What to Do When Things Go Wrong

1. What to Do When Things Go Wrong An Ethical Solution Robert A. Durham, PhD, PE Marcus O. Durham, PhD, PE

2. If you can smilewhen things go wrong,you have someone in mind to blame.

3. Role of Engineer in Forensics • Engineering training focuses on technical skills • Skills needed to resolve dispute or discrepancy lacking • Engineers often first responders in investigation • Two sides to issue • How is discrepancy resolved ethically? • At least two “correct” answers

4. History Lesson • US / Canadian Legal system • derived from English Common Law “ In almost every case except the very plainest, it would be possible to decide the issue either way with reasonable legal justification.” - Lord Macmillian Lord Chief Justice of England

5. BackgroundWhat is a Project? • Project – extensive undertaking of multiple tasks for a definite purpose and a set time • Objective – maximize return on investment • Project has tradeoffs • Time (t), Money ($), Quality (Q) • Customers goals • Maximize Q, meet t, minimize $ • Suppliers goals • Meet Q, meet t, maximize $ $ t Q

6. Background Project Management • There are relationship limits between Q, t & $ • As Q, $ and/or t • As $, Q  and/or t • Q, t and $ have limits • Set by customer and/or supplier • Basis of all disputes: a perceived disparity in the quality, money, time or some combination $ Q t

7. EthicProjects The ethic of the engineer / project manager is to Balance the needs and expectations of the customer and the supplier

8. BackgroundNecessary Skills • Three skills required for any Project: People, Money, Technical • People – Who is involved? What is the relationship? How is performance? • Money – Income, Expenses, Contracts, Limits • Technical – Are people qualified? Is technology adequate? Are there reasonable alternatives?

9. Is Something Wrong?How to Tell • Catastrophic failures become obvious • Catastrophic failures are always the result of at least two compounding failures • Sometimes “gut feel” that something is amiss • In either case • Perform analysis, see what is wrong, • Determine appropriate response

10. DecisionsThe Flowchart Questions 1. Part of Vision? 2. Ethical? 3. People in Limits? 4. Time in Limits? 5. Money in Limits? 6. Technology in Limits? 7. Quality in Limits? 8. Safety in Limits? 9. Environmental Limits? 10. Legal in Limits?

11. Flowchart Evaluation

12. EthicRisk Management The ethic of the engineer charged with “picking up the pieces” is to Follow the Process • Stop the loss • Gather data • Evaluate options • Determine consequences • Prepare report • Make decision on recovery • Start recovery

13. Stop Loss • First, most important step • Procedure determined by nature of problem • Personal Injury – render aid, seek pro help • Fire – stop small or abandon, ensure extinguished • E, M, C Malfunction – remove energy source • People – remove from process, use finesse • Financial – control cash flow • In all cases follow policy & legal requirements

14. Gather Data • Used for later evaluation or justification • Can be docs, photos, statements, physical • Protect in as pristine condition as possible • Secure, protect, label, store • Numerous standards address process • ASTM E678-98 • ASTM E860-97 • ASTM G145-196 • NFPA 921

15. Gather Data • Use Scientific Method* to determine root cause of failure • Identify Problem • Define Problem • Collect Data • Analyze Data • Develop Hypothesis • Test Hypothesis (Cognitive or Experimental) • Select Final Opinion * NFPA 921

16. Putting Out Fires • Fire is analog for any problem • Fire needs three things • Fuel • Oxygen (Environment) • Spark (Ignition) • For any failure need three things • Fuel (History) • Environment • Trigger Environment Fuel Spark

17. Evaluate OptionsAnalyze Data • What is the origin of the failure? • Begin with big picture • Look at all events and surroundings • Recognize pattern • Determine detailed effects • Hard to see the forest for the trees

18. Evaluate OptionsAnalyze Data • What is the root cause of the failure? • Begin with detailed observations • Then move to generalization • Consider all possibilities • In and around area of origin • A possible cause must have • Fuel, a proper environment, and a “spark” that ignites • Eliminate possibilities until only one cause remains

19. Evaluate OptionsAnalysis • Generally more than one issue • Analysis involves finding all conditions • Components of a system can be delineated • Each should be investigated to determine if it was part of the problem • Seldom yes / no • Eliminate components until most probable is left

20. Evaluate OptionsExternal Factors • Seldom is one component responsible for failure • Once components are identified • Research external influences • Could be • Design, manufacturing or application

21. Evaluate OptionsExternal Factors • Design • Systematic process of contriving plans for a particular purpose • Implies special knowledge • Compromises are necessary for success • Designer expected to know technical problems that could occur, and takeactions to mitigate • Eliminate, protect, warn

22. Evaluate OptionsExternal Factors • Manufacturing • Process of putting components together into a working system • Implies ability to create, produce or turnout finished product • Often low margin – Compromises save $ • Compromises OK, but must be consistent with quality and safety

23. Evaluate OptionsExternal Factors • Application • How the system is employed • Under direction of user or owner • Typically intended for use without knowledge of design, manufacturing or compromises • User has responsibility to apply prudently • User not expected tomodify, abuse, or overload

24. Evaluate OptionsExternal Factors • If failure occurs, list possible external factors • Eliminate possibilities if did not contribute – • Note why eliminated • Eliminate until most probable cause • If properly • Designed, • Manufactured and • Applied Failure will not occur

25. Evaluate OptionsOpinion • After looking at origin, cause, analysis and external factors, a hypothesis can be developed • Hypothesis tested against all known facts • If all facts cannot be resolved, • Hypothesis is eliminated • Iterative process – often useful to employ “sounding board” or “devil’s advocate”

26. Evaluate OptionsOpinion • Final hypothesis obtained • When all available data correlates reasonably • Opinion - judgement based on special knowledge • Opinion - belief or conclusion held with confidence based on evaluating all possibilities and developing the most probable scenario • Opinion - based on ethics, character, and outstanding technical skills

27. EthicOpinions The ethic of the engineer is to • Base opinions on all the evidence obtained and • Be willing to change if contradictory information is obtained.

28. Determine Consequences • What is the result of the failure? • Are there any damages? • What steps can be taken to recover damages? • What can be done to prevent future failures? • Can the “fuel” be eliminated • Can the environment be modified • Can the “spark” be avoided

29. Prepare Report • Purpose of report • Convey necessary information to decision makers • Format of report varies by circumstances • Written reports - external consumption • all background, methods, analysis, and opinions • Memoranda - list high points • Verbal - information without record (important) • Regardless of format, reports should always include statement such as • Opinions can be modifiedif new information becomes available

30. Recovery Decision • In case of failure resulting in damages • Recovery can be attempted • Methods of recovery • Warranty (implied and explicit) • Insurance claims • Supplier relationships, contracts, etc. • Final option is legal recovery • Generally, only “winner” in a legal recovery are the legal players

31. Recovery DecisionNegligence • Often legal claim is based on negligence • Negligence four points – all must be present • Duty - responsibility to perform what is reasonably expected • Breach of duty – failure to perform reasonably • Proximate cause – event sufficiently related to damages • Damage – actual harm

32. Attempt Recovery • Follow procedures appropriate for recovery method • Method decisions are not final • If one method doesn’t work, other options can be attempted • When necessary – get outside help • Avoid litigation if at all possible

33. Final ThoughtsNon – Technical Prevails • Regardless of technical “rightness” of engineer’s opinion, other, non-technical factors often have most influence in recovery decision. • Additional Cost • Negligence / responsibility • Probability of Success • Potential Recovery • Reputation

34. Final Thoughts • Sometimes it is better to abandon the problem, and chalk it up to experience • Stuff Happens • Often a “perfect” analysis or solution is impossible • Engineer has the responsibility to findthe least erroneous solution

35. EthicsSummary • Three Phases • Project development / management • Things going wrong • Post mortem / opinion • Ethical responsibilities in all three phases • Balance interests • Follow process • Evaluate everything • Be willing to modify opinion based on new information