- New approaches needed to manage and operate safely within complex systems in an increasingly unpredictable world
- Traditional specialist engineering education and professional development must adapt to include learning from different sectors and social sciences
The Engineering X Safer Complex Systems (SCS) mission has published 18 new case studies examining the systemic successes and failures of different events around the world and how approaches to the design, construction, operation, management, or governance of complex systems have resulted in safe or unsafe outcomes.
From fires and train crashes to flood management and nursing care, the case studies provide a new resource to support the education and professional development necessary to achieve safer complex systems.
The case studies cover a wide variety of events, involving different complex systems, geographies, and stakeholders, such as the 2011 Brisbane floods, the 2019 economic and health crises in Chile, and major fires in Dhaka and the Cape. Also covered are failures of humanitarian supply chains in famine areas, the partial collapse of new school buildings in Edinburgh, the Netherlands Delta flood protection programme, and the structural integrity of offshore wind turbines. Several well-known accidents from the past are revisited, including the capsizing of the Herald of Free Enterprise and Hatfield rail crash.
Many of the lessons learned are specific to a certain location or particular combination of factors but there are some common themes that are transferable and relevant to all sectors:
- Lack of systemic thinking and action over the lifetime of the systems
- Little or no attention to structure of governance early in activity
- Treating complex uncertain issues and risks with tools developed for complicated ones
- Lack of alignment of purpose between actors
- Ill-defined boundaries of responsibility, authority, accountability, and legal structures
- Unverified assumptions
- Poor information sharing in the face of a blame or project-driven culture
- Inconsistent and poor data management to support statistical analysis and modelling
- Safety is seen as an engineering or technology issue rather than a cultural or social issue
Dame Judith Hackitt DBE FREng, Chair of the Engineering X Safer Complex Systems Board, said: “The most severe threats to our civilisation are complex sociotechnical issues with many interdependencies and no right or wrong solutions. What is striking is that although these case studies come from a wide range of geographies, disciplines and sectors there are lessons to be learned that are more widely applicable.
“Engineers' problem-solving and systems thinking skills are important to successfully responding to the world’s challenges, but in order to take on these responsibilities the profession must be fit for purpose.
“Those of us already in the workforce need to reach out beyond the silos into which our training has often funnelled us. We must learn lessons from and work more widely with others across international boundaries and with all parts of society in order to develop an inclusive, safe and sustainable future. The training and education of our future engineers must be reconfigured to develop and maintain their interest in addressing the many challenges and prepare them for working in a world of ever-increasing complexity.
“We encourage everyone to read and reflect on all these case studies—including those from outside their own sector—share them with their networks and, together, consider how the lessons learned might be applicable in their own professional situations.”
The Safer Complex Systems programme intends to further develop, and build from, the case study content to influence university curricula, continuing professional development (CPD) and chartership (CEng).
The case studies are:
- Cyber–physical system shortfalls in the 2011 Brisbane flood (Australia)Project lead: Dr Giuliano Punzo, University of Sheffield, UK
- Australian climate extremes and building transport network resilience (Australia)Project lead: Dr Kirsten MacAskill, University of Cambridge, UK
- Planned Adaptive Regulation: Learnings from the Delta Programme (The Netherlands)Project lead: Dr Richard Judge, Bartlett Judge Associates, UK
- A comparative study of fire risk emergence in informal settlements in Dhaka and Cape Town (South Africa, Bangladesh)Project lead: Danielle Antonellis, Kindling, USA
- Community evacuation from wildfire events (USA, Canada)Project lead: Professor Steve Gwynne, Movement Strategies, UK
- Towards a simple and safer nuclear sector: The 2005 THORP internal leak (UK)Project lead: Professor Francis Livens, University of Manchester, UK
- Bexley train crash—a system failure (UK)Dr Chris Elliott MBE FREng, Pitchill Consulting, Switzerland
- Revisiting the causes of the Hatfield Rail Crash (UK)Project lead: Professor Roger Kemp MBE FREng, Lancaster University, UK
- A systems approach to reducing train accident risk (UK)Project lead: Brian Tomlinson, Network Rail, UK
- Understanding and utilising data for a seasonally agnostic railway (UK)Project lead: Dr Brian Haddock, Network Rail, UK
- Ro Ro passenger ferry safety: the capsizing of the Herald of Free Enterprise(UK and Belgium)
Project lead: Professor Chengi Kuo, University of Strathclyde, UK - Towards intelligent dynamics of an active transport system for biking (Colombia)Project lead: Professor Andrés Medaglia Gonzalez, Universidad de Los Andes, Colombia
- Complex systemic failures in the Edinburgh Schools case (UK)Project lead: Dr Jonathan Gosling, Cardiff University, UK
- Systemic failures in nursing home care (Australia)Project lead: Professor Dr Joachim Sturmberg, University of Newcastle, Australia
- Humanitarian supply chains: systems failures, recovery and emerging alternatives (International)Project lead: Claire Travers, Field Ready, Sweden
- Social innovators as a human sensing network solving humanitarian challenges of the XXI century (Chile)Project lead: Matías René Rojas De Luca, Socialab, Chile
- Improving resilience to major safety events by analysing case studies(USA, Japan, Australia, Hungary and UK)
Project lead: Professor Richard Taylor MBE, University of Bristol, UK - Beyond the boundaries: characterising situational uncertainty in complex systems (International)Project lead: Dr Richard Judge, Bartlett Judge Associates, UK
Professor Brian Collins CB FREng, Chair of the SCS Case Study steering committee, led an online event on 25 May 2022 showcasing the work of the awardees and including a panel discussion. Following this event, all case studies were published in full on the Engineering X website.
Dame Judith Hackitt will talk about safer complex systems and other positive lessons we can learn about how to make the world better when she delivers a public lecture at the Engineering Professors Council annual congress on 7 June 2022.
Engineers and non-engineers in academia, industry, and government with an interest and expertise in safety and complex systems are invited to join the mission’s growing global community to better understand and operate complex systems in safe way. Please contact Hazel Ingham, Senior Manager, Engineering X.
Notes for Editors
- Engineering X is an international collaboration founded by the Royal Academy of Engineering and Lloyd’s Register Foundation that brings together some of the world’s leading problem-solvers to address the great challenges of our age. Our global network of expert engineers in academia and industry are working in partnership with leaders in business, government and civil society to share knowledge and best practice, explore new approaches and technologies, and educate and train the next generation of engineers to improve safety and deliver impact.
The Engineering X, Safer Complex Systems mission was launched in June 2019 to enhance the safety of complex infrastructure systems globally. Safer Complex Systems is governed through a board chaired by Dame Judith Hackitt DBE FREng, current Chair of Enginuity, Board member of High-Value Manufacturing Catapult, and former Chair of the Health and Safety Executive. - The Royal Academy of Engineering is harnessing the power of engineering to build a sustainable society and an inclusive economy that works for everyone. In collaboration with our Fellows and partners, we’re growing talent and developing skills for the future, driving innovation and building global partnerships, and influencing policy and engaging the public. Together we’re working to tackle the greatest challenges of our age.
- Lloyd’s Register Foundation is an independent global charity that helps to protect life and property at sea, on land, and in the air. The Foundation has partnered with the Royal Academy of Engineering to tackle the most pressing engineering safety and sustainability problems and to develop these into practical and accessible outputs for the engineering profession and affected communities.
Media enquiries to Pippa Cox at the Royal Academy of Engineering Tel. +44 207 766 0745; email: [email protected]