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 G’Day mates, howareya? Greetings from South
Australia. I’m finishing up a month’s vacation, camping in the outback around Alice Springs. Actually, we made a big circle around the Simpson
Desert. It is really BIG country. Our camping consisted of throwing a swag out on the ground (with amazing nightly views of the stars) and
cooking over open fires. (A “swag” consists of sleeping gear wrapped up taco-style in a heavy tarpaulin during the day. At night, the tarpaulin is
unrolled to form a ground cloth.) It’s been a great trip, but I’m more than ready to crawl into my bed at home and sit in the hot
tub to watch the stars come up in the California morning.
I had lots of time to think about this issue’s TBD while traveling hundreds of
kilometers a day over rough dirt roads. Since I didn’t spend much time in the industrial sections of the country, I didn’t find much material that directly
related to the technical aspects of system safety. However, I did come across many interesting examples of “unintended consequences” in action.
It’s not so much “unintended consequences” but rather the unknown interconnections between things and actions that I find most interesting. A
large part of our job as system safety professionals is in helping to identify previously unknown, and unexpected, interconnections and dependencies.
A station (ranch) that we visited that had an artesian “bore” (well) for a water supply. A few years ago, a turbine was installed on the bore to
produce electrical power for the homestead. That worked great until a mining company, located many miles away, drew the water down to the
point where the turbine no longer worked. The mining company installed motor-generator sets for the station, and provides fuel and maintains the
system, all at no charge. The end result is the same for the rancher (except for the extra noise from the generators) but clearly has significant impacts
upon the environmental costs of the overall system. Not only did the draw-down reduce the amount of water available to others in the area, but it
also created a shift in energy production from a clean source to one based on burning coal. Thus, an operation at one location has had widely
significant impacts. In addition, there is an ongoing question of whether the artesian basin is capable of being recharged or whether it is “ancient” water
that will be lost for use by the inhabitants of the area.
Another interesting example was associated with putting in a telegraph line
from Darwin to Adelaide in the 1870s. This project required ensuring adequate water for the installation and later for its operation and
maintenance. The government drilled many bores and routed the line along existing springs to supply this need. Once the water was available, it
became possible to drive cattle south from the “top end” (northern Australia) along the telegraph lines, opening up a new industry to the area
and displacing the local Aborigines as it grew. The presence of the water points also allowed the construction of a railroad line from Adelaide to Alice
Springs toward the end of the century. As the railheads moved north over time, the nature of the cattle-droving operations changed to accommodate
the new destinations. The impacts of the original telegraph line have resulted in widespread cultural, economic and environmental impacts on an
entire region of the country, as well as on the lives of many indigenous peoples who had lived in this area for up to 50,000 years.
A final pastoral example is the unintentional sowing of grass seeds from the stuffing of camel saddles used in northern Australia in the early days. The
grass thus seeded has spread throughout the northern, wet regions of Australia. As it turns out, this grass makes extremely good cattle feed, and
the result is a booming cattle-export business in the Darwin area. Much of the export goes to Southeast Asia, but much also goes to the U.S., where it
helps feed Americans but adversely impacts the American cattle-ranching business. As you can imagine, there are wide-ranging consequences
associated with the use of this particular grass as saddle stuffing more than a hundred years ago. It’s pretty interesting to contemplate the connections and changes.
An example that’s a bit closer to the traditional field of system safety is associated with gluing high-strength plastic windows into automobiles in
order to strengthen the “crash cage” of the car. The windows become an integral part of the structure of the cage that protects the occupants during
a crash. While this approach has significant benefits from the point of view of crash protection, it creates its own set of hazards and risks. In order to
be effective, the plastic must be very strong, somewhat flexible, and firmly attached to the vehicle. It is effectively unbreakable, uncuttable and cannot
be knocked out from the inside. Now consider what happens when a car’s electronics fail while in the hot sun. Since it’s necessary to use the electrical
system to open the doors on new vehicles, there is significant potential for people to become trapped in the vehicle and die from heat exhaustion.
Also, if it becomes necessary to cut a car apart to extricate occupants, the fire department will find it very difficult and may not be able to perform a
rescue in time. Thus, in this case, changes intended to provide safety improvements introduce new, unwanted hazards.
What intrigues me is how often, and how unexpectedly, changes result in unintended consequences. The effects of our actions seem to spread out
like ripples in a pond when a pebble is dropped into it. The trick is to identify and prepare for the effects in advance, or possibly to avoid dropping the
pebble in the first place.
Unfortunately, I don’t know of an easy way to predict the impact of the
unintended consequences of our actions. It’s relatively easy to predict hazards within a specific system under development using our standard
hazard analysis techniques. However, when we allow the scope of our “system” to expand to include “everything,” the task becomes daunting. I
suspect that the best we can expect is to keep our minds open to understanding and including elements of the environment that are outside
of our limited area of focus and identify what we can from experience or from a good imagination.
Once these “external” elements have been identified, they need to be
evaluated, assessed and brought to the attention of the decision-makers. Hopefully, the decision-makers will be sensitive to the need to provide
mitigation and/or corrective actions. We should probably be resigned to the fact that, in many cases, these unwanted effects can become overriding
considerations (such as global warming caused by burning fossil fuels) although mankind may be unable or unwilling to modify its behavior in time
to avoid the unwanted consequences. There seems to be a strong tendency for us to proceed with short-term benefits, even when we know
that they will cause ripples reaching far beyond those benefits. We appear to be an optimistic lot that assumes we’ll be able to find solutions to our
problems later on; yet we also tend to be willing to pass along the task of finding them to future generations, or to others who don’t necessarily benefit with us.
At any rate, I believe that it is within the scope of our services to attempt to identify these types of unintended consequences so that the designers and
decision makers have an opportunity to find solutions now, or to abandon the project if need be.
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