“We must ensure this never happens again.”
This is a common reaction to instances of catastrophic failure. However, in complex engineering systems, this statement is inherently paradoxical. If the right lessons are learned and the appropriate measures are taken, the same failure will most likely never happen again. But, catastrophes in themselves are not completely preventable, such that the next time around, failure will occur somewhere new and unforeseen. Welcome to the world of complexity.
Boiled down to its fundamentals, engineering deals with the practical – the development of tools that work as intended. Failure is a human condition, and as such, all man-made systems are prone to failure. Furthermore, success should not be defined as the absence of failure, but rather how we cope with failure and learn from it – how we conduct ourselves in spite of failure.
Failure and risk are closely linked. The way I define risk here is the probability of an irreversible negative outcome. In a perfect world of complete knowledge and no risk, we know exactly how a system will behave beforehand and have perfect control of all outcomes. Hence, in such an idealised world there is very little room for failure. In the real world however, knowledge is far from complete, people and man-made systems behave and interact in unforeseen ways, and changes in the surrounding environmental conditions can drastically alter the intended behaviour. Therefore, our understanding of and attitude towards risk, plays a major role in building safe engineering systems.
The first step is to acknowledge that our perception of risk is very personal. It is largely driven by human psychology and depends on a favourable balance of risk and reward. For example, there is a considerable higher degree of fear of flying than fear of driving, even though air travel is much safer than road travel. As plane crashes are typically more severe than car crashes, it is easy to form skewed perceptions of the respective risks involved. What is more, driving a car, for most people a daily activity, is far more familiar than flying an airplane.
Second, science and engineering do not attempt to predict or guarantee a certain future. There will never be a completely stable, risk free system. All we can hope to achieve is a level of risk that is comparable to that of events beyond our control. Risk and uncertainty arise in the gap between what we know and what we don’t – between how we design the system to behave and how it can potentially behave. This knowledge gap can lead to two types of risk. There are certain things we appreciate that we do not understand, i.e. the known unknowns. Second, and more pernicious, are those things we are not even aware of, i.e. the unknown unknowns, and it is these failures that wreak the most havoc. So how do we protect ourselves against something we don’t even see coming? How do engineers deal with this second type of risk?
The first strategy is the safety factor or margin of safety. A safety factor of 2 means that if a bridge is expected to take a maximum service load of X (also called the demand), then we design the structure to hold 2X (also called the capacity). In the aerospace industry, safety protocols require all parts to maintain integrity up to 1.2x the service load, i.e. a limit safety factor of 1.2. Furthermore, components need to sustain 1.5x the service load for at least three seconds, the so-called ultimate safety factor. In some cases, statistical techniques such as Monte Carlo analyses are used to calculate the probability that the demand will exceed the capacity.
The second strategy is to employ redundancies in the design. Hence, back-ups or contingencies are in place to prevent a failure from progressing to catastrophic levels. In structural design, for example, this means that there is enough untapped capacity within the structure, such that a local failure leads to a rebalancing/redirection of internal loads without inducing catastrophic failure. Part of this analysis includes the use of event and fault trees that require engineers to conjure the myriad of ways in which a system may fail, assign probabilities to these events, and then try to ascertain how a particular failure affects other parts of the system.Unfortunately, some engineering systems today have become so complex that it is difficult to employ fault and event trees reliably. Rising complexity means that is impossible to know all functional interactions beforehand, and it is therefore difficult, if not impossible, to predict exactly how failure in one part of the system will affect other parts. This phenomenon has been popularised by the “butterfly effect” – a scenario in which, in an all-connected world, the stroke of a butterfly’s wings on one side of the planet, causes an earthquake on the other.
The increasing complexity in engineering systems is driven largely by the advance of technology based on our scientific understanding of physical phenomena at increasingly smaller length scales. For example, as you are reading this on your computer or smartphone screen, you are, in fact, interacting with a complex system that spans many different layers. In very crude terms, your internet browser sits on top of an operating system, which is programmed in one or many different programming languages, and these languages have to be translated to machine code to interact with the microprocessor. In turn, the computer’s processor interacts with other parts of the hardware such as the keyboard, mouse, disc drives, power supply, etc. which have to interface seamlessly for you to be able to make sense of what appears on screen. Next, the computer’s microprocessor is made up of a number of integrated circuits, which are comprised of registers and memory cells, which are further built-up from a network of logic gates, which ultimately, are nothing but a layer of interconnected semiconductors. Today, the expertise required to handle the details at a specific level is so vast, that very few people understand how the system works at all levels.
In the world of aviation, the Wright brothers were the first to realise that no one would ever design an effective aircraft without an understanding of the fields of propulsion, lift and control. Not only did they understand the physics behind flight, Orville and Wilbur were master craftsmen from years of running their own bike shop, and later went as far as building the engine for the Wright Flyer themselves. Today’s airplanes are of course significantly more sophisticated than the aircraft 100 years ago, such that in-depth knowledge of every aspect of a modern jumbo jet is out of the question. Yet, the risk of increasing specialism is that there are fewer people that understand the complete picture, and appreciate the complex interactions that can emerge from even simple, yet highly interconnected processes.
With increasing complexity, the solution should not be further specialisation and siloing of information, as this increases the potential for unknown risks. For example, consider the relatively simple case of a double pendulum. Such a system is described by chaotic behaviour, that is, we know and understand the underlying physics of the problem, yet it is impossible to predict how the pendulum will swing a priori. This is because at specific points, the system can bifurcate into a number of different paths, and the exact behaviour depends on the nature of the initial conditions when the system is started. These bifurcations can be very sensitive to small differences in the initial conditions, such that two processes that start with almost the same, but not identical, initial conditions can diverge considerably after only a short time.Under these circumstances, even small local failures within a complex system can cascade rapidly, accumulate and cause global failure in unexpected ways. Thus, the challenge in designing robust systems arises from the fact that the performance of the complete system cannot be predicted by an isolated analysis of its constituent parts by specialists. Rather, effective and safe design requires holistic systems thinking. A key aspect of systems thinking is to acknowledge that the characteristics of a specific layer emerges from the interacting behaviour of the components working at the level below. Hence, even when the behaviour of a specific layer is governed by understood deterministic laws, the outcome of these laws cannot be predicted with certainty beforehand.
In this realm, engineers can learn from some of the strategies employed in medicine. Oftentimes, the origin, nature and cure of a disease is not clear beforehand, as the human body is its own example of a complex system with interacting levels of cells, proteins, molecules, etc. Some known cures work even though we do not understand the underlying mechanism, and some cures are not effective even though we understand the underlying mechanism. Thus, the engineering design process shifts from well-defined rules of best practise (know first then act) to emergent (act first then know), i.e. a system is designed to the best of current knowledge and then continuously iterated/refined based on reactions to failure.
In this world, the role of effective feedback systems is critical, as flaws in the design can remain dormant for many years and emerge suddenly when the right set of external circumstances arise. As an example, David Blockley provides an interesting analogy of how failures incubate in his book “Engineering: A very short introduction.”
“…[Imagine] an inflated balloon where the pressure of the air in the balloon represents the ‘proneness to failure’ of a system. … [W]hen air is first blown into the balloon…the first preconditions for [an] accident are established. The balloon grows in size and so does the ‘proneness to failure’ as unfortunate events…accumulate. If [these] are noticed, then the size of the balloon can be reduced by letting air out – in other words, [we] reduce some of the predisposing events and reduce the ‘proneness to failure’. However, if they go unnoticed…, then the pressure of events builds up until the balloon is very stretched indeed. At this point, only a small trigger event, such as a pin or lighted match, is needed to release the energy pent up in the system.”
Often, this final trigger is blamed as the cause of the accident. But it isn’t. If we prick the balloon before blowing it up, it will subsequently leak and not burst. The over-stretched balloon itself is the reason why an accident can happen in the first place. Thus, in order to reduce the likelihood of failure, the accumulation of preconditions has to be monitored closely, and necessary actions proposed to manage the problem.
The main challenge for engineers in the 21st century is not more specialisation, but the integration of design teams from multiple levels to facilitate multi-disciplinary thinking across different functional boundaries. Perhaps, the most important lesson is that it will never be possible to ensure that failures do not occur. We cannot completely eliminate risk, but we can learn valuable lessons from failures and continuously improve engineering systems and design processes to ensure that the risks are acceptable.
David Blockley (2012). Engineering: A very short introduction. Oxford University Press. Oxford, UK.
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