It is guaranteed that Management will manage – anything they do can be regarded as ‘managing’. How they manage, and what results from that, are highly variable and uncertain.
There is no way that an outside observer can say, given a particular situation, how a company’s Management will handle it. Without specific foreknowledge of the personnel & practices of Management at that company, no standard of conduct can be applied. This contrasts greatly with the practices of other professions. Medical personnel have, for many situations (including ’emergencies’, which are routine for them), protocols for handling the situations. Engineers, especially for disciplines that depend upon public funding, have practices and formal methods which may be expected to be applied to an arbitrary scenario.
The history of man-made disasters is littered with a detritus that illustrates these points. I do not have the data for a statistical analysis to verify what I believe to be true. I do have numerous anecdotes, from personal experience and from highly-publicized incidents, which have a consistent pattern.
An excellent example is available from the Shuttle Challenger ‘accident’ in 1986. The shuttle, with a crew that included the first participant (a civilian) from the “Teacher in Space Project“, exploded during the ascent after launch.
Shuttle booster engines were solid-rocket boosters (SRBs) which were made in segments. The segments had, at their joints, elastomer O-rings to provide a seal against the hot, high-pressure gases of the SRB. Launches in cold weather had a temperature limit – the O-rings stiffened with cold, and could not provide a seal.
Earlier shuttle launches in cold weather (and within temperature limits) led to Management questioning of Engineering. They asked, in essence, ‘Hey, the O-rings were fine at 6 degrees Centigrade. They’ll do just fine a tad lower, won’t they?’ Since that ‘tad lower’ was not really beyond limits, Engineers conceded the point. Subsequent launches, which managed to broach the limits, brought more insistent appeals from Management: ‘Hey, we flew with no problems 1.5 degrees under limit, so maybe you guys are being too cautious’.
It went on like this until Challenger’s last launch. Engineer Roger Boisjoly did his damnedest to intercede with Management when he learned that launch conditions were the coldest ever. He was over-ruled, and disaster followed.
The fallacy which led Management to cause the disaster is ‘confirmation bias‘. It may have also involved the psychology revealed in the fascinating diversion known as ‘Auctioning a Dollar Bill’. When someone gets around to bidding 99 cents, someone must bid $1 – break even. And at that point, some damn fool will tell himself, ‘It’ll only cost me a penny, and I’ll win!‘. That opens the floodgates, and the dollar bill may find a new, proud, incredibly foolish owner for $5, $10, $50, or more.
A subsequent disaster investigation included Prof. Feynman‘s minority view: “For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled.”
At this writing, we watch the daily horror of oil erupting from a broken well pipe, 1 mile below the surface of the Gulf of Mexico. This economic and environmental disaster will result in reams of analysis and commentary. I offer an anticipatory viewpoint.
There is a lot of excellent Engineering in oil & gas drilling. The BP Deepwater Horizon originally set a ‘blowout preventer’ which is designed to handle ‘worst-case’ scenarios. It has a shear mechanism that is supposed to, either by operator action or by its own backup ‘dead man’s switch‘, cut the well pipe and close it. It failed to do so. It should not have been one device. Blowout preventers are sometimes stacked, providing different mechanisms to shut off a well. They may be stacked with other safety devices. It would have certainly been as prudent to do so for an extremely inaccessible wellhead, as for wellheads in less extreme locations.
An Engineer looking at the situation prior to drilling would do a risk-benefit analysis. What are the risks to equip the well various ways? What are the benefits? Equipping a well with a single blow-out preventer (albeit a version with differing and redundant activation mechanisms) carries a different risk than having redundant blow-out preventers. The benefit of redundancy? A greatly reduced chance of environmental catastrophe.
A Manager would also do a risk-benefit analysis. The risks of having redundant blow-out preventers are clear: higher initial cost, delayed initial oil production, and higher maintenance costs. The benefit is less clear, because to a Manager, a 1-in-1000 chance of disaster is, for that single well, equivalent to zero. I am confident that BP Managers have been saying ‘We couldn’t have anticipated having a huge floating rig explode and sink, severing all control of the blow-out preventer. We chose the most prudent and fiscally sound configuration possible.’
I do wonder if any BP Managers have been considering ‘How much is this costing BP in loss of production, clean-up costs, and lawsuits compared to a more reliable wellhead configuration?‘
My first assignment for ‘Big E‘, a company which is mostly known for making batteries, was as the first of two support Engineers on one of the two most important joint ventures in all of Big E. By ‘all’, I mean the entire corporation, which then included about 5 other divisions.
The joint venture was for the development and production of a battery charger. This was not, according to the cautious information proffered during my interview, a routine battery charger. It was a Marvel. It could charge tiny batteries extremely rapidly without heating or degrading them. The technology was being provided by the joint venture Partner, a European person of significant eccentricity. He even had a patent.
At 8:00 sharp on the first day with my assignment, I was given the confidential portfolio. It was about 3/4 inch thick. I scanned its somewhat disorganized contents for relevant material, and settled upon The Patent. I did not find a ‘marvel’.
What I did find was comparable to the following. Gardeners sometimes use fertilizer dispensers in-line with a water hose. The dispenser is typically positioned between the hose end and the nozzle. If positioned between the faucet and the hose, the fertilizer would be delivered identically.
The Patent was for a electronic equivalent of that example. A conventional and well-known electronic circuit was patented for having a component in an atypical, but equivalent, position. (The Patent Examiner, we learned months later, had awarded the patent on precisely that narrow basis and not upon any other novelty.) It was a fertilizer delivery device.
An hour with this patent and some supporting documents convinced me that the marvel was bogus. I spent another two hours searching the portfolio to insure that I hadn’t missed some ‘secret sauce’. I had not.
I met with the Boss for a review after lunch. After reviewing his understanding of the situation, and determining that he had nothing surprising to add, I explained the situation. It was something of a revelation to him, although he did have some bewilderment. After all, he had traveled to Europe and had held a tiny battery in his hand while it was charged extremely rapidly without heating – or so it seemed at the time.
The next year & a half was dictated by Corporate Management according to a Stage-Gate Process. A Stage of development was followed periodically by a review and a determination whether to proceed – the Gate. The Stages were pre-planned as if the Project was known to be valid and worthwhile. The Stage-Gate Process served to implement confirmation.
The blatant reality that the project had no technical basis in fact was not a consideration. I was repeatedly assured that later Stages would test the real capabilities of the project. Corporate Management, deeply committed to a pig-in-a-poke that they had loudly and publicly bragged about at its inception, acted as if the puny Engineer’s objections would disappear as each Stage successfully passed its Gate.
No intervening incident could affect their resolute commitment to the Project. A massive fire in a prototype was explained away by the joint venture Partner, who had direct access to Corporate Management both in the offices of Big E and in numerous cocktail lounges.
A Stage, just short of final financial commitment and contractual consummation of the joint venture, arrived to actually test whether the project had a functional, practical, marketable, manufacturable, and profitable product. It did not. The joint venture Partner was a bit delusional about Engineering, for which he was not trained or knowledgeable, so the project was deficient in even routine Engineering aspects.
The second major joint venture was also problematic, and the Corporate Management, which was so easily convinced that they could pick winners, was convinced to find other employment.
I was rewarded, at the next salary review, with the information that one of those departed Corporate Managers had, before he left, ordered my annual salary adjustment cut by 1/3. I guess that settles the question of ‘Who’s to blame?’, huh?
The failings of Engineering are usually exceptions which confirm my assertions. The famous Verrazano Narrows bridge collapse was due to faulty Engineering. A previously unfamiliar phenomenon – vortex generation in winds – combined with natural vibration modes of the bridge to allow a high wind to shake the bridge to bits.
How many bridges since have failed due to ‘resonance phenomena’? Zero.
How many Managers use the same delusional thinking and make the same mistakes as their predecessors? That, unfortunately, is as common as tar balls on a Louisiana beach.
This post is dedicated to Sharon Christa McAuliffe, Teacher in Space,
and Shuttle Challenger crew Francis “Dick” Scobee, Michael J. Smith, Ellison Onizuka,
Judith Resnik, Ronald McNair, and Gregory Jarvis.