Learning from Surprises
When an unexpected event occurs, the most important question is why it was unexpected.
Three years ago, a new period of volcanic activity began in the Reykjanes peninsula in Iceland after about 800 years of dormancy. The first eruption occurred in in March 2021, and since then, one eruption has followed another. Lava from the latest eruption destroyed a geothermal water pipeline from the Svartsengi power plant, close to Grindavík, a town now evacuated due to safety concerns following an eruption last November. The consequence was loss of geothermal water for heating across the Reykjanes Peninsula, home to tens of thousands, now during the coldest time of the year. Clearly, this event was unexpected.
Following the volcanic eruptions last November, work began on a backup pipeline, which has now been put into use. But why wasn't this work started earlier?
Why was the event unexpected?
The sudden loss of geothermal water for heating on the Reykjanes Peninsula in Iceland was a serious unexpected event. When such an event occurs, our reactions are usually the same. We try to fix the problem. And we immediately start looking for explanations. This search usually revolves around two things. On the one hand, finding a technical explanation. On the other hand, finding a scapegoat. Once a technical explanation has been found or a scapegoat has been identified, the search for explanations very often stops. But at the same time, this ensures that we do not learn from the event and that we will be just as unprepared the next time a similar event occurs.
An unexpected event can essentially have three explanations. Firstly, a mistake may have been made. Secondly, the explanation may lie in an unforeseeable event, a statistical anomaly. Thirdly, expectations may have been wrong, i.e., the event should not have been unexpected. When it comes to the direct consequence of a natural disaster, it is clear that the first explanation does not apply. The second explanation also does not apply in this case, because after the seismic activity began three years ago, it was clear that such an event could occur and that it was indeed quite likely.
Two causes led to the loss of water for heating in the Reykjanes Peninsula. Firstly, that lava flowed over the pipeline and ruined it. Secondly, that there was no backup pipeline. These two causes, together, led to the event. The only explanation for the loss of hot water in the Reykjanes Peninsula is therefore the third one: Expectations were wrong; we did not expect the seismic activity to break the pipeline. It came as a surprise and this is why we were unprepared. The question that must be asked is therefore: Why was this event unexpected? This can also be put this way: Why were we unprepared, especially since the lava flow should not have been unexpected? Only by looking for and finding the answer to this question can we learn from the event and thus find ways to avoid similar events in the future.
The roots of unexpected events are often systemic
Recently, I was involved in the analysis of of a serious accident that occurred in a large production facility. A technical explanation for the incident was quickly found. Due to the seriousness of the matter, it was not left at that, but an attempt was made to find a scapegoat. He was also quickly found. But the root cause of the incident was in fact not technical failure, nor was the scapegoat solely responsible even though his actions contributed to the incident. The root cause was a systemic failure. To identify it, extensive and detailed analysis was needed. Fortunately, the company's senior management emphasized conducting such an analysis. It revealed that the incident should not have been unexpected, and subsequently, necessary changes were made to safety standards and monitoring, expected to be sufficient to minimise the probability of such events in the future.
As long as we don’t examine causality, we will not learn
The question of why hot water stopped flowing in the Reykjanes Peninsula calls for a detailed and honest analysis of causes and effects. What the root causes are has not yet been determined, but it is likely that they may be of three types. Firstly, it may be unclear which party is responsible for reacting to signs of danger and taking action. Secondly, procedures may be unclear. Thirdly, information flow may be inadequate. All these are systemic causes, that is, a flaw in the system that is supposed to respond when indications of possible events emerge. To find out what failed, a thorough analysis of causes and effects must take place.
An investigation of this kind is complex and requires both expertise in logical cause-effect analysis and knowledge of the subject matter. But besides the challenges posed by the complexity of the analysis, the other main obstacles to a successful analysis are two tendencies. On the one hand, the tendency to avoid finding real explanations, because the outcome of such analysis may be uncomfortable. On the other hand, the tendency to look for scapegoats and the fear of those involved of being made scapegoats. We must be aware of these obstacles and avoid letting them prevent us from learning from unexpected events. Coming back to the situation in my homeland, we are at the mercy of powerful natural forces. Sometimes they act without warning, but more often events can be predicted. We need to have a reliable and effective response system, not only to be able to quickly intervene after natural disasters occur, leading to unexpected consequences, but to ensure that immediate necessary measures are taken as soon as the likelihood of such events materialises. To do this, we must be able to learn from events that surprise us but should not have done so. Because this was not the first, nor will it be the last one.
This article was inspired by the work of Eli Schragenheim and Avner Passal.
We came back from Iceland last Saturday. The airport was cosy and warm as commercial electric heaters had been temporarily installed but no hot water obviously. Not a great problem.
I am so impressed with how remedial work, even temporary, has been carried out such as pipe replacement and laying a new gravel road over the still hot lava! Amazing! In the UK we'd have to have interminable meetings, draw up plans, put work out to tender and H&S would tell us to keep away from the fresh lava for 2 years while it cooled! Makes us non-icelanders look pathetic.
Thought provoking thank you. You are probably aware of all the oil refineries being set on fire around the world. Also over the past two years in the usa alone there have been 100? Food production facilities burned to the ground. I do not remember reading anywhere how these fires started, who was responsible etc
I have often wondered about Iceland’s current erupting volcanoes. Hawaii’s devastating fire, the Canadian fires last summer. All natural disasters?