(41k) How the Platypus Killed the Black Swan – a Story about Recognising Risk

When the idea of a black swan event was first developed, it seemed to be the panacea for all things we felt were unpredictable. But this was a false premise. In high hazard industries there is very little that is truly unpredictable, therefor it is not correct to assume that low likelihood events are back swans. So why can we not assume an event is truly unpredictable? In the processing industries the hazards are known. We understand the failure mechanisms and can model the consequences. The assumption that because it has not occurred at your facility before and therefore it was unpredictable is false – we know these events have occurred elsewhere. While the specific sequence that leads up to the event may be unique (though not always), we definitely know for example that when a flammable vapour is exposed to an ignition source within its flammable range, it will ignite. The fundamental laws of physics and chemistry have not changed, we must continue to live within them. So how do we move away from blaming the black swan for catastrophic events? We must look to the platypus. The platypus is special type of mammal called a monotreme and is endemic to Australia (the black swan is also a native animal of Australia). For all intents and purposes, the platypus should not exist. It is one of only two mammals that lays eggs, it has the bill of a duck, the tail of a beaver, the claws of an otter and the fur of a seal. It lives by fresh water in burrows and swims to find prey using electronic pulses. It is also one of only a few mammals that produce a toxin for defence. It is also mainly nocturnal, making them very difficult to find in the wild. Why then should we look to something as unlikely as a platypus? Catastrophic events are a combination of smaller unlikely events that culminate in a consequence. For example, you may have had a corrosion issue that led to a pin hole leak, that found an ignition source that then caused a fire that impinged on structural steel, resulting in larger collapse of equipment feeding into the fire. This is a plausible sequence of events but relies on us being open to the idea that evens can escalate. We may just look at the corrosion issue and determine we have it managed and would not lead to a massive equipment loss. Even if it leaked, we then discount the chance of ignition etc. Each step along the way we are seeing signals that we can have the event, but we are discounting them or deciding they are something else. We may see a splash of a tail in the water and think we have seen a beaver, or we may see the tip of a bill and think it is a duck. In both instances we need to investigation further to see if indeed we have a platypus. Searching for a platypus in a facility is all about finding the weak signals and piecing them together to see what we actually have, not making assumptions based on single points of evidence. Not all platypuses are hazardous, the females do not have any toxic capability, but the males have a spike on their back legs that can envenomate a human. Finding and managing the platypuses hiding in our facilities will mean that we eradicate the black swans. This paper will explore some of the biases we have to seeing the platypuses, and how to overcome them so you can actively manage them. Ask yourself “is there a platypus hiding here?”