Archive for category Risk Management

The Onagawa Reactor Non-Meltdown

On March 11, 2011, the strongest earthquake in Japanese recorded history hit Tohuku, leaving about 15,000 dead. The closest nuclear reactor to the quake’s epicenter was the Onagawa Nuclear Power Station operated by Tohoku Electric Power Company. As a result of the earthquake and subsequent tsunami that destroyed the town of Onagawa, the Onagawa nuclear facility remained intact and shut itself down safely, without incident. The Onagawa nuclear facility was the vicinity’s only safe evacuation destination. Residents of Onagawa left homeless by the natural disasters sought refuge in the facility, where its workers provided food.

The more famous Fukushima nuclear facility was about twice as far from the earthquake’s epicenter. The tsunami at Fukushima was slightly less severe. Fukushimia experienced three core meltdowns, resulting in evacuation of 300,000 people. The findings of the Fukushima Nuclear Accident Independent Investigation Commission have been widely published. They conclude that Fukushima failed to meet the most basic safety requirements, had conducted no valid probabilistic risk assessment, had no provisions for containing damage, and that its regulators operated in a network of corruption, collusion, and nepotism. Kiyoshi Kurokawa, Chairman of the commission stated:

THE EARTHQUAKE AND TSUNAMI of March 11, 2011 were natural disasters of a magnitude that shocked the entire world. Although triggered by these cataclysmic events, the subsequent accident at the Fukushima Daiichi Nuclear Power Plant cannot be regarded as a natural disaster. It was a profoundly manmade disaster – that could and should have been foreseen and prevented.

Only by grasping [the mindset of Japanese bureaucracy] can one understand how Japan’s nuclear industry managed to avoid absorbing the critical lessons learned from Three Mile Island and Chernobyl. It was this mindset that led to the disaster at the Fukushima Daiichi Nuclear Plant.

The consequences of negligence at Fukushima stand out as catastrophic, but the mindset that supported it can be found across Japan.

Despite these findings, the world’s response Fukushima has been much more focused on opposition to nuclear power than on opposition to corrupt regulatory government bodies and the cultures that foster them.

Two scholars from USC, Airi Ryu and Najmedin Meshkati, recently published “Why You Haven’t Heard About Onagawa Nuclear Power Station after the Earthquake and Tsunami of March 11, 2011,their examination of the contrasting safety mindsets of TEPCO, the firm operating the Fukushima nuclear plant, and Tohoku Electric Power, the firm operating Onagawa.

Ryu and Meshkati reorted vast differences in personal accountability, leadership values, work environments, and approaches to decision-making. Interestingly, they found even Tohuko Electric to be weak in setting up an environment where concerns could be raised and where an attitude of questioning authority was encouraged. Nevertheless, TEPCO was far inferior to Tohoku Electric in all other safety culture traits.

Their report is worth a read for anyone interested in the value of creating a culture of risk management and the need for regulatory bodies to develop non-adversarial relationships with the industries they oversee, something I discussed in a recent post on risk management.

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A New Era of Risk Management?

The quality of risk management has mostly fallen for the past few decades. There are signs of change for the better.

Risk management is a broad field; many kinds of risk must be managed. Risk is usually defined in terms of probability and cost of a potential loss. Risk management, then, is the identification, assessment and prioritization of risks and the application of resources to reduce the probability and/or cost of the loss.

The earliest and most accessible example of risk management is insurance, first documented in about 1770 BC in the Code of Hammurabi (e.g., rules 23, 24, and 48). The Code addresses both risk mitigation, through threats and penalties, and minimizing loss to victims, through risk pooling and insurance payouts.

Golden Gate BridgeInsurance was the first example of risk management getting serious about risk assessment. Both the frequentist and quantified subjective risk measurement approaches (see recent posts on belief in probability) emerged from actuarial science developed by the insurance industry.

Risk assessment, through its close relatives, decision analysis and operations research, got another boost from World War II. Big names like Alan Turing, John Von Neumann, Ian Fleming (later James Bond author) and teams at MIT, Columbia University and Bletchley Park put quantitative risk analyses of several flavors on the map.

Today, “risk management” applies to security guard services, portfolio management, terrorism and more. Oddly, much of what is called risk management involves no risk assessment at all, and is therefore inconsistent with the above definition of risk management, paraphrased from Wikipedia.

Most risk assessment involves quantification of some sort. Actuarial science and the probabilistic risk analyses used in aircraft design are probably the “hardest” of the hard risk measurement approaches, Here, “hard” means the numbers used in the analyses come from measurements of real world values like auto accidents, lightning strikes, cancer rates, and the historical failure rates of computer chips, valves and motors. “Softer” analyses, still mathematically rigorous, involve quantified subjective judgments in tools like Monte Carlo analyses and Bayesian belief networks. As the code breakers and submarine hunters of WWII found, trained experts using calibrated expert opinions can surprise everyone, even themselves.

A much softer, yet still quantified (barely), approach to risk management using expert opinion is the risk matrix familiar to most people: on a scale of 1 to 4, rate the following risks…, etc. It’s been shown to be truly worse than useless in many cases, for a variety of reasons by many researchers. Yet it remains the core of risk analysis in many areas of business and government, across many types of risk (reputation, credit, project, financial and safety). Finally, some of what is called risk management involves no quantification, ordering, or classifying. Call it expert intuition or qualitative audit.

These soft categories of risk management most arouse the ire of independent and small-firm risk analysts. Common criticisms by these analysts include:

1. “Risk management” has become jargonized and often involves no real risk analysis.
2. Quantification of risk in some spheres is plagued by garbage-in-garbage-out. Frequency-based models are taken as gospel, and believed merely because they look scientific (e.g., Fukushima).
3. Quantified/frequentist risk analyses are not used in cases where historical data and a sound basis for them actually exists (e.g., pharmaceutical manufacture).
4. Big consultancies used their existing relationships to sell unsound (fluff) risk methods, squeezing out analysts with sound methods (accused of Arthur Anderson, McKinsey, Bain, KPMG).
5. Quantitative risk analyses of subjective type commonly don’t involve training or calibration of those giving expert opinions, thereby resulting in incoherent (in the Bayesian sense) belief systems.
6. Groupthink and bad management override rational input into risk assessment (subprime mortgage, space shuttle Challenger).
7. Risk management is equated with regulatory compliance (banking operations, hospital medicine, pharmaceuticals, side-effect of Sarbanes-Oxley).
8. Some professionals refuse to accept any formal approach to risk management (medical practitioners and hospitals).

While these criticisms may involve some degree of sour grapes, they have considerable merit in my view, and partially explain the decline in quality of risk management. I’ve worked in risk analysis involving uranium processing, nuclear weapons handling, commercial and military aviation, pharmaceutical manufacture, closed-circuit scuba design, and mountaineering. If the above complaints are valid in these circles – and they are –  it’s easy to believe they plague areas where softer risk methods reign.

Several books and scores of papers specifically address the problems of simple risk-score matrices, often dressed up in fancy clothes to look rigorous. The approach has been shown to have dangerous flaws by many analysts and scholars, e.g., Tony Cox, Sam SavageDouglas Hubbard, and Laura-Diana Radu. Cox shows examples where risk matrices assign higher qualitative ratings to quantitatively smaller risks. He shows that risks with negatively correlated frequencies and severities can result in risk-matrix decisions that are worse than random decisions. Also, such methods are obviously very prone to range compression errors. Most interestingly, in my experience, the stratification (highly likely, somewhat likely, moderately likely, etc.) inherent in risk matrices assume common interpretation of terms across a group. Many tests (e.g., Kahneman & Tversky and Budescu, Broomell, Por) show that large differences in the way people understand such phrases dramatically affect their judgments of risk. Thus risk matrices create the illusion of communication and agreement where neither are present.

Nevertheless, the risk matrix has been institutionalized. It is embraced by government (MIL-STD-882), standards bodies (ISO 31000), and professional societies (Project Management Institute (PMI), ISACA/COBIT). Hubbard’s opponents argue that if risk matrices are so bad, why do so many people use them – an odd argument, to say the least. ISO 31000, in my view, isn’t a complete write-off. In places, it rationally addresses risk as something that can be managed through reduction of likelihood, reduction of consequences, risk sharing, and risk transfer. But elsewhere it redefines risk as mere uncertainty, thereby reintroducing the positive/negative risk mess created by economist Frank Knight a century ago. Worse, from my perspective, like the guidelines of PMI and ISACA, it gives credence to structure in the guise of knowledge and to process posing as strategy. In short, it sets up a lot of wickets which, once navigated, give a sense that risk has been managed when in fact it may have been merely discussed.

A small benefit of the subprime mortgage meltdown of 2008 was that it became obvious that the financial risk management revolution of the 1990s was a farce, exposing a need for deep structural changes. I don’t follow financial risk analysis closely enough to know whether that’s happened. But the negative example made public by the housing collapse has created enough anxiety in other disciplines to cause some welcome reappraisals.

There is surprising and welcome activity in nuclear energy. Several organizations involved in nuclear power generation have acknowledged that we’ve lost competency in this area, and have recently identified paths to address the challenges. The Nuclear Energy Institute recently noted that while Fukushima is seen as evidence that probabilistic risk analysis (PRA) doesn’t work, if Japan had actually embraced PRA, the high risk of tsunami-induced disaster would have been immediately apparent. Late last year the Nuclear Energy Institute submitted two drafts to the U.S. Nuclear Regulatory Commission addressing lost ground in PRA and identifying a substantive path forward: Reclaiming the Promise of Risk-Informed Decision-Making and Restoring Risk-Informed Regulation. These documents acknowledge that the promise of PRA has been stunted by distrust of the method, focus on compliance instead of science, external audits by unqualified teams, and the above-mentioned Fukushima fallacy.

Likewise, the FDA, often criticized for over-regulating and over-reach – confusing efficacy with safety – has shown improvement in recent years. It has revised its decades-old process validation guidance to focus more on verification, scientific evidence and risk analysis tools rather than validation and documentation. The FDA’s ICH Q9 (Quality Risk Management) guidelines discuss risk, risk analysis and risk management in terms familiar to practitioners of “hard” risk analysis, even covering fault tree analysis (the “hardest” form of PRA) in some detail. The ASTM E2500 standard moves these concepts further forward. Similarly, the FDA’s recent guidelines on mobile health devices seem to accept that the FDA’s reach should not exceed its grasp in the domain of smart phones loaded with health apps. Reading between the lines, I take it that after years of fostering the notion that risk management equals regulatory compliance, the FDA realized that it must push drug safety far down into the ranks of the drug makers in the same way the FAA did with aircraft makers (with obvious success) in the late 1960s. Fostering a culture of safety rather than one of compliance distributes the work of providing safety and reduces the need for regulators to anticipate every possible failure of every step of every process in every drug firm.

This is real progress. There may yet be hope for financial risk management.

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Common-Mode Failure Driven Home

In a recent post I mentioned that probabilistic failure models are highly vulnerable to wrong assumptions of independence of failures, especially in redundant system designs. Common-mode failures in multiple channels defeats the purpose of redundancy in fault-tolerant designs. Likewise, if probability of non-function is modeled (roughly) as historical rate of a specific component failure times the length of time we’re exposed to the failure, we need to establish that exposure time with great care. If only one channel is in control at a time, failure of the other channel can go undetected. Monitoring systems can detect such latent failures. But then failures of the monitoring system tend to be latent.

For example, your car’s dashboard has an engine oil warning light. That light ties to a monitor that detects oil leaks from worn gaskets or loose connections before the oil level drops enough to cause engine damage. Without that dashboard warning light, the exposure time to an undetected slow leak is months – the time between oil changes. The oil warning light alerts you to the condition, giving you time to deal with it before your engine seizes.

But what if the light is burned out? This failure mode is why the warning lights flash on for a short time when you start your car. In theory, you’d notice a burnt-out warning light during the startup monitor test. If you don’t notice it, the exposure time for an oil leak becomes the exposure time for failure of the warning light. Assuming you change your engine oil every 9 months, loss of the monitor potentially increases the exposure time from minutes to months, multiplying the probability of an engine problem by several orders of magnitude. Aircraft and nuclear reactors contain many such monitoring systems. They need periodic maintenance to ensure they’re able to detect failures. The monitoring systems rarely show problems in the check-ups; and this fact often lures operations managers, perceiving that inspections aren’t productive, into increasing maintenance intervals. Oops. Those maintenance intervals were actually part of the system design, derived from some quantified level of acceptable risk.

Common-mode failures get a lot press when they’re dramatic. They’re often used by risk managers as evidence that quantitative risk analysis of all types doesn’t work. Fukushima is the current poster child of bad quantitative risk analysis. Despite everyone’s agreement that any frequencies or probabilities used in Fukushima analyses prior to the tsunami were complete garbage, the result for many was to conclude that probability theory failed us. Opponents of risk analysis also regularly cite the Tacoma Narrows Bridge collapse, the Chicago DC-10 engine-loss disaster, and the Mount Osutaka 747 crash as examples. But none of the affected systems in these disasters had been justified by probabilistic risk modeling. Finally, common-mode failure is often cited in cases where it isn’t the whole story, as with the Sioux City DC-10 crash. More on Sioux City later.

On the lighter side, I’d like to relate two incidents – one personal experience, one from a neighbor – that exemplify common-mode failure and erroneous assumptions of exposure time in everyday life, to drive the point home with no mathematical rigor.

I often ride my bicycle through affluent Marin County. Last year I stopped at the Molly Stone grocery in Sausalito, a popular biker stop, to grab some junk food. I locked my bike to the bike rack, entered the store, grabbed a bag of chips and checked out through the fast lane with no waiting. Ninety seconds at most. I emerged to find no bike, no lock and no thief.

I suspect that, as a risk man, I unconsciously model all risk as the combination of some numerical rate (occurrence per hour) times some exposure time. In this mental model, the exposure time to bike theft was 90 seconds. I likely judged the rate to be more than zero but still pretty low, given broad daylight, the busy location with lots of witnesses, and the affluent community. Not that I built such a mental model explicitly of course, but I must have used some unconscious process of that sort. Thinking like a crook would have served me better.

If you were planning to steal an expensive bike, where would you go to do it? Probably a place with a lot of expensive bikes. You might go there and sit in your pickup truck with a friend waiting for a good opportunity. You’d bring a 3-foot long set of chain link cutters to make quick work of the 10 mm diameter stem of a bike lock. Your friend might follow the victim into the store to ensure you were done cutting the lock and throwing the bike into the bed of your pickup to speed away before the victim bought his snacks.

After the fact, I had much different thought thoughts about this specific failure rate. More important, what is the exposure time when the thief is already there waiting for me, or when I’m being stalked?

My neighbor just experienced a nerve-racking common mode failure. He lives in a San Francisco high-rise and drives a Range Rover. His wife drives a Mercedes. He takes the Range Rover to work, using the same valet parking-lot service every day. He’s known the attendant for years. He takes his house key from the ring of vehicle keys, leaving the rest on the visor for the attendant. He waves to the attendant as he leaves the lot on way to the office.

One day last year he erred in thinking the attendant had seen him. Someone else, now quite familiar with his arrival time and habits, got to his Range Rover while the attendant was moving another car. The thief drove out of the lot without the attendant noticing. Neither my neighbor nor the attendant had reason for concern. This gave the enterprising thief plenty of time. He explored the glove box, finding the registration, which includes my neighbor’s address. He also noticed the electronic keys for the Mercedes.

The thief enlisted a trusted colleague, and drove the stolen car to my neighbor’s home, where they used the electronic garage entry key tucked neatly into its slot in the visor to open the gate. They methodically spiraled through the garage, periodically clicking the button on the Mercedes key. Eventually they saw the car lights flash and they split up, each driving one vehicle out of the garage using the provided electronic key fobs. My neighbor lost two cars though common-mode failures. Fortunately, the whole thing was on tape and the law men were effective; no vehicle damage.

Should I hide my vehicle registration, or move to Michigan?

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In theory, there’s no difference between theory and practice. In practice, there is.

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Belief in Probability – Part 1

Years ago in a meeting on design of a complex, redundant system for a commercial jet, I referred to probabilities of various component failures. In front of this group of seasoned engineers, a highly respected, senior member of the team interjected, “I don’t believe in probability.” His proclamation stopped me cold. My first thought was what kind a backward brute would say something like that, especially in the context of aircraft design. But Willie was no brute. In fact he is a legend in electro-hydro-mechanical system design circles; and he deserves that status. For decades, millions of fearless fliers have touched down on the runway, unaware that Willie’s expertise played a large part in their safe arrival. So what can we make of Willie’s stated disbelief in probability?

autobrakes
Friends and I have been discussing risk science a lot lately – diverse aspects of it including the Challenger disaster, pharmaceutical manufacture in China, and black swans in financial markets. I want to write a few posts on risk science, as a personal log, and for whomever else might be interested. Risk science relies on several different understandings of risk, which in turn rely on the concept of probability. So before getting to risk, I’m going to jot down some thoughts on probability. These thoughts involve no computation or equations, but they do shed some light on Willie’s mindset. First a bit of background.

Oddly, the meaning of the word probability involves philosophy much more than it does math, so Willie’s use of belief might be justified. People mean very different things when they say probability. The chance of rolling a 7 is conceptually very different from the chance of an earthquake in Missouri this year. Probability is hard to define accurately. A look at its history shows why.

Mathematical theories of probability only first appeared in the late 17th century. This is puzzling, since gambling had existed for thousands of years. Gambling was enough of a problem in the ancient world that the Egyptian pharaohs, Roman emperors and Achaemenid satraps outlawed it. Such legislation had little effect on the urge to deal the cards or roll the dice. Enforcement was sporadic and halfhearted. Yet gamblers failed to develop probability theories. Historian Ian Hacking  (The Emergence of Probability) observes, “Someone with only the most modest knowledge of probability mathematics could have won himself the whole of Gaul in a week.”

Why so much interest with so little understanding? In European and middle eastern history, it seems that neither Platonism (determinism derived from ideal forms) nor the Judeo/Christian/Islamic traditions (determinism through God’s will) had much sympathy for knowledge of chance. Chance was something to which knowledge could not apply. Chance meant uncertainty, and uncertainty was the absence of knowledge. Knowledge of chance didn’t seem to make sense. Plus, chance was the tool of immoral and dishonest gamblers.

The term probability is tied to the modern understanding of evidence. In medieval times, and well into the renaissance, probability literally referred to the level of authority –  typically tied to the nobility –  of a witness in a court case. A probable opinion was one given by a reputable witness. So a testimony could be highly probable but very incorrect, even false.

Through empiricism, central to the scientific method, the notion of diagnosis (inference of a condition from key indicators) emerged in the 17th century. Diagnosis allowed nature to be the reputable authority, rather than a person of status. For example, the symptom of skin spots could testify, with various degrees of probability, that measles had caused it. This goes back to the notion of induction and inference from the best explanation of evidence, which I discussed in past posts. Pascal, Fermat and Huygens brought probability into the respectable world of science.

But outside of science, probability and statistics still remained second class citizens right up to the 20th century. You used these tools when you didn’t have an exact set of accurate facts. Recognition of the predictive value of probability and statistics finally emerged when governments realized that death records had uses beyond preserving history, and when insurance companies figured out how to price premiums competitively.

Also around the turn of  the 20th century, it became clear that in many realms – thermodynamics and quantum mechanics for example – probability would take center stage against determinism. Scientists began to see that some – perhaps most – aspects of reality were fundamentally probabilistic in nature, not deterministic. This was a tough pill for many to swallow, even Albert Einstein. Einstein famously argued with Niels Bohr, saying, “God does not play dice.” Einstein believed that some hidden variable would eventually emerge to explain why one of two identical atoms would decay while the other did not. A century later, Bohr is still winning that argument.

What we mean when we say probability today may seem uncontroversial – until you stake lives on it. Then it gets weird, and definitions become important. Defining probability is a wickedly contentious matter, because wildly conflicting conceptions of probability exist.  They can be roughly divided into the objective and subjective interpretations. In the next post I’ll focus on the frequentist interpretation, which is objective, and the subjectivist interpretations as a group. I’ll look at the impact of accepting – or believing in – each of these on the design of things like airliners and space shuttles from the perspectives of Willie, Richard Feynman, and NASA. Then I’ll defend my own views on when and where to hold various beliefs about probability.

Autobrake diagram courtesy of Biggles Software.

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Is Fault Tree Analysis Deductive?

Endeavor over Golden Gate BridgeAn odd myth persists in systems engineering and risk analysis circles. Fault tree analysis (FTA), and sometimes fault trees themselves, are said to be deductive. FMEAs are called inductive. How can this be?

By fault trees I mean Boolean logic modeling of unwanted system states by logical decomposition of equipment fault states into combinations of failure states of more basic components. You can read more on fault tree analysis and its deductive nature at Wikipedia. By FMEA (Failure Mode & Effects Analysis) I mean recording all the things that can go wrong with the components of a system. Writers who find fault trees deductive also find FMEAs, their complement, to be inductive. I’ll argue here that building fault trees is not a deductive process, and that there is possible harm in saying so. Secondarily, I’ll offer that while FMEA creation involves inductive reasoning, the point carries little weight, since the rest of engineering is inductive reasoning too.

Word meanings can vary with context; but use of the term deductive is consistent across math, science, law, and philosophy. Deduction is the process of drawing a logically certain conclusion about a particular instance from a rule or premise about the general. Assuming all men are mortal, if Socrates is a man, then he is mortal. This is true regardless of the meaning of the word mortal. It’s truth is certain, even if Socrates never existed, and even if you take mortal to mean living forever.

Example from a software development website:

FMECA is an inductive analysis of system failure, starting with the presumed failure of a component and analyzing its effect on system stability: “What will happen if valve A sticks open?” In contrast, FTA is a deductive analysis, starting with potential or actual failures and deducing what might have caused them: “What could cause a deadlock in the application?”

The well-intended writer says we deduce the causes of the effects in question. Deduction is not up to that task. When we infer causes from observed effects, we are using induction, not deduction.

How did the odd claims that fault trees and FTAs are deductive arise? It might trace to William Vesely, NASA’s original fault tree proponent. Vesely sometimes used the term deductive in his introductions to fault trees. If he meant that the process of reducing fault trees into cut sets (sets of basic events or initiators) is deductive, he was obviously correct. But calculation isn’t the critical aspect of fault trees; constructing them is where the effort and need for diligence lie. Fault tree software does the math. If Vesely saw the critical process of constructing fault trees and supplying them with numerical data (often arduous, regardless of software) as deductive – which I doubt – he was certainly wrong. 

Inductive reasoning, as used in science, logic and philosophy, means inferring general rules or laws from observations of particular instances. The special use of the term math induction actually refers to deduction, as mathematicians are well aware. Math induction is deductive reasoning with a confusing title. Induction in science and engineering stems from our need to predict future events. We form theories about how things will behave in the future based on observations of how similar things behaved in the past. As I discussed regarding Bacon vs. Descartes, science is forced into the realm of induction because deduction never makes contact with the physical world – it lives in the mind.

Inductive reasoning is exactly what goes on when you construct a fault tree. You are making inferences about future conditions based on modeling and historical data – a purely inductive process. The fact that you use math to solve fault trees does not make fault trees any more deductive than the presence of math in lab experiments makes empirical science deductive.

Does this matter?

It’s easy enough to fix this technical point in descriptions fault tree analysis. We should do so, if merely to avoid confusing students. But more importantly, quantitative risk analysis – including FTA – has its enemies. They range from several top consultancies selling subjective, risk-score matrix methodologies dressed up in fancy clothes (see Tony Cox’s SIRA presentation on this topic) to some of NASA’s top management – those flogged by Richard Feynman in his minority report on the Challenger disaster. The various criticisms of fault tree analysis say it is too analytical and correlates poorly with the real world. Sound familiar? It echoes a feud between the heirs of Bacon (induction) and the heirs of Descartes (deduction). Some of fault trees’ foes find them overly deductive. They then imply that errors found in past quantitative analyses impugn objectivity itself, preferring subjective analyses based on expert opinion. This curious conclusion would not follow, even if fault tree analyses were deductive, which they are not.

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Science is the belief in the ignorance of experts. – Richard Feynman

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