At its best, that's how the American military works, putting hugely consequential decisions in young hands, mentored by old hands.

Another argument for taking a team approach is that a team is, or can be, much more than the sum of its parts. According to psychologists who study memory formation both individual and collective, people remember an incident most vividly if they've participated in a group that discussed it afterward. Safety-oriented tailgate talks at jobsites are a good time to bring up lessons learned, fresh off the docket.

Group discussions about accidents and close calls also build up the motivational memory. Through such discussions, even people who weren't at the scene of an explosion feel the emotional impact, and it inspires them to go the extra kilometer. As Yogi Berra might have said, no one wants to experience disaster déjà vu all over again.

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