Learning from Trending, Precursor Analysis, and System Failures

Abstract

Models of reliability growth relate current system unreliability to currently accumulated experience. But “experience” comes in different forms. Looking back after a major accident, one is sometimes able to identify previous events or measurable performance trends that were, in some sense, signaling the potential for that major accident: potential that could have been recognized and acted upon, but was not recognized until the accident occurred. This could be a previously unrecognized cause of accidents, or underestimation of the likelihood that a recognized potential cause would actually operate. Despite improvements in the state of practice of modeling of risk and reliability, operational experience still has a great deal to teach us, and work has been going on in several industries to try to do a better job of learning from experience before major accidents occur. It is not enough to say that we should review operating experience; there is too much “experience” for such general advice to be considered practical. The paper discusses the following: 1. The challenge of deciding what to focus on in analysis of operating experience. 2. Comparing what different models of learning and reliability growth imply about trending and precursor analysis.