(and the one person who could have made a difference)Accidents are rarely accidental. Paradoxically, there is almost always one person who could have spoken up courageously and prevented a catastrophe. This article explores why they didn't do that. The tragic and avoidable accidents from recent history, that I describe here, are the result of various combinations of cost-cutting for profit, risk-taking for fame, or ignorance of the complexities of modern systems.
In his wonderful book The Black Swan, Nissam Taleb vigorously points out that leaders and planners tend to underestimate and neglect the potentially devastating calamities that can occur as the result of highly improbable events until they finally do occur. Today we are seeing the entire country of Japan brought to its knees because some planner didn't take account of the possible occurrence of giant tsunami waves that do occur, but less often than once in a century. Anyone who has lived as long as I have has learned to create an internal "payoff matrix" before he leaps to the next great opportunity. This is a statistical tool that is useful in keeping you alive. You estimate "what is the worse thing and the best thing that could happen" in this situation. And then multiply each by the probably of its occurrence. For example, the upside might be an unbelievably exotic and romantic adventure with a new and desirable partner! And the downside might be the remote possibility of AIDS. The analyst learns to avoid attractive opportunities like this, in which the payoff matrix contains a +++ in one of the squares, and a "minus-infinity" (death) in the other square -- even if the probability is really pretty small. If the payoff is national destruction and calamity, we don't build the nuclear power plant eighteen feet above high-tide, even though the twenty-foot tsunami comes only once a century. And above all. We don't put the back-up generator in the basement!
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There is a category of mishaps called "normal accidents," in which a tightly-coupled complex system experiences multiple unexpected component failures. The initial phases of the catastrophic failure of Three Mile Island nuclear power plant was of this type. It wasn't until the operators made some bad decisions that the situation became hopeless. In the end, even with clueless operators, a total meltdown was avoided. With modern technology and massive redundancy, these types of accidents are mercifully rare. In aerospace we have an expression that I have heard many times,
"We can make the system foolproof. But we can't make it damn-fool proof." (emphasis added /JC). For example, if a modern airplane's electrical or hydraulic system fails, the backup systems will usually come to the rescue even for such a major systems breakdown. However, if the pilot is intoxicated, or has a stewardess on his lap (as in one of our examples), the situation is usually beyond repair. I hear you saying, "A thing like that could never happen." But we are talking here about world-class accidents that did in fact occur. They require world-class stupidity or arrogance for their occurrence. (Just think, if Monica Lewinsky had chosen to have her now famous blue dress dry-cleaned to remove all traces of the president's DNA, the forty-third President of the United States would have been Al Gore instead of George W. Bush, and the world would be a vastly different place than it is today -- no war in Iraq, etc.)
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In the fall of 2007, workers at the Byron nuclear power plant in Illinois (just outside Chicago) were using a wire brush to clean a badly corroded steel pipe-one in a series that circulate cooling water to essential emergency equipment -- when something unexpected happened: the brush poked through. The resulting leak caused a 12-day shutdown of the two reactors for repairs. The plant's owner, the Exelon Corporation, had long known that corrosion was thinning most of these pipes. But rather than fix them, it repeatedly lowered the minimum thickness it deemed safe. By the time the pipe broke, Exelon had declared that pipe walls just three-hundredths of an inch thick -- less than one-tenth the original minimum thickness -- would be good enough. (This is also not an "accident.")
http://www.realitysandwich.com/disasters_arrogance_and_greed That incident at Exelon's Byron nuclear power plant, seems like a classic example of the
"We can make the system foolproof. But we can't make it damn-fool proof" axiom.
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