What to Do When
Things Go Wrong
An Ethical Solution
Robert A. Durham, PhD, PE
Marcus O. Durham, PhD, PE
If you can smile
when things go wrong,
you have someone in mind to blame.
Role of Engineer in Forensics
• Engineering training focuses on technical skills
• Skills needed to resolve dispute or discrepancy
lacking
• Engineers often first responders in investigation
• Two sides to issue
– How is discrepancy resolved ethically?
• At least two “correct” answers
History Lesson
• US / Canadian Legal system
– derived from English Common Law
“ In almost every case except the very plainest, it
would be possible to decide the issue either way
with reasonable legal justification.”
- Lord Macmillian
Lord Chief Justice of England
Background
What is a Project?
• Project – extensive undertaking of multiple tasks for
a definite purpose and a set time
• Objective – maximize return on investment
• Project has tradeoffs
– Time (t), Money ($), Quality (Q)
$
• Customers goals
– Maximize Q, meet t, minimize $
• Suppliers goals
– Meet Q, meet t, maximize $
t
Q
Background
Project Management
• There are relationship limits between Q, t & $
– As Q, $ and/or t
– As $, Q  and/or t
• Q, t and $ have limits
– Set by customer and/or supplier
• Basis of all disputes: a perceived disparity in the
quality, money, time or some combination
$
t
Q
Ethic
Projects
The ethic of the engineer / project
manager is to
Balance the needs and expectations
of the customer and the supplier
Background
Necessary Skills
• Three skills required for any Project:
People, Money, Technical
• People – Who is involved? What is the
relationship? How is performance?
• Money – Income, Expenses, Contracts, Limits
• Technical – Are people qualified? Is technology
adequate? Are there reasonable alternatives?
Tech
Folks
Money
Is Something Wrong?
How to Tell
• Catastrophic failures become obvious
– Catastrophic failures are always the result of at least
two compounding failures
• Sometimes “gut feel” that something is amiss
• In either case
– Perform analysis,
see what is wrong,
– Determine appropriate
response
Decisions
The Flowchart
Questions
Start
1. Part of Vision?
2. Ethical?
3. People in Limits?
Initialize
4. Time in Limits?
5. Money in Limits?
Questions
No
6. Technology in Limits?
7. Quality in Limits?
Yes
Evaluate
8. Safety in Limits?
9. Environmental Limits?
10. Legal in Limits?
Continue
Project
Flowchart Evaluation
Temporary
Condition?
Yes
Time to
Bail Out?
Repeated
Event?
What is
Sacrificed?
No
Approval?
No
No
Resolvable
Condition?
No
Resolve
Problems
Document
Events
Loss
Control
Within
Constraints?
Yes
Continue
Project
Ethic
Risk Management
The ethic of the engineer charged with “picking
up the pieces” is to
Follow the Process
1.
2.
3.
4.
5.
6.
7.
Stop the loss
Gather data
Evaluate options
Determine consequences
Prepare report
Make decision on recovery
Start recovery
Stop Loss
• First, most important step
• Procedure determined by nature of problem
–
–
–
–
–
Personal Injury – render aid, seek pro help
Fire – stop small or abandon, ensure extinguished
E, M, C Malfunction – remove energy source
People – remove from process, use finesse
Financial – control cash flow
• In all cases follow policy & legal
requirements
Gather Data
• Used for later evaluation or justification
• Can be docs, photos, statements, physical
• Protect in as pristine condition as possible
• Secure, protect, label, store
• Numerous standards address process
–
–
–
–
ASTM E678-98
ASTM E860-97
ASTM G145-196
NFPA 921
Gather Data
• Use Scientific Method* to determine root cause of
failure
–
–
–
–
–
–
–
Identify Problem
Define Problem
Collect Data
Analyze Data
Develop Hypothesis
Test Hypothesis (Cognitive or Experimental)
Select Final Opinion
* NFPA 921
Putting Out Fires
• Fire is analog for any problem
• Fire needs three things
– Fuel
– Oxygen (Environment)
– Spark (Ignition)
• For any failure need three things
– Fuel (History)
– Environment
– Trigger
Environment
Fuel
Spark
Evaluate Options
Analyze Data
• What is the origin of the failure?
• Begin with big picture
– Look at all events and surroundings
• Recognize pattern
• Determine detailed effects
• Hard to see the forest for the trees
Evaluate Options
Analyze Data
• What is the root cause of the failure?
• Begin with detailed observations
– Then move to generalization
• Consider all possibilities
– In and around area of origin
• A possible cause must have
– Fuel, a proper environment, and a “spark” that ignites
• Eliminate possibilities until only one cause
remains
Evaluate Options
Analysis
• Generally more than one issue
• Analysis involves finding all conditions
• Components of a system can be delineated
• Each should be investigated to determine if it
was part of the problem
– Seldom yes / no
• Eliminate components until most probable is left
Evaluate Options
External Factors
• Seldom is one component responsible for failure
• Once components are identified
– Research external influences
• Could be
– Design, manufacturing or application
Application
Manufacturing
Design
Evaluate Options
External Factors
• Design
– Systematic process of contriving plans for a particular
purpose
• Implies special knowledge
• Compromises are necessary for success
• Designer expected to know technical problems
that could occur, and take
actions to mitigate
• Eliminate, protect, warn
Evaluate Options
External Factors
• Manufacturing
– Process of putting components together into a
working system
• Implies ability to create, produce or turnout
finished product
• Often low margin – Compromises save $
• Compromises OK, but must be consistent with
quality and safety
Evaluate Options
External Factors
• Application
– How the system is employed
• Under direction of user or owner
• Typically intended for use without knowledge of
design, manufacturing or compromises
• User has responsibility to apply prudently
• User not expected to
modify, abuse, or overload
Evaluate Options
External Factors
• If failure occurs, list possible external factors
• Eliminate possibilities if did not contribute –
– Note why eliminated
• Eliminate until most probable cause
• If properly
– Designed,
– Manufactured and
– Applied
Failure will not occur
Evaluate Options
Opinion
• After looking at origin, cause, analysis and
external factors, a hypothesis can be developed
• Hypothesis tested against all known facts
• If all facts cannot be resolved,
– Hypothesis is eliminated
• Iterative process – often useful to employ
“sounding board” or “devil’s advocate”
Evaluate Options
Opinion
• Final hypothesis obtained
– When all available data correlates reasonably
• Opinion - judgement based on special
knowledge
• Opinion - belief or conclusion held with
confidence based on evaluating all possibilities
and developing the most probable scenario
• Opinion - based on ethics, character, and
outstanding technical skills
Ethic
Opinions
The ethic of the engineer is to
1.Base opinions on all the evidence
obtained and
2.Be willing to change if contradictory
information is obtained.
Determine Consequences
• What is the result of the failure?
• Are there any damages?
• What steps can be taken to recover damages?
• What can be done to prevent future failures?
– Can the “fuel” be eliminated
– Can the environment be modified
– Can the “spark” be avoided
Prepare Report
• Purpose of report
– Convey necessary information to decision makers
• Format of report varies by circumstances
– Written reports - external consumption
• all background, methods, analysis, and opinions
– Memoranda - list high points
– Verbal - information without record (important)
• Regardless of format, reports should always include
statement such as
– Opinions can be modified
if new information becomes available
Recovery Decision
• In case of failure resulting in damages
– Recovery can be attempted
• Methods of recovery
– Warranty (implied and explicit)
– Insurance claims
– Supplier relationships, contracts, etc.
• Final option is legal recovery
• Generally, only “winner” in a legal recovery are
the legal players
Recovery Decision
Negligence
• Often legal claim is based on negligence
• Negligence four points – all must be present
– Duty - responsibility to perform what is reasonably
expected
– Breach of duty – failure to perform
reasonably
– Proximate cause – event sufficiently
related to damages
– Damage – actual harm
Attempt Recovery
• Follow procedures appropriate for recovery
method
• Method decisions are not final
– If one method doesn’t work, other options can be
attempted
• When necessary – get outside help
• Avoid litigation if at all possible
Final Thoughts
Non – Technical Prevails
• Regardless of technical “rightness” of engineer’s
opinion, other, non-technical factors often have
most influence in recovery decision.
• Additional Cost
• Negligence / responsibility
• Probability of Success
• Potential Recovery
• Reputation
Final Thoughts
• Sometimes it is better to abandon the problem,
and chalk it up to experience
• Stuff Happens
• Often a “perfect” analysis or solution is
impossible
• Engineer has the responsibility to find
the least erroneous solution
Ethics
Summary
• Three Phases
– Project development / management
– Things going wrong
– Post mortem / opinion
• Ethical responsibilities in all three phases
– Balance interests
– Follow process
– Evaluate everything
• Be willing to modify opinion based on
new information