By R. Bruce Wright, CPCU
The articles found in this newsletter span the range from broad brush, big picture philosophy down to nitty-gritty practical tips. In that spirit of variety, here’s our first book review!
I recently read a fascinating book that in one volume tells twenty tales of real events when things went wrong. Everyone who knows us also knows that this phrase "when things went wrong" is how we refer to those circumstances or events that most people call "accidents." The ultimate outcomes (the so called "accidents") covered in these twenty stories range from amusing to tragic, some very tragic indeed, but they share a couple of common themes, themes we at Synebar have spent years trying to promote to our clients, for them to see, understand and learn from, and even to use in their daily work.
One such major theme is that when things go wrong it is almost never the result of just a single error. Almost every time a series of errors, oversights and missteps pile one on the next to produce the ultimate failure, or accident, if you must call it that.
The second theme is that if you want to understand why things went wrong, or what "caused an accident," it is important to focus your attention on the process, not on the people. It is a fact that people very seldom, in fact, almost never, intentionally make mistakes, but they fall into them all too easily if the process they are given leads them into opportunities for mistakes. Faulty processes contain traps that wait to snare the unfortunate or unlucky, regardless of their good intent.
For some vivid illustrations of those themes, I commend to your attention The Atomic Chef: And Other True Tales of Design, Technology, and Human Error by Steven M. Casey, Ph.D., published by Aegean. His work on ergonomics has led him to the same conclusions about human behavior and error to which our safety work has led us. Better yet, he has a knack for telling stories that makes them quite unforgettable. Rather than lecture, he simply tells each story fact by fact, giving readers the time to draw conclusions of their own. The events he relates are an interesting mix, historic events you may recall only dimly if at all and all too freshly remembered events taken from the headlines of our daily papers and network newscasts. For example- You have heard of Richard Reid, better known as the "Shoe Bomber," but do you know how he got onboard his flight? Or another example- Singer John Denver’s fatal crash in what was dubbed an "experimental aircraft" made national headlines, but the fact that his airplane was one of over 1,200 built to specs drawn up by renowned aircraft designer Burt Rutan did not. Rutan later designed, built and piloted the Voyager which became the first aircraft to fly non-stop around the world without refueling and in 2004 his SpaceShipOne design won the $10 million "X-Prize" as the first private spacecraft to exceed an altitude of 328,000 feet twice within a 14 day period. With a pedigree like this, what could go wrong in a short practice hop? The answers to these questions, and to other questions that emerge from less famous, but equally instructive incidents reveal themselves in the narratives played out in the pages of the Atomic Chef.
From the eager, but ultimately doomed, workers of the opening title story, to the suicidal ferry line owner in the last, Casey shows us how faulty processes, poor designs, and even eagerness to please can create traps for us, and how all types of people can make errors if the circumstances are right. I commend it to you for the lessons it so ably demonstrates. You can find it at Amazon.com, at any good local book store, or even at the library. It will make you smile, shake your head, wince in disgust, perhaps even shed a tear, and ultimately even learn a thing or two. I hope you will take the time to read it.
Editor's note: Neither the author nor anyone else connected with Synebar Solutions has any financial relationship with, or has received any remuneration of any kind from the author or publishers of The Atomic Chef: And Other True Tales of Design, Technology, and Human Error in exchange for this review. Darn!