Point Lookout: a free weekly publication of Chaco Canyon Consulting
Volume 24, Issue 11;   March 13, 2024: On Anticipating Consequences

On Anticipating Consequences


Much of what goes wrong when we change systems to improve them falls into a category we call unanticipated consequences. Even when we lack models that can project these results accurately, morphological analysis can help us avoid much misery.
The S.S. Eastland, in Cleveland, Ohio, around 1911

The S.S. Eastland, in Cleveland, Ohio, around 1911. She already had stability problems in 1911 due to the weight of heavy equipment installed in 1903. Still to come were replacement of hardwood decking with concrete in the main dining room and aft deck, and lifeboats and rafts on her upper deck in early 2015, which led to her capsizing on July 24.

Image from the Detroit Publishing Company collection at the Library of Congress, courtesy Wikimedia.

Following a community-level or society-level catastrophe, an almost-formulaic utterance of officials, speaking to the public through media, begins something like, "Due to unforeseen events,…" or "Because of unintended consequences,…" For example, at the start of World War I, in 1915, and following the loss of RMS Titanic and 2224 people on 15 April 1912, the U.S. Congress passed the Seamen's Act. Among other regulations, the act required that vessels carry enough lifeboats for all on board. The SS Eastland was therefore retrofitted with lifeboats for 2,000. [Eastland Memorial Society 2007]

In the case of the Eastland, however, this decision had unintended consequences. She had a history of instability. Beyond the retrofitting of lifeboats, she had undergone recent changes that made her even more top-heavy. At 6:30 AM on July 24, at the wharf in Chicago, minutes after the start of loading the first of thousands of passengers, the ship began to list to starboard. The listing increased until the ship finally settled on her port side at 7:32 AM. Trapped or crushed by heavy furniture and equipment, 844 died, including 841 passengers.

In retrospect, The hallmark of incidents involving unintended —
and sometimes unanticipated — consequences is
the urge to ask, "What were they thinking?"
what happened to the Eastland makes so much sense that one wonders, "What were they thinking?" And that is the hallmark of incidents involving unintended, and sometimes unanticipated consequences. What happened to the Eastland was unintended, but certainly not unanticipated. During testimony before Congress regarding the Seamen's Act, A.A. Schantz, general manager of the Detroit and Cleveland Navigation Company argued against increasing lifeboat requirements for Great Lakes vessels, of which the Eastland was one, because the additional weight would cause many vessels to become top heavy and prone to capsizing.

Natural questions arise:

  • How can we improve our capacity to anticipate unwelcome consequences?
  • How can we avoid situations likely to be fraught with unwelcome consequences?
  • When someone does notice an elevated risk of unwelcome consequences, how can we limit the chances of inappropriately rejecting the warning?

How we can improve our ability to anticipate

One approach for improving anticipation effectiveness involves studying problem solving techniques, and applying them to the matter at hand to model results of making a change. But we don't always have the time or resources these approaches require. A low-cost, rapid alternative exploits a technique known as morphological analysis. [Ritchey 1998]

One of the advantages of morphological analysis is its applicability to problems that are mathematically intractable. Another advantage is that its discipline compels us to consider features of the problem space that we might otherwise overlook or avoid. Let's see how this works in an example studying the effects of a set of changes on the attributes of a system.

Direct effects

We begin with direct effects. When we make a change to a system, some of the system's attributes might change as a result. For example, after the 1903 season, the owners of the SS Eastland added an air conditioning system for passenger comfort. This added weight to the vessel, increasing its draft. In this example, increased draft was a direct effect of adding air conditioning. Increased draft eventually became a problem for navigation because the waters of the Black River in Michigan weren't deep enough for the Eastland, and that became a problem to be solved. Direct effects aren't always problematic, but this one was.

To uncover all direct effects can be tricky, and that's why morphological analysis can be helpful. It works like this. We begin examination of the system we're changing by listing the attributes we care most about. For example, our list might consist of the set {A1, A2, A3, A4}. A1 might be, for example, the draft of the Eastland.

Next, we make a list of the changes we're planning to make. In our example, let's suppose the changes are {C1, C2, C3}. C1 might be, in our example, air conditioning. The number of attributes is immaterial, as is the number of changes. Typically there will be many of both, but I'm keeping the numbers small for this illustration.

What we want to know in this example is how each change affects each attribute. To guide our consideration, we form the so-called outer product of these two lists:

C1-A1, C1-A2, C1-A3, C1-A4, C2-A1, C2-A2, C2-A3, C2-A4, C3-A1, C3-A2, C3-A3, C3-A4

This list provides a framework for close examination of the direct effects of each change on each system attribute. C1-A1 might be the effect of air conditioning on vessel draft. We might not be able to project each direct effect in detail, but using the framework gives us confidence that we won't overlook any direct effects.

Indirect effects

Suppose we make a change that produces a change in a system attribute as a direct effect. That change in one system attribute can produce secondary changes in other system attributes. We can regard these secondary changes as indirect effects of the first change. So, for example, C1 might change A1, and that can cause a change in A2. The change in A2 is an indirect effect of C1.

In our example of the SS Eastland, the increased draft (A1) resulting from the added weight of the air conditioning (C1) decreased the vessel's speed (A2).

Although morphological analysis provides no direct assistance with tracking indirect effects on system attributes, in most cases, we will need to attend to indirect effects.

Compensation chains

The purpose of some system changes is compensation for the direct or indirect effects of other system changes. In our abstract example, suppose C3 is such a compensating change with respect to the attribute A4. Then the change in A4, namely C1-A4 + C2-A4 + C3-A4, consists of two direct effects (C1-A4 + C2-A4) and one compensation effect (C3-A4).

We need not treat compensating changes differently from other changes, except that they can often occur at later dates, after we realize the need for them as a result of other changes.

Most important, compensation changes can occur in chains. That is, we decide to deploy C5 because of the effects of C4, which we decided to deploy because of the effects of C3. Compensation chains can indicate a loss of coherence in system architecture, as we patch and patch again, trying to keep the system running. Even one such chain can indicate the need for a thorough system review.

In the case of the SS Eastland, the 1903 season revealed that its speed performance was well below the contract requirement. After that season, the owners decided to deploy an Ellis and Eaves induced draft system to increase power. The combined weight of this system and the air conditioning equipment is what created the vessel draft issue, which was addressed by shifting equipment around within the vessel. And that reconfiguration contributed to her stability problems. [Eastland Memorial Society 2007] Those stability problems would eventually lead to the loss of the vessel and 844 lives.

Last words

Tracing the changes made to a complex system over the life of that system can reveal details about how the system responds to change. That information can be sufficient to prevent formation of compensation chains or what is worse — compensation loops. Even though we might lack the ability to project all effects of changes on the basis of first principles, knowledge of the system's response to previous changes might provide all that is necessary to project its response to future changes. Go to top Top  Next issue: Top Ten Ways to Make Meetings More Effective  Next Issue

101 Tips for Managing ChangeIs your organization embroiled in Change? Are you managing a change effort that faces rampant cynicism, passive non-cooperation, or maybe even outright revolt? Read 101 Tips for Managing Change to learn how to survive, how to plan and how to execute change efforts to inspire real, passionate support. Order Now!


Comprehensive list of all citations from all editions of Point Lookout
[Eastland Memorial Society 2007]
Eastland Memorial Society. "The Eastland," Archived from the original on 24 March 2016, Available here. Retrieved 24 February 2024. Back
[Ritchey 1998]
Tom Ritchey. "General Morphological Analysis: A general method for non-quantified modeling," Proceedings of the 16th EURO Conference on Operational Analysis, Brussels, 1998. Available here. Back

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