One of the best conference speakers I’ve ever listened to is Gordon Graham. Fortunately for me, he was the key note speaker this morning at the 59th Annual IAEM Conference and EMEX 2011. And in his normal, passionate, eccentric and engaging style managed to captivate the audience talking about something that would normally put everyone to sleep – or paying more attention to their smartphones.
He talked about risk management.
He did so with more expressive theatrics and graphic sound effects than I recall. I especially enjoy how he channels Leonardo DiCaprio’s character in “Titanic”, undulating his body to Celine Dion’s title song, “My Heart Will Go On.” Hard to explain, you really had to be there.
He was using the story of the Titanic as an example of the difference between 'proximate' cause and 'root' cause. “If you ask 100 people what caused the Titanic to sink, 99 of them will say … the iceberg,” he said.
Certainly, the iceberg was the proximate cause that sunk the Titanic. What was the root cause? “When it was designed, it was fatally flawed!” he thundered. Fingering the iceberg as the reason the Titanic sunk is akin to treating the symptom and not the cause. It doesn’t matter how many iceberg-detecting devices you build, a poor design trumps mother nature – or human stupidity – every time.
There is a reason tragedies (like the Titanic) happen over and over again. Identifying the most obvious cause and developing control measures to mitigate the most obvious cause overlooks what Adam Weiner in his great book Don't Try This At Home calls, “a little pride and a lot of bad engineering”. This is what he says:
The Titanic was designed so the hull’s 16 separate buoyant compartments, divided by watertight doors, would stay afloat even if four of its compartments were breached. The iceberg punctured six compartments. The bulkheads dividing the compartments came up to 10 feet above the waterline, beyond which water would flood adjacent sections even if not breached. "If the compartments had been completely watertight, that is, if water could not spill over the tops of the bulkheads, the 'Titanic' would not have sunk," he said.
You know, I’m sure I’ve read something similar about a different tragedy recently. Oh, yeah. It was how the defences at the Fukushima Dai-Ichi nuclear power plant in Japan were built to withstand the largest expected tsunami waves - 5.7 meters. The largest waves were 14 meters. The IAEA report says that "... although tsunami hazards were considered both in the site evaluation and the design of the Fukushima Dai-ichi NPP as described during the meetings and the expected tsunami height was increased to 5.7 m (without changing the licensing documents) after 2002, the tsunami hazard was underestimated."
The point being: There is always an iceberg. The real challenge is looking behind it.
