Point Lookout: a free weekly publication of Chaco Canyon Consulting
Volume 14, Issue 51;   December 17, 2014:

On the Risk of Undetected Issues: II

by

When things go wrong and remain undetected, trouble looms. We continue our efforts, increasing investment on a path that possibly leads nowhere. Worse, time — that irreplaceable asset — passes. How can we improve our ability to detect undetected issues?
A schematic representation of the blowout preventer that failed in the Deepwater Horizon incident

A schematic representation of the blowout preventer that failed in the Deepwater Horizon incident in 2010 in the Gulf of Mexico. In a report released in June of 2014, the U.S. Chemical Safety Board explained how undetected issues in the blowout preventer, including miswiring and design flaws, led to the disaster. The report also states that these issues could be present today in blowout preventers in widespread use throughout the industry, and that additional blowout preventer failures are possible. The CSB Web site offers a marvelous video, including computer animation of the failure. Image courtesy U.S. Chemical Safety Board.

As we saw last time, the difference between a risk and an issue is that risks are adverse events that might or might not happen. They are uncertain. On the other hand, issues are adverse events that have already arisen, or are certain to do so. Undetected issues are especially problematic when we treat them as risks, instead of mounting serious efforts to uncover them.

Let's now explore tactics for uncovering undetected issues. The general principle underlying all these approaches is an obvious one: Look for undetected issues in the places where you're most likely to find them.

Involve the customer in development — from the beginning
When developers and customers collaborate, they educate each other. Customers don't always know what they want or need. Sometimes they think they know, but they're mistaken. Still, customers can make valuable contributions to development processes, and participation in development helps refine their knowledge of what they want or need. The sooner this happens, the closer the product comes to delighting the customer. And when this mutual education doesn't happen — or when it happens too late — we sometimes discover issues only after the product is delivered.
Use what you're building — early
Actual usage is Actual usage is the method
most likely to expose the
problems that arise
in actual usage
the method most likely to expose the problems that arise in actual usage. Use what you're building (or parts thereof) as early as possible, or recruit actual users to do so. If needed, install placeholders for incomplete components. Placeholders are usually worth the investment, because early usage that exposes serious problems can reduce rework.
Exploit organizational history
In retrospectives, note the occurrence of undetected issues, the time it took before they were detected, and the cost of not having detected them promptly. Review the observations for patterns. Apply this information to future and ongoing efforts, checking for repetitions of these patterns, and incorporating into designs of products, services, projects, controls, and procedures, clever mechanisms that will signal the presence of any of these patterns. Use the cost information to set the levels of these investments.
Account for the effects of cognitive biases
Cognitive biases are patterns of thinking that lead to systematic deviations from rationality and objectivity. They can cause us, for example, to dismiss indications of undetected issues in products or projects. Learn about cognitive biases and incorporate safeguards into your processes to reduce the impact of cognitive biases.
Test with undetected issues in mind
Tests and inspections typically focus on determining whether the items tested meet requirements and quality standards. That isn't enough. If you have evidence of patterns of undetected issues in earlier work, broaden the testing focus to check for undetected issues. If you're unaware of patterns of undetected issues, make some brilliant guesses.

Your organization probably has a number of projects underway. Almost certainly there are some undetected issues. What are they? Where are they? First in this series  Go to top Top  Next issue: The Perils of Novel Argument  Next Issue

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