Point Lookout: a free weekly publication of Chaco Canyon Consulting
Volume 14, Issue 50;   December 10, 2014:

On the Risk of Undetected Issues: I

by

In complex projects, things might have gone wrong long before we notice them. Noticing them as early as possible — and addressing them — is almost always advantageous. How can we reduce the incidence of undetected issues?
The damaged Apollo 13 Service Module, as seen from the command module

The damaged Apollo 13 Service Module, as seen from the command module. The damage was caused when an oxygen tank exploded as a result of damaged insulation on a wire powering a sensor inside the tank, according to the findings of the Apollo 13 Review Board, which conducted a post-mission investigation. In effect, the investigation discovered the undetected issue, even though the Board did not have access to the Service Module, which was destroyed on re-entry into Earth's atmosphere. The Board's analysis demonstrates that, in principle, the issue could have been detected prior to launch. Photo courtesy U.S. National Aeronautics and Space Administration.

Language and terminology are the tools we use to express our thoughts. But language and terminology can do much more — they can actually influence the way we think. And that influence isn't always helpful.

Consider risk. In project management, and fields closely related, there's an ongoing conversation about differences between the term risk and the term issue. Although disagreement and confusion persist, most people agree about two points. First, a risk is an event or condition that might or might not occur, while an issue is an event or condition that has already occurred, or which will certainly occur. Second, both risks (if they occur) and issues have adverse consequences for objectives.

The principal difference between risks and issues is that risks have probability less than 100%; issues have probability 100%.

This distinction leaves at least one situation uncovered: what do we call adverse events that have occurred (or which certainly will occur), but which as yet have escaped notice? I call them undetected issues. Undetected issues can be problematic, because although we treat them as risks, they aren't risks at all.

How does all this relate to our use of language? When we think of undetected issues as risks, we tend to regard them as not yet having happened, as opposed to having happened and not yet having been detected. Thinking about them this way can be problematic. For example, thinking of a condition as not yet having happened can lead to dismissing as pointless — or not worthwhile — any plan to determine whether or not it has already occurred. Why search for something that hasn't happened?

On the other hand, we might be more willing to expend resources to uncover the presence of undetected issues. When we do search, we're more likely to find them.

For example, consider the mission of Apollo XIII. A liquid oxygen tank exploded during Hour 55 of the mission due to When we think of undetected issues
as risks, we tend to regard them
as not yet having happened, as
opposed to having happened
and not yet having been detected
damaged insulation on wires inside the tank, which resulted from procedures executed years earlier. Before installation in the vehicle, the damage was a risk. After installation, it was not a risk at all — it was an undetected issue. And post-incident, a thorough investigation did uncover the undetected issue. How would the mission have been affected if NASA — before launch — had conducted a more thorough search for undetected issues?

Many project teams now develop risk management plans. Few of these plans address the risk of undetected issues. If we think clearly about the distinctions among issues, risks, undetected issues, and the risk of undetected issues, we're more likely to include mechanisms in the design of our systems — and procedures, schedule, and resources in the design of our projects — that facilitate detecting as-yet-undetected issues.

We'll explore some practices that can help teams uncover undetected issues next time.  Next in this series Go to top Top  Next issue: On the Risk of Undetected Issues: II  Next Issue

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