It blows my mind how little we pay attention to #water systems in the US. We talk about ‘developing countries’ or ‘sh*tholes’, ignorant about the dire situation 52k water systems face right here in the #US. @VarunaIoT 1/15
The water system requires an understanding of #complexsystems and failures points within systems. Thankfully, Dr. Richard Cook already wrote the ‘How Systems Fail’ treatise (for public health systems), and I’ll apply to our water systems in the US. 2/15 https://www.researchgate.net/publication/228797158_How_complex_systems_fail">https://www.researchgate.net/publicati...
Complex systems are intrinsically hazardous systems: we know the constituents of your water in real-time UNTIL it leaves the treatment plant. In the pipes? Little to no visibility. 2020 has seen 10& #39;s of thousands of violations. That’s a HUGE issue 3/15 https://obipublic.epa.gov/analytics/saw.dll?PortalPages">https://obipublic.epa.gov/analytics...
Complex systems are heavily and successfully defended against failure. Until they’re not. We don’t know what to defend against because the #EPA hasn’t updated the contaminants list/defenses required for decades 4/15 https://amzn.to/3fk7MPN ">https://amzn.to/3fk7MPN&q...
Catastrophe requires multiple failures - single point failures are not enough. Flint’s, and thousands of other US cities, #water issue was a convergence of multiple failures. 5/15 https://www.pbs.org/wgbh/nova/video/poisoned-water/">https://www.pbs.org/wgbh/nova...
We keep talking about the issue wrong! Post-accident attribution to a ‘root cause’ is fundamentally wrong and hindsight biases post-accident assessments of human performance. Again, see Flint point above and ‘Rethinking Root Cause Analysis’ 8/15 https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis#">https://psnet.ahrq.gov/perspecti...
We focus on infrastructure and ignore people. Human operators have dual roles: as producers and as defenders against failure. Human expertise in complex systems is constantly changing but we are failing to equip the fast retiring workforce of ‘producers and defenders’... 9/15
But we must use new tech and train new folk. To address risk (in old approaches and new tech) and accept that ‘actions at the sharp end resolve all ambiguity’. We have to change the business model of the industry to & #39;pay-for quality not usage amount& #39; 13/15 https://www.linkedin.com/pulse/near-future-water-cities-seyi-fabode-1e/">https://www.linkedin.com/pulse/nea...
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