The Book of the Week is “Inviting Disaster” by James R. Chiles, published in 2002. This is an ebook that describes the causes of fatal mechanical failures in aviation and industry.
Human error is always a factor. There is never just one cause. “A disaster occurs through a combination of poor maintenance, bad communication, and shortcuts.” Taking shortcuts such as omitting the testing of newly manufactured machine parts leads to improper, unsafe modification by end users.
In the stages leading up to a catastrophe, when workers realize they are in trouble, most react with intense concentration, anger at the malfunctioning equipment, fear and even panic.
Hypervigilance is a form of extreme panic with trembling hands, hyperventilation and heart palpitations; the mind blanks on what one was taught in training, and perception narrows. Often this causes people to take a course of action with the best of intentions– that makes conditions worse.
Architectural engineers must make sure buildings are designed to withstand the natural disasters that typically hit the areas where they are located. About every sixteen years, Manhattan gets hit by a hurricane that might cause, say, a particular building to collapse. That was why, shortly after it was built in 1978, the Citicorp Building had to be structurally modified at great expense. However, many deaths were likely prevented.
A common chain of events precipitates disasters in third world countries. A light manufacturing plant might be erected in a lower-class residential area. As time passes, however, the owner might want to begin making hazardous products.
Certain conditions prevail: There is a dearth of laws governing environmental impact; the local economy would suffer if the plant couldn’t expand; the local residents enjoy living there. Over time, people become sloppy about safety.
Before lots of accidents, internal memos warning of an unsafe situation go unheeded. “The bureaucratic solution is to let the memo sit in the inbox for a while– then send it back for more explanation.” It is easier than making trouble, and in the short term, economically advantageous.
One way companies such as Boeing are checking themselves from making the same mistake twice is by continually adding to a knowledge base– confidential archives of troubleshooting reports that are actually read by designers.
Read the book to learn about other ways deadly mishaps could have been, and can be avoided.