[xmca] On a lighter notr: Railroad gauge (Avery cultural-historical example)

From: Rick Iedema (r.iedema@unsw.edu.au)
Date: Sun Jul 16 2006 - 17:56:00 PDT

>From railroads to health care ...
In health care they've imported root cause analysis (RCA) with a vengeance
to sort out iatrogenic (clinician or clinical-system caused) errors. This
started in the US Veterans Affairs hospitals in the 1990s with Jim Bagian's
appointment to these hospitals' unacceptably high levels of "avoidable
injuries and deaths". Trained at NASA, Bagian introduced RCA as a way of
getting clinicians to investigate their own and each others' work practices.
Quite confronting! RCA has since been rolled across a number of other
countries, including the UK and Australia, where it is now mandatory to
investigate 'serious errors and near misses' (deaths, near deaths,
wrong-side surgery, etc). Clinicians go to 3-day training courses (I
attended one) where they learn 'the RCA technique'. I was pleased to learn
that there are people like Gano are injecting a bit of complexity thinking
into all of this (thanks Steve). The link with narrative is really
interesting, because health care RCAs are done by a team of clinicians
trying to reconstruct what happened: they talk about how the incident could
have happened (taking medical notes and other documentation into account);
RCA team members talk to colleagues to ask them 'what happened'; this gets
reported back to the RCA team as 'this happened (according to so and so)',
and there is a lot of negotiating about 'what caused what' and diagram
drawing, but the whole process is really a sussing out of what causes are
socially, organizationally, politically and practically identifiable and
Rick Iedema


-----Original Message-----
From: xmca-bounces@weber.ucsd.edu [mailto:xmca-bounces@weber.ucsd.edu] On
Behalf Of Ana Marjanovic-Shane
Sent: Monday, 17 July 2006 9:24 AM
To: eXtended Mind, Culture, Activity
Subject: Re: [xmca] On a lighter notr: Railroad gauge (Avery
cultural-historical example)

This is a very interesting way to find causes -- I did not know that it
had a formal name, too. Sometimes, narratives are also set in a reverse
time order -- at least partially. Many films start with the "end" and
than they flash back to tell the story from the "beginning". IN that
process they may go back and forth in time, "filling in" missing details
in each pass. One of the first to do so was "Citizen Cane" with his
famous last words: "rosebud".
Many other modern narratives go back and forth in time, often searching
for root causes in the similar manner as the Apollo method. And very
often they actually play with this notion of a "root cause" creating
strange loops ("After the Rain" a Macedonian film is a great example of
a kind of *moebius* strip).
I think that the railroad example is a little different kind of "cause"
than the mostly physical causes you quoted in your example. I mean --
the reason for railroad gouge being 4 feet 8 1/2" -- is not the same as
a cause of an explosion. This particular RR gouge was not an inevitable
effect when that width was set for the first time (whenever it might
have happened) in the same sense as when you have all the conditions for
an explosion to take place. At any point of time, this gouge might have
been changed and it wasn't because it was: costly, impractical, not
considered, a coincidence, etc. It still might change in the future...
So in a way -- it is "caused" by the Roman (or earlier) chariots/wagon
makers and corresponding road fitting, but in a way -- there are many
more branches of causes than in physical causality that it becomes
difficult to call it a "cause". It was certainly "enabled" by all the
different decisions along the historical path, and these decisions were
made in many ways we don't know from the shorthand example.
If we compare this with the "cause" for the QWERTY keyboard -- both were
products of a certain kind of thinking and reasoning to solve a
particular practical issue at hand. But they were not the ONLY
possibilities at that time. So if Apollo reasoning defined branching
going backwards in time, I think that this kind of "causality" has
branches in both directions in time...
Maybe I am wrong...

Steve Gabosch wrote:
> This marvelous informal article Ana copied about how ancient chariot
> wheel widths eventually became transformed into modern US, British and
> Canadian railroad track widths is a perfect illustration of a "root
> cause analysis," a process followed in many industries to try to
> understand and find solutions for accidents, waste, and other
> undesirable things. I recently took a class series at work in this,
> which spurred me to stir up that little discussion about causality the
> other week. It had got me wondering how causality figures into CHAT
> analysis.
> There are actually a number of different root cause analysis methods.
> The one Boeing uses, the "Apollo" method, developed by Texas engineer
> and accident investigator Dean Gano in the 1980's, has an interesting
> philosophical premise: we live in an infinite continuum of causes.
> There is no single "root" cause, just causes that are more available
> to influence or eliminate. According to Gano, effects always have at
> least two causes: some causal condition, and some causal action. The
> effect combustion typically has two causal conditions, oxygen and
> fuel, and an action, ignition. The solution to preventing a fire
> might be to remove the possibility of ignition. Removing the fuel and
> perhaps the oxygen could also be solutions. A causal analysis of a
> fire might include asking why the fuel was there (flammable liquid
> fell from a truck) why did it fall (not secured properly) why wasn't
> it secured properly (latch was broken) why was the latch broken
> (maintenance didn't have the replacement part) - and so forth and so on.
> An especially notable aspect of this causal analysis approach is the
> way it sharply distinguishes itself from storytelling. As Gano
> explains it, storytelling begins at some point in the past and works
> its way to the present. Causal analysis begins in the present and
> works its way to the past. Stories or narratives are linear. Causal
> analyses are branched, not linear. In a causal analysis, every effect
> branches into multiple causes. In the narrative, beginning at some
> point in the past, this happened, and then that happened, and then the
> next thing happened, moving in a linear direction toward the present.
> In causal analysis, beginning in the present, this happened, which was
> caused by that and that happening, which was caused by this, that and
> the other thing happening, moving in an ever-branching pattern toward
> the past. A large part of the "Apollo" method (this term was chosen
> because it had both a space age and an ancient ring to it) consists in
> teaching ways to facilitate a group to develop a causal analysis chart
> that lines up the causes and effects logically while also keeping
> track of the complex branching. The point is to (1) identify the
> upstream causes that can change or eliminate the undesirable
> downstream effects, and thereby (2) choose/suggest solutions that
> management will like (cost, ease of implementation, etc.). Other
> features of this method include an emphasis on avoiding blaming,
> stopping asking why too soon, getting evidence for all causal actions
> and causal conditions, and thinking in terms of events, not
> categories. Gano calls this a "new way of thinking" and it does break
> through numerous paradigms that reinforce business as usual.
> Philosophically, it applies a number of materialist ideas.
> The analysis of the origins of the standard 4 foot 8-1/2 inch US
> railroad gauge Ana copied for us (do visit the site as Ana and Mike
> suggest) proceeds not as a story, but as a causal analysis. It keeps
> asking "why" and "what caused that to happen?" and proceeds farther
> and farther back into British and then Roman past. The process used
> was from the present toward the past. Perfect example of an "Apollo"
> causal analysis.
> - Steve
> PS On the site Ana provided, what did the Canadian National Railroad
> system engineer Worth mean by "parallel evolution" when he said:
> "None of this is to suggest that messrs. Trevithick, Stephenson, etc.,
> used design manuals from the Sumerian and Akkadian empires in deciding
> upon the 4'-8 1/2" gauge. It only illustrates the principle of
> parallel evolution, i.e., that 'everything that rises must converge'.
> At 09:22 PM 7/15/2006 -0400, you wrote:
>> This is very amusing, but after you have read and enjoyed this, try
>> this site:?
>> http://www.spikesys.com/Trains/st_gauge.html
>> Jim
>> Begin forwarded message:
>>> *The US standard railroad gauge (distance between the rails) is 4
>>> feet, 8.5 inches.
>>> That's an exceedingly odd number. ???Why was that gauge used?*
>>> *Because that's the way they built them in England , and English
>>> expatriates built the US Railroads.
>>> *
>>> **
>>> *Why did the English build them like that?
>>> Because the first rail lines were built by the same people who built
>>> the
>>> pre-railroad tramways, and that's the gauge they used.
>>> Why did "they" use that gauge then?
>>> Because the people who built the tramways used the same jigs and tools
>>> that they used for building wagons, which used that wheel spacing.
>>> *
>>> *Okay! ??Why did the wagons have that particular odd wheel spacing?
>>> Well, if they tried to use any other spacing, the wagon wheels would
>>> break on some of the old, long distance roads in England , because
>>> that's the spacing of the wheel ruts.
>>> So who built those old rutted roads?
>>> *
>>> *Imperial Rome built the first long distance roads in Europe (and
>>> England )
>>> for their legions. ??The roads have been used ever since.
>>> And the ruts in the roads?
>>> *
>>> *Roman war chariots formed the initial ruts, which everyone else had
>>> to match for fear of
>>> destroying their wagon wheels. Since the chariots were made for
>>> Imperial Rome , they
>>> were all alike in the matter of wheel spacing.
>>> The United States standard railroad gauge of 4 feet, 8.5 inches is
>>> derived from the
>>> original specifications for an Imperial Roman war chariot. And
>>> bureaucracies live forever.
>>> So the next time you are handed a specification and wonder what
>>> horse's ass came up with it, you may
>>> be exactly right, because the Imperial Roman army*
>>> *chariots were made just wide enough to accommodate the back ends of
>>> two war horses!*
>>> Now, the twist to the story
>>> *When you see a Space Shuttle sitting on its launch pad, there are
>>> two big booster rockets attached to the sides of the main fuel tank.
>>> These are solid rocket boosters, or SRBs.
>>> The SRBs are made by Thiokol at their factory at Utah . The
>>> engineers who designed the ?SRBs would have preferred to make them a
>>> bit fatter, but the SRBs had to be shipped by train from the factory
>>> to the launch site.
>>> The railroad line from the factory happens to run through a tunnel
>>> in the mountains.
>>> The SRBs had to fit through that tunnel.
>>> *
>>> *The tunnel is slightly wider than the railroad track, and the
>>> railroad track, as you now know, is about as wide as two horses'
>>> behinds.
>>> *
>>> *So, a major Space Shuttle design feature of what is arguably the
>>> world's most advanced transportation system was determined over two
>>> thousand years ago by the width of a horse's ass.** And you thought
>>> being a horse's ass wasn't important!*
> _______________________________________________
> xmca mailing list
> xmca@weber.ucsd.edu
> http://dss.ucsd.edu/mailman/listinfo/xmca

Ana Marjanovic'-Shane,Ph.D.

151 W. Tulpehocken St.

Philadelphia, PA 19144

Home office: (215) 843-2909

Mobile: (267) 334-2905

ana@zmajcenter.org <mailto:ana@zmajcenter.org>

http://www.speakeasy.org/~anamshane <http://www.speakeasy.org/%7Eanamshane>

_______________________________________________ xmca mailing list xmca@weber.ucsd.edu http://dss.ucsd.edu/mailman/listinfo/xmca

_______________________________________________ xmca mailing list xmca@weber.ucsd.edu http://dss.ucsd.edu/mailman/listinfo/xmca

This archive was generated by hypermail 2b29 : Tue Sep 05 2006 - 08:13:16 PDT