Month: December 2016

Happy winter holiday of your choosing!  🙂

We were back in the garden.

I had been jostled awake as my fellow conference attendees exited the auditorium for our morning break.  After catching my bearings (and a quick check for drool) I joined them in the garden.

One of the nice things about this conference was the international flavor of the participants.  The speakers and practitioners were drawn mostly from the EU: Lund University in Sweden, Delft University in the Netherlands, and Paris Science and Lettres in France; with additional cohorts from Japan, the States, Brazil, and Russia.  As I navigated to the main house for coffee and a morning snack the conversations I overheard reflected this diversity: Dutch, German, Japanese, Portuguese, a stray strand of English, and probably others I did not recognize. This was much different than the aviation conferences I had attended during the previous ten years: English is the standard language of flight, and dominated lectures and conversations at these venues.  It was invigorating and a bit lonely at the same time.

After some coffee mixed with orange juice (they had run out of cream by the time I arrived) and a slice of veg and egg frittata, it was back to the auditorium.  And we were in for a treat: a presentation by Liberty Mutual’s Chief of Human Factors Research on the strengths and perils of sociotechnical systems.

For those not familiar, sociotechnical systems are those that combine people, technology, and the rules and procedures needed to operate effectively.  These systems tend to be large, such as hospitals, transportation and power generation systems, and nuclear power plants.  One common feature of these large entities is stratified leadership: corporate management, middle management, supervisors, and, at the bottom of the heap, the sharp end workers.  He explained that due to the complexity of these systems, no one person can understand them in full; and, depending on where you were compartmentalized by expertise, location in the hierarchy, and focus of attention, your mental model and goals could be vastly different than others operating within the same system.  Because each person or team in the structure has an incomplete model, decisions made in one area (which naturally ripple throughout a system) led to not only to intended consequences, but, in his experience as an insurance investigator, a vastly greater array of unintended consequences. (The eventual and permanent closure of Mill Stone (CT) Reactor 1 due to deferred maintenance was raised as an example.) He recommended that organizations should be viewed as control systems, and we should be careful which processes and goals are stressed as operational process and management commitment to safety are only two of the goals that need to be balanced.

I drifted through most of the day, catching lectures in railway control room operations, measuring excess capacity within systems, and resilience in healthcare, before drifting off again during another session I had been looking forward to, a panel discussion on resilience in practice by representatives from aviation, maritime and other domains.  I again woke, disappointed (and slightly defeated, did I really come all this way just to nap?), during the break.  Fortunately, two of the most dynamic presentations of the event were yet to come.

More soon!

“Here be dragons.”

This was the lecture I had travelled to Portugal to hear: my rock star, David Woods, speaking on resilience engineering.

It was the second morning of the conference, and we were back in the main auditorium.  I was seated in my normal spot, the center of the back row.  The breeze drifting in from the garden through the side doors cooled my skin (and the room, still warm from the afternoon before) ever so slightly.  Outside birds chirped, leaves rustled, and the occasional car horn blared.

Dr. Woods’ lecture began along the usual lines: we live in an adaptive universe* and this universe has basic rules, but these rules aren’t always what you think they are.  All systems have finite resources and change is constant; this, combined with our misunderstanding of ‘the rules’ and the interconnectedness of our systems lead to unexpected consequences (a.k.a. surprises).  And, most important, if you wait until you are surprised to take action, it is already too late.

So, the question became, how do we prepare ourselves to be surprised?  Surprise happens, he posited, at system boundaries.  These boundaries are ill-defined, and are often based on incomplete information.  Thus it is hard to know where the borders of safe operations are.  To add to the challenge, these boundaries move around, and if there is a boundary, there is something beyond the boundary.  “Here be dragons”, the slide stated, just below a medieval image of a pair of fire-breathing reptiles guarding a stone wall.  We were getting to the good stuff.**

The answer, Dr. Woods posed (and I was here to hear it!), is unease.  We should be uneasy with our complex and precarious systems, we should be uneasy with the plans, procedures, automation and rules we use to support them, we should be uneasy with the constant adjustments our systems require of us to remain stable.  We need to be uneasy with our constant drive for optimality, to better match our response capability to what happens (be, as he called it, regularly irregular), to become better at anticipating and preparing for crunches.  We need to maintain this unease, he continued, so we are alert and can recognize, adapt and effectively respond to unexpected events.

But wait!  What was this?  Have my eyes, itchy from lack of sleep, suddenly become heavy?  No No No No No!  This cannot be happening.

I sit up straight, slap my cheeks to wake myself up, and double down on taking notes.  I.  Will.  Not.  Fall.  Asleep.  During.  This.  Talk.

And for a few minutes I am fine.  But the breeze over my shoulders is now warm, and my eyes become harder and harder to keep open.  I tell myself it is okay to just listen, just for a minute.

What?  I missed a slide?  My eyes are wide open.  I am frantically scribbling notes, determined to stay awake.  But my body betrays me: my eyes are so heavy, the room so warm, the dim lights of the auditorium soooooo invite me to slumber.  My eyes close again.

And with that, the eleven hours of sleep I’ve had over the past four nights catch up with me, and I am out, blissfully napping in the back row of the lecture hall.

* Dr. Woods uses the term ‘adaptive universe’ to describe environments that are constantly evolving in response to small changes.

** At this point my proofreader shared “Ever since I learned Genesis 3:24 I have suspected that the good stuff was usually beyond something involving fire.  Like the Advanced Propulsion course in 1974.”

Earthquake, tsunami, flood and fire, these are not the first things that came to mind when I arrived in Lisbon.  But it turns out that back in 1755 the city was almost destroyed by this very sequence of events.  One morning, the sea bed 120 miles southwest of the city shifted, and the resulting wave surged inland, reaching well in to the countryside.  Once the waters receded, people fled from high ground to the port, only to be drowned by subsequent waves, waves so strong and fast they were difficult for even horses to outrun.  Fires then broke out and raged for five days, reducing much of the city to ash.  Recent reviews of historical records suggest the quake was felt (and the waves travelled) as far as Brazil.

The destruction was extensive; most of Lisbon’s buildings were leveled or burned, including the palace, the royal library, the royal hospital and most churches.  While the royal family escaped physically unharmed, the king was psychologically traumatized, and responsibility for the city’s recovery fell on the shoulders of the prime minister, the Marquis de Pombal.  After a year spent assessing the damage and possible recovery strategies, the city’s planner presented the Marquis with four options ranging from reinforcing existing structures to razing large sections of town and rebuilding without restraint.  The Marquis chose to begin anew, ordered that debris be cleared from the city, and had it rebuilt, with the new masonry buildings constructed with internal wooden support cages, the first seismically protected structures in Europe.

These days we take it for granted that after a disaster, teams of government, insurance and public health impact assessors will swarm the area, determining the extent of damage and injury.  But this had never been done before 1755.  After the quake, the Marquis of Pombal took the then-unusual step to do just that, dispatching letters to all the parishes in the land requesting information regarding the quake and its after-effects.  The questions were both scientific (When did the ground began to shake?  How long did it last?  Did the sea rise or fall, how many times, and how high or far?) and practical (How many deaths and how much structural damage did your locality experience?) and  the Marquis used these reports to respond to the disaster.  At some point they had found their way to Portugal’s National Archives, and this is where the final presenter of the day, an engineering professor interested in natural disasters, had found them.

The project was two-fold: historical research using machine-learning techniques. The researcher and his students had been granted access to the files, used an optical scanner to ‘read’ the text, and then sought to see patterns in the data.  At the time of the presentation his team was in the midst of their analysis, and his talk focused on their progress rather than their findings.  There were gaps in the records; over time many had been lost, damaged, or returned to their home parish and lost to time.  The reports were in an older version of Portuguese, one not fully compatible with modern language interpretation programs.  In addition, the script of the day was highly stylized (especially the letter ’s’), and this posed challenges for the machine learning algorithms they were using to translate the documents.  Once these processes are complete and reports are assembled and translated, they will be available for advanced data analysis.  After short remarks to close the day, we retired to the courtyard for fado and a local port wine.

The school was built on the crest of a hill that overlooked the Rio Tajo, and had large cement apartments not blocked the view, on a clear day we could have seen the harbor.  The area had originally been a country estate, and the sixteenth-century manor house was now the school’s executive offices and meeting rooms.  The school’s courtyard had been the home’s garden, and features, including a fountain and gazebo, were still in place.  The dining rooms and the garden of this structure was where we took our meals, and in this case, our music.  During the afternoon sessions tents had been erected to shade us, and we sat, warm summer breeze on our shoulders, discussing the day’s lectures and catching up on each others’ research.  Once dizzy with wine, I began to explore the grounds, the frescoes on the courtyard walls, the flower beds, a small gazebo. I was delighted when I discovered the veranda of the main house, and its view of neighboring orchards and a sliver of water in the distance.

But it was not to last.  Overcome with fatigue, I returned to the hotel, hoping for some sleep.

More next week!