What Could Go Wrong…And Why It Often Does

“Of course, we consider risks.”

 

That’s the response from governmental agencies and companies when the subject of risk preparedness is introduced. Then, why do we so frequently experience disasters like the compromised Fukushima reactor, British Petroleum oil spill, and Flint water contamination, or threats like the Kaspersky software “surprise”?

 

“Unpredictable events.” “Black Swans.” “A natural disaster.” “Limited human and financial resources.” “The perfect storm.” “Human negligence…malfeasance.” Plenty of explanations and excuses.

 

Here’s one more: the lack of a What Could Go Wrong process.

 

I can hear the objections: we have time-tested standards, a quality control process, risk officers, risk-based checklists, a project management program, experienced reviewers.

 

We can do a better job with threat identification and prevention. Different levels of risk require different approaches. For adhering to standards and design norms, checklists are okay, and most organizations do a good to very good job with this category of risks. Most do a fair to good job with conventional risks—how to prevent spills, what if a fire breaks out? Where we do a poor to awful job is with “barrier-free threats”, that is, risks that fall outside an organization’s scope of work or competency, or outside conventional risks, and have the potential to drastically affect a project, product performance, or a policy’s effectiveness.

 

A water treatment plant with a scope of work to produce treated water that meets drinking water standards at the plant’s fence line, and a community that doesn’t understand, or neglects, the consequences of unstable water conveyed by lead pipes outside the fence line. Kaspersky software, where a What Could Go Wrong process would have started with this question: Knowing what we do about Russia, what if this company is a “wholly owned subsidiary” of the Russian government. A new state-of-the-art German frigate that wasn’t designed to counter traditional threats—as a January 2018 Wall Street Journal article puts it: “(The) frigate was determined…to have an unexpected design flaw: It doesn’t really work”. And that’s highly regarded German engineering. The Fukushima nuclear reactor that wasn’t able to resist a tsunami, though it’s located on an island in an earthquake-prone region. Instead, we struggle with after-the-fact accusations, “patches”, litigation, and PR initiatives.

 

Such threats aren’t Black Swans—an asteroid strike, a Los Angeles magnitude earthquake in Michigan, nuclear war. Nor is the standard perfection. Rather, identifying unconventional risks—threats—by employing a disciplined, barrier-free What Could Go Wrong process.

 

The essentials of such a process are:

  • Activation as early as practical, before project initiation or policy definition
  • A leader who drives big picture What Could Go Wrong questioning, discourages small picture problem solving, and doesn’t allow “What if” questioning to be shut down by statements such as: “That’s outside our scope”, “There isn’t budget for that”, “We’re following all the standards”.
  • Engaging one or more subject-matter experts (“rabble rousers”) with no formal role in the enterprise and no incentive to tell the organization what it would like to hear.
  • 1-2 days is long enough to identify big-picture threats if the right people are present; not a costly or time-intensive process.
  • Concise and clear documentation of the big picture threats, for action as deemed appropriate by top leaders, not just the project team

 

If an organization doesn’t have a process along these lines and thinks that such disasters can’t happen to them, they’re kidding themselves, and while such a process wouldn’t protect against all possible threats, they could be better identified and might be mitigated. Just as important, risks could be communicated to the public, company leaders, etc., in an audience-appropriate manner, and considered in planning and decision-making. Such a process, done well, could have prevented the Flint and BP debacles, and could have mitigated the Fukushima disaster.

 

Lawyers often warn us that if we don’t know something we may not be as liable as if we knew ahead of time. The problems with this legally protective approach: 1) We have an ethical, if not legal, obligation to investigate and address threats, especially risks to health and public safety, and 2) How did this legally protective approach work for the principals in the Flint, Fukushima, and BP disasters? Addressing such threats appropriately ought to be one of a leader’s most important jobs. Far from being an assault on private enterprise or interference with government experts, such a process safeguards the interests of these entities because it helps them avoid disasters and grave harm.

 

How much time and money are organizations willing to spend on public relations and remediation in the wake of disasters, while neglecting big picture What Could Go Wrong questioning ahead of time? We can do better. We have the talent. We need the will and the process.

See No Evil

In the wake of the Las Vegas massacre, many are asking the question that was asked after the West learned about the trains to Auschwitz, after 9/11, and after the Paris theater massacre: “Why did he (they) do it?”

 

We look for clues, we hear from people who knew the perpetrators, we wring our hands, but we find it hard to apply the word that best describes the act: evil.

 

After each of these horrendous acts of violence, the usual explanations are trotted out: mental illness, an overabundance of guns, festering grievances, addictions, brainwashing, but most of us, in our secret hearts if not our public voices, aren’t satisfied that these things adequately explain such monstrosities.

 

Though not popular in the sociology and psychology fields, many believe that human beings are born with a conscience. One of the most eloquent and understandable explanations for native (though not fully developed) conscience is supplied by C. S. Lewis in Mere Christianity. Even so, our conscience is far from fully formed at birth. Like a physical muscle, it must be exercised and developed, and this occurs via good formation.

 

The conscience “muscle”, properly formed, wards off evil; that is, grievously disordered behavior, but if this “muscle” becomes atrophied, or is damaged, disorder invariably results. Mental illness, addictions, strong emotions, and brainwashing can also weaken the conscience “muscle”, though a well-formed conscience can ameliorate the effects.

 

All human beings experience temptations, and many experience inclinations toward evil. Some succumb to the urge to commit evil acts without willfully embracing evil. Though they commit the act, they do not succumb wholeheartedly, and may later repent.

 

The embrace of evil is different, dismissing conscience, disregarding the welfare of others, considering the evil act and willfully committing it as the self’s prerogative. Addictions, emotions, propaganda, and mental disorders are peripheral to the willful embrace of evil. What’s more, those who dismiss conscience and willfully embrace evil are often more skilled at concealing their attitude and schemes than those who commit evil acts but are still pricked by conscience.

 

One cannot set aside conscience without doing grave harm to oneself. We are so wired, and we cannot un-wire ourselves and still make a pretense of being healthy. A person with a well-formed conscience could not sit in a room with Adolf Hitler, Heinrich Himmler, Joseph Stalin, or Mao Zedong for ten minutes without realizing that something was very wrong,

 

The elimination of conscience that results in the embrace of evil—not merely succumbing to the temptation to commit an evil act—produces a grossly disordered self-regard and a cancerous self-hatred, a death wish if you will, even if the person doesn’t acknowledge it. Self-regard to the degree that no one else’s welfare matters, self-hatred as a natural consequence of the destruction of conscience and the willful embrace of evil; a form of possession in the sense that the self no longer exists apart from the evil.

 

Though temptations and inclinations toward evil may remain, a well-formed conscience strengthens the will to resist evil, and the experience of self-giving love is a powerful anti-virus to the “evil germ”.

 

The answer to the question “Why did he do it?” is evil exists, and some embrace it.