NEAR MISSES - CAN THEY BE LEVERAGED TO PREVENT SEVERE ACCIDENTS?

NEAR MISSES - CAN THEY BE LEVERAGED TO PREVENT SEVERE ACCIDENTS?

Amit Shah, Shruti Singh and Arash Azadegan, PhD

If learning from mistakes is too costly, could learning from near-misses be a more reasonable alternative in mitigating the effect of accidents? A near-miss is an event, observation, or situation that possesses the potential for improving a system’s performance and flexibility in the face of a disruptive force. On the upside, recognizing near misses helps in making future decision making by not only identifying the root cause of the issue, but by also helping take more educated actions. However, for near misses to work effectively, recognition, disclosure and classification of near misses is very important. For instance, how far the performance by members of a supply network can be stretched (before it breaks) is one potential benefit of near-misses.

One way for this recognition to happen is through near-miss mockups or experiments. Closely related to emergency fire alarm drills, near miss experiments can help identify weak links and prepare the system to cope up with future accidents. By introducing small and deliberate near-misses, we identify its weaknesses and hope to make it more resilient in coping with more serious circumstances. Small-scope experiments help find out further shortcomings and loopholes that can be filled so as to minimize future high impact occurring from accidents. This will not only allow us to leverage near misses to prevent future disruptions in the supply chain but, but can also provide the supply chain with more flexibility and adaptability. Thus, it will prepare the industry for similar disruptions in the future and will also give it a chance to figure out what else they could change to be better prepared if any of our proposed experiments were to actually occur. Since these experiments will be in controlled conditions, it will not impact the supply chain, but they will certainly give us an idea of what needs to be changed in order to handle a similar or a larger crisis.

Another aspect of near miss that be looked at is the extent of the impact it has on the operational structure. Near misses which have a smaller impact are easier to reproduce and control, whereas, larger near misses are more practical, more extensive and more insightful but at the same time are more complex to reproduce. The larger near misses are the ones that will test the limitations of the supply chain and may provide for a steeper learning curve. Higher sloped learning curve provides the basis to help more easily identify, prevent or mitigate major accidents.

A third aspect of near misses importance is their probability of occurrence. The ones with the most probability provide the most visibility of what could go wrong. But the ones with the least probability could be the one to cause most number of hidden problems. These are the ones for which a supply chain may not be prepared and hence, the ones which may lead to potential accidents. Testing with these scenarios is of immense importance to manage the risk associated with them and also to expose the system’s limitations during these scenarios.

        Fire drills and war games are common learning tools in fire departments and the military. Indeed, running exercises are frequent means for testing military preparedness. As supply chains become more competitively fierce, it may be necessary to seriously consider the need for near-miss “mockups”. After all, how did each of us learn how to ride a bike without training wheels if mom or dad let go of the handle, knowing that they would catch us before falling over?  Some parents run this particular near-miss exercise in a soft, grass-laden backyard to curtail any possible bruises. Such is the spirit behind running near-miss experiments. Toughening through learning with minimal possible damage.  

Hurricane Warnings – What their lack of specificity leads to -

By Sowjanya Goddey and Arash Azadegan, PhD.

Sep 9, 2013 

By now everyone one has heard about  the destruction left behind by Superstorm Sandy last year.  The largest hurricane to ever hit the U.S. mid-Atlantic and North East regions, ended up flooding streets, tunnels and subway lines and cutting power in and around New York City. The damage was $68 Billion including 7.5 million homes & businesses and costing over 300 lives. Are we, as advocates and poll bearers of public awareness to be held responsible for the damages caused by the likes of Sandy? Perhaps or perhaps not. Nevertheless, our warning systems may be able to do a better job.

Federal and state agencies declared before the storm that 90% of the East coast would get affected but did not announce what kind of damage it could impose. There were neither clear warnings nor proper evacuation protocols across the coastal areas issued by the government. At the minimum, this caused areas of confusion.

For instance, even though the forecast for sandy was fantastic, not issuing clearer hurricane watches or warnings along the New Jersey and New York coasts were a clear drawback. In comparison, the hype factor of hurricane Irene (last year’s weak sister to Sandy) was a clear contradiction. Irene did cause a significant amount of damage in New England area, but it was nowhere close to the hype that was created prior to the event. So, the Irene hype created a false prediction, which left people in a fix as what to truly believe.

Another area of confusion was in not issuing hurricane watches or warnings along the New Jersey and New York coasts. Lack of clarity in communicating the message to general public was a problem. For instance, The National Hurricane Center issued warnings that the storm would become extra tropical and thus not become a hurricane as it pushed inland. To the general public, the message is unclear. What does “extra tropical” really mean? Moreover, the National Hurricane Center allowed the local National Weather Service offices to issue their own warnings. Finally, the information issued by NHC or NWS were all over the place. For instance, some of the warnings such as “High wind warnings” were not only issued along the coasts where Sandy made landfalls, but also as far south as North Georgia. The broader the area that the warnings affect, the larger the worry and concerns become for the public.

State and local officials issued mandatory evacuations orders for many thousands of families in the low-lying areas and also shut down the mass transit systems just hours before the super storm hit them. Although, people who could afford to evacuate and bunk in at a friend or relative’s place or at the luxuries of a hotel did evacuate for their safety. What did the others do? They stayed back assuming the damage would not be major since there were no dramatic warnings. If people were told to evacuate their homes, then many people did. But lack of preparatory time and the lack of infrastructure in the face of such surges caused chaos.

In the end, we couldn’t escape the deaths and destruction induced by both of these storms. This is where we have to ask ourselves – how much information is too much or too little? How to broadcast the to be issued warnings to general public in a simple and less complex way? How to process the issued data?  To what extent, can we relay on it?

So the aftermath was the wrath of homes, loss of lives, flooding, shortage of food and water, shortage of disaster shelter homes, gasoline shortages, power outages, closure of roads & public transportation, non-operating traffic signals, closed out restaurants & diners, businesses and adding salt to the swollen wound was the fact that it was peak winter. It was a total chaos. Life came to a standstill for weeks. It took couple of weeks for some to rebound and months for others. Some of them such as New York & New Jersey tourism, businesses & homes are still recuperating. We cannot really blame anyone here. No one saw this coming.

To draw the line is like searching for McKenna’s gold (looking for a moving target?). Yet, we do have the treasures of past experiences that can be put to good use. And yet, we cannot assuredly rely on these. We must realize that every storm is different in its own way. Ironically, that is the reason they have their individual names. So what does it prepare us for? Predictable as well as unpredictable conditions!!  Every storm has its way of telling a story on how closer are we getting in predicting the next one. Our suggestion to everyone of those like us looking for answers to nature’s fury whether it is a storm or draught or Tsunami is - make the best of the inventory and tools we have. Strengthen upon the weaker links especially the infrastructure. Wait, watch and learn! And above all, it’s ok to not know everything.