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RE: Speaking out

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Professor Astaneh-Asl,

What you say may be true. But it is not really helpful to resolving the
issue. There is a great deal of politics involved, and I don't just mean
those involving the government, I mean the power struggles between
individuals and groups. As David Merrick points out psychology and for that
matter also sociology are important aspects to consider.

Whilst at the end of the day, an individual maybe responsible for defects,
it is unhelpful to go in search of a culprit. People go on the defensive and
refuse to disclose information. Whether trying to improve quality or reduce
accidents you avoid looking for individuals to blame.

Individuals cause defects because systems put them into a position where
they are able to cause defects. Individuals designed those systems, but
likewise they were operating in a system which permits them to be there and
permits them to produce defects.

As they say in QA, you cannot inspect quality into a system, it has to be
designed in. The journey is also more important than the destination, so
in-process checking/inspection is better than end of task inspection. All
the systems have to be designed: the design system, and the production
system. There has to be a feedback mechanism in the system, which permits
self-regulation of the system, so that it can automatically adapt and adjust
to a highly variable operating environment. It is not simply a matter of
continuous improvement but adaptation.

The systems involved are clearly not adaptive and self-regulating staying on
a path aimed towards an ideal. Adaptive maybe: for clearly if set up an
expert panel, then that expert panel is the best group of people to consult
for expert advice. The self-regulating mechanism however has to re-instate
the status as an independent review panel of experts. It is also important
that there is a pipeline of next generation experts waiting to flow onto the
panel, as the existing experts retire.

It may be appropriate that the panel represents the wisdom of the elders,
and so only comprises of persons who have retired from practice, and have no
stake in any project. From a QA viewpoint, they should also be involved in
vetting organisations and individuals, to determine who has appropriate
experience, and short listing. Those on the short list being ranked. When a
review project comes along a project can be classified such that it can be
directed to the top experts, or to those on the shortlist who need more
experience. Such proposals will have their own problems, and that is the
reason why systems should be adaptive and self-regulating. (By
self-regulating I mean the system receives feedback and adjusts its own
behaviour to get back on the right path.)

By focusing on the system, more people are likely to help improve the
system, including those people who may otherwise be considered part of the
problem. Person 'C' may be incompetent, but person 'C' was employed by
person 'B' and person 'B' employed by person  'A', and so on up the
organisational hierarchy. That is a lot of people to fire in a big

The output of a car manufacturer is not 100% perfect, nor is the output of a
university. For that matter the car manufacturer probably has higher
standards of compliance, 50% is not good enough, even if it is to the
universities. Therefore cannot expect the people in any organisation to be
100% of the required skill level, therefore systems have to be in place to
fill in the gaps. Even if the gaps in skill are plugged, still have the
pressures and politics of the job and the market place, which lead to less
than desirable decisions. So the systems have to be continuously adapting
towards some ideal, can never declare we have arrived.

Reference to CalTrans or Earthquake advisory board is also a reference to
who, and so is just as unhelpful as a reference to an individual.

The requirements of the system need to be defined, and then an appropriate
system designed.

There is a need for expert input into the design of structures for
earthquake, a separate need for new research into earthquake design, and a
need for an independent panel of experts to check and review designs. And a
need to identify those who are expert.

Since already have a system it is a matter of identifying where the system
deviates from the ideal objectives. Then identify how to get the system back
on that ideal path, and keep on that path as it starts to deviate again in
the future. Part of the design-solution is technical, much more of it is
psychological and political. For politics read Machiavelli's The Prince, and
Sun Tzu's Art of War.

You need the power base of the organisations you criticise to bring about
change. The media doesn't care how much it exaggerates if it sells papers
this week, they can apologise next week. Also hazard to life is not simply a
matter of probability, it is a matter of subjective opinion. People take
risks. The contention that engineers can make it safe to live in an
earthquake zone is misleading and potentially irresponsible. Complying with
a code of practice, doesn't make something safe, it makes it acceptable. And
what we accepted last year, may be unacceptable next year, and the year
after acceptable again. It is subjective.

Bridges and buildings which do not comply with a design code, are not
entirely defective or entirely unacceptable, they are simply less than
desirable. History and economics may dictate that we have to accept less
than our ideals. We cannot upgrade everything to comply with our new ideals.
Also the world probably doesn't have the material resources for extremely
high levels of performance everywhere. Therefore potentially better to
develop improved monitoring and control systems.

As I understand it, in PNG, bridges are closed during the flood season. The
floods underscore piers, and debris in the water shears the bridges from the
piers. At the end of the flood season the Bailey type bridges are collected,
assessed, new piers constructed and the bridges re-instated. A
design-solution chosen because bridges which can clear the flood waters,
would be unsightly and also require much travel out of the way to get onto
the bridge. They therefore have to plan for seasonal closure of the bridges
and not become 100% reliant on what is on the other side of the bridge.
Design requires a psychological understanding of the needs of the end-users.

As I understand it our urban/rural road design manual has roads designed for
the 95th percentile road speed. Not sure how they got these speeds, but the
inference, in the manual, is that 5% of the road users will be unable to
negotiate a bend at the specified speed. The specified speed is however, the
maximum limit, individuals can choose to travel at a lower speed. There is
also an expectation that 5% of the users may also be travelling in excess of
the speed limit. The design doesn't provide for the safety of those who
break the law, but may provide for safety of those who may be exposed to the
hazards created by those breaking the law. Also much of the manual is about
deliberately putting curves into a road, to avoid long stretches of straight
road which may send drivers to sleep. So many of our rural roads have dips
and bends in them to deliberately remove the view of the horizon. But many
also don't comply with the manual.

Resource constraints are often a major part of the design solution, and so
less than ideal is more often the case. As long as deviations from the ideal
can be justified, and are found acceptable or can be tolerated, there should
be no issue. More especially so if have a system which can improve at some
future date.

And should have control systems which prevent operating at 100% capacity.
Operating at 100% capacity is generally inefficient. At any point in time
some percentage of all bridges should be shut down for maintenance or
complete replacement. Therefore traffic control systems, and mass transit
systems, and dependent systems, should be designed to accommodate such shut

The industrial world is far too dependent on technological systems, with a
lack of maintenance, and little to no back up systems, or inappropriate
backup. A slide rule doesn't require electricity and so is a better fall
back than an emergency power supply. A bridge is better than a ferry if
walking across the bridge, but the benefit diminishes if using motorised
transport. We need a balance of alternative systems, a need to protect
diversity, rather than competition.

We have become dependent on technology, fail to see such as a privilege and
otherwise become less tolerant of failures in such technology, and
potentially excessively and unrealistically demanding in the performance

We need to be more self-reflecting, and contemplate how we could have
handled things better. What we say may be true, but how we present it, may
be harmful and unhelpful.

What I am indicating is that the desired quality of the bridges is not just
a technical matter, it is subjective and involves a great deal of politics
between individuals and their conflicting needs. Those politics need to be
understood, if change is to be brought about. Get to understand the people
and systems they operate in, and work together to change the systems and
peoples perceptions. Punishment tends to generate a desire for revenge and
gets away from the issue. If a person perceives they are in the line of fire
for punishment, being fired or imprisoned, then they will defend themselves
and be unhelpful. If assist to avoid problems in the future without focusing
on the individuals personal errors in the past then they will be more
willing to assist you to help them. The real objective is to prevent future
accidents and/or hazards, not punish someone for causing. The focus of
attention therefore cannot be permitted to make people feel nervous about
discussing a situation.

If there is corruption, do you want to punish someone, or remove the
problem, if any, that such corruption generates? If the latter seek less
emotive words, and avoid using the word corruption. Whilst the word may fit
the situation, it is unhelpful to use. Plus if you remove personnel are
there appropriate resources to replace them: or will it pose a far greater

Conrad Harrison
B.Tech (mfg & mech), MIIE, gradTIEAust
South Australia

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