Instant‐Expertise in Failure Causation: Developing and Presenting a Network of Causes and Recommendations Extracted from Past Failures

Abstract

Systems engineering failures like schedule slips, budget overruns, and other setbacks, occur often and can be costly, but the literature provides little guidance on why these failures occur or how to prevent them. In our previous work we argued that systems engineering failures are manifestations of similar underlying problems, and thus leveraged literature on the theory of accident causation, as well as the many accident investigation reports, to understand better how and why project failures occur and potential ways of preventing these failures. We developed a database of over 900 examples of failure causes and over 600 examples of remedial actions. In this paper, we detail our process for building this database into an interactive network‐based solution aid that anyone experiencing problems in their project or organization can access. The interactive solution aid provides the user with “instant expertise” in accident causation and remediation because it provides users with summaries and simplifications of the causes and remediation measures from the failures we studied.

Preventing slips, overruns, and cancellations: Application of system accident investigations and theory to the understanding and prevention of engineering project failures

“…Since our sample is relatively small and was not selected randomly, we cannot definitively (and with statistical certainty) conclude that in project failures actors failed to train exactly Table 4. Cause definitions and presences [14].…”

“…The two causes with high presence (>70%) in project failures (failed to consider design aspect and failed to supervise) are both internal nodes in with Table 6. Recommendation code definitions [14].…”

“…Our work is currently available in an interactive web-based platform, where the user is able to click on a certain cause, see what other causes are related to that selected cause, and then see recommendations related to that set of causes, available at: https://engineering.purdue.edu/ VRSS/research/force-graph/index_html. For details on how we constructed this interactive version of the network and how we propose practitioners use the network to identify problems and potential solutions in their own organizations, see [14].…”

“…A note on definitions: Both system accidents and project failures are "undesired and unplanned (but not necessarily unexpected) event[s] that result in (at least) a specified level of loss" [13]. We use "system accident" (which we shorten to "accident" for ease of reading) to refer to those events that directly result in loss of life, injury, or damage to property [14]. System accidents are a generalization of "process accidents" in the chemical process industry (cf.…”

“…We do not consider here occupational safety accidents such as falls from ladders or mishandling of lathes. We use "project failures" for all other undesired project events, such as failure to achieve mission objectives, budget or schedule overruns, cancellations, and quality or performance issues [14]. In both cases, this paper focuses on systems that are technologically and organizationally complex, and usually expensive, both in terms of direct and indirect losses.…”