Knowledge conduits

I am willing to bet that those of you over a certain age have, at least once, felt that you were turning into one of your parents. I recently heard an interviewee on the radio relating such a scenario. I know that it has happened to me. My parents would regularly say things that I dismissed as old-fashioned or overprotective. Years later, I find myself saying the same things and even using the same phrases. The passage of time and experience has reinforced the value in the advice I previously tried to dismiss. The fact that the words trigger the memory of my parents highlights how firmly the messages were absorbed. It is a perfect example of knowledge transfer processes, which occur within many families and social groups.

Having previously steered clear of the genre, I have started reading science fiction. The story is based on artificial and non-human intelligence. Octopuses are recognised as being intelligent and it is easy to find stories, videos and documentaries that back this up. However, as the book describes, they tend to be solitary animals and have a short lifespan, so it is not possible for knowledge to be passed from one generation to the next. As illustrated above, human lifespan, social groups, language and culture are ideal for knowledge transfer; human development and progress is built on this mechanism.

So why are organisations so poor at doing this? In his book Show Me the Bodies: How We Let Grenfell Happen, author Peter Apps reveals many shocking examples of poor behaviour, including the use of cheaper flammable materials and the faking and suppression of fire test results. No great insight was needed to realise that something like the Grenfell Tower disaster would happen. The facts leading up to it were readily available.
Grenfell is just the latest in a long line of inquiries that have looked at root causes and provided lessons for learning and adoption. In 1986, the explosion of the Space Shuttle Challenger, caused by the failure of an ‘O’ ring, was attributed to organisational burnout and inertia. The Space Shuttle Columbia accident happened in 2003. Testimony to the investigation board stated that comparison of the two shuttle disasters showed that NASA as an organisation had not, at the time, learnt from previous mistakes.

Also worth reading is the Haddon-Cave independent report into the broader issues surrounding the loss of an RAF Nimrod in 2006. It found that many of the lessons to be learned were not new and that the organisational causes echo “other major accident cases, in particular the loss of the Space Shuttles Challenger and Columbia, and cases such as the Herald of Free Enterprise, the King’s Cross Fire, the Marchioness disaster and BP Texas City.” The information on the Boeing 737 MAX crashes shows that lessons continue to be ignored.

The Columbia accident report has direct relevance to NDT and I have previously used some of the findings in presentations: there was no schedule margin to accommodate unforeseen problems; managers were concerned with the foam strike’s possible effect on the launch schedule; requests for imagery of the wing struck by the foam were not acted on; and there were missed opportunities where actions may have resulted in the discovery of debris damage. Afterwards, high-sensitivity remote visual inspection was deployed that resulted in investigations of indications due to soot and bird droppings.

The first part of the Grenfell book title was a comment made by a person in charge of fire safety regulations in buildings. Similarly, there was a widespread assumption that because the Nimrod had successfully flown for 30 years, it was safe. The argument that nothing has happened so far, so there is no need to change anything, has been used to me in the context of NDT.

It is important that the NDT profession looks at and passes on knowledge to avoid complacency. The challenge is how to do this effectively going forward.

I wish you all a Happy New Year.

Please note that the views expressed in this column are the author’s own personal ramblings for the purpose of encouraging discussion within NDT News. They do not represent the views of Jacobs or BINDT.

Letters can be mailed to The Editor, NDT News, Midsummer House, Riverside Way, Bedford Road, Northampton NN1 5NX, UK. Email: ndtnews@bindt.org or email Bernard McGrath direct at bernard.mcgrath1@jacobs.com