I have no known personal problem with your posting my e-mail. I suppose it might be blasphemous enough to cause some interesting responses. I guess I have enough conviction in my opinion to show the world how much I don't really know.

Actually, as I think about it, maybe we should allow this whole thought process to mature a bit first so it isn't quite so one sided. While I have many concerns about the process that we use to develop recommendations, I don't in any way think that it is a waste of time or is somehow wrong. I have great confidence that we do in fact accomplish much good with our efforts. The concern isn't so much about whether or not we are doing the right thing, it is more along the lines of being more clear about how it is accomplished and judged.

I am convinced that I help products become much safer than they would have been if someone hadn't facilitated the process that I help to create. (I am convinced of this based upon examples of similar products which were created by the same design teams before I arrived on the scene. The "before" and "after" configuration in terms of enhanced safety is often quite striking.) System safety works, but I think the reason that it works is quite different than most folks realize.

My engineers have taken to jokingly describing our work as that of "holistic facilitators". While this is a bit of a "new age" joke, it is also closely related to what I perceive our job to be, with the emphasis on "good works" such as safety, the environment, and human factors. (We get hired fairly regularly for our system engineering support without the emphasis on safety.) It is this aspect of our work that I think is most important, and it is important because it gets the recommendation creation process to the designers and "risk accepters" (as you indicated is needed in the accident investigation field).

My way of working is to become the safety lead for a diverse group of involved project personnel (and customers/users when practical) who use the system safety process within the concurrent engineering effort. (Actually, we often have to facilitate the creation of the concurrent engineering effort as part of our work because it often isn't in place when we first show up.) We help identify the potential hazards and then help figure out how to resolve them. Once that has occurred and everyone has agreed upon how to get the risks under control, we help make sure that the controls are implemented and verified.

I believe that it is the process of working with the design team to figure out the problems and solutions in terms that are appropriate for the project that makes system safety so powerful and valuable. The questions of how to you make sure that the hazards are properly identified and controlled are important and interesting, but we help make things better even if we never do figure out objective answers to recommendation development.

How do you envision this discussion to cause a litigation problem? I am not quite sure what I said that might get lawyers interested. I think I said that we don't really have much hard and fast evidence to based our decisions on. I suppose that means that we could be in a position of basing claims on the subjective opinions of "experts" in court. I think we already do that. There are of course the existing rules, regulations, laws, standards and "best industry practices" that need to be complied with when appropriate. I believe the questions that we have been worrying are those that fall outside of these known practices, or worse, when the existing standards are not necessarily the best safety practices (even though they may be the state of the art).

And more complicated! By the way, it appears that the Japanese are moving to incorporate something like system safety into their normal way of designing and developing products. If this turns out to be true, it should be an extremely interesting experiment in implementing system safety in a commercial environment.

That is very true. The choice of controls needs to include an understanding of how the system (including people) will behave after the controls have been put into place. The EU has a requirement to perform after-market evaluations of the actual use of the system to ensure that the assumptions (foreseeability considerations) are in fact correct. (I believe that this is in the product liability directive, but I am not positive about that.) They have been explicit in their understanding that of necessity we make guesses, but then they say that we need to do something to validate our guesses based upon actual use. I haven't heard of anyone actually doing this after-market evaluation, but it is certainly an interesting concept.

I agree with you. If you don't know the system, you can't do much with it. Unfortunately, this step seems to be the most likely to be skipped. I have never been able to figure out why, except that it might be embarrassing to admit that you don't understand how the thing works. My experience agrees with you statement, once you ask the question it is amazing how little anyone knows about the system. I have found that the confusion is often greatest among the designers themselves, especially the different specialties such as hardware design, software, and electronics. They seem to work on such different mental models of the system that it is difficult for them to determine that they don't understand each other.

It does indeed apply. I have never spent that much time hammering out the operation of a system as you seem to have, but it sounds like a good idea. Next time I get an appropriate project I will try mapping the operations on a flow chart type of representation and see what happens. I bet it will be enlightening to all concerned.

>More to follow when I get a chance. >--

I look forward to your next response. Subsequent exchanges on this topic are compiled in the indexed files provided to Active Participants in the Experimental On-line Investigation Research Project. To become a participant see Notice at home page.

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