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Introduction providing a behind the scenes look at the World Trade Center catastrophe Combining firsthand accounts of employees' escapes with an in depth look at the structural reasons behind the towers' collapse Chiles addresses the uestion Were the towers two tall heroes or structures with a fatal flaw An up close and human look at some infamous foul upsIf you

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Inviting Disaster Lessons From the Edge of Technology

Combining captivating storytelling with eye opening findings Inviting Disaster delves inside some of history's worst catastrophes in order to show how increasingly smart systems leave us wide open to human tragedyWeaving a dramatic narrative that explains how breakdowns in these systems result in such dis The author does a good job mixing older disasters with new The Big Book of Team Coaching Games opening findings Inviting Disaster delves inside some La masajista y el hotel Red Pleasure of history's worst catastrophes in Before I Wake order to show how increasingly smart systems leave us wide Conceptos De Relatividad Y Teoria Cuantica open to human tragedyWeaving a dramatic narrative that explains how breakdowns in these systems result in such dis The author does a good job mixing Vanished Kingdoms older disasters with new

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Asters as the chain reaction crash of the Air France Concorde to the meltdown at the Chernobyl Nuclear Power Station Chiles vividly demonstrates how the battle between man and machine may be escalating beyond manageable limits and why we all have a stake in its outcomeIncluded in this edition is a special Chiles offers a history of many disasters accidents misfor

10 thoughts on “Inviting Disaster Lessons From the Edge of Technology

  1. says:

    “Vast machines running out of control might sound like something beyond human ken but one way to keep matters in perspective is to think of a frontier Americans know all about frontiers having lost our western one than a hundred years ago No new geographic frontiers have opened for us since then but a different kind of frontier is well under way and was opening even as the West was being won It is the ‘machine frontier’ and it is still unconuered A machine frontier has in a virtual sort of way the same characteristics as a geographic frontier dangers and rewards bounded at the edges by unknown territory So if we wanted to plot a movie prototype testers would be our explorers; facility operators would be the cowboys; and entrepreneurs eager to dominate the new markets would serve as our cattle barons While some technological dangers can be charted other risks of a new technology cannot be known with certainty or in some cases even imagined until much later” James R Chiles Inviting Disaster Lessons from the Edge of TechnologyOn June 1 2009 Air France Flight 447 was cruising high above the Atlantic Ocean traveling from Rio de Janeiro to Paris Entering into the clouds of a large thunderstorm system the pitot tubes which measure air speed appear to have become blocked by ice crystals This blockage caused the Airbus 330’s autopilot to disengage Reacting instinctively the co pilot grabbed the controls and did exactly what I would have done in his place Yank back on the stick When you are in a plane after all and you sense danger the natural reaction is to get as far from the ground as possible To gain altitude and fast Of course I am not a pilot And you really shouldn’t yank back the stick of an airplane The Airbus 330 began to climb dramatically Losing speed and with the nose up the plane – which aside from the airspeed indicator was in perfectly normal operating condition – began to stall Chimes and a warning voice filled the cockpit captured on a cockpit voice recorder later pulled miraculously from the sea “Stall” the warning voice said “Stall” This was repeated seventy five times To avoid a stall you need to push the nose down and gain speed Despite not being a pilot and having a sub rudimentary understanding of physics this is something even I understand The copilot however in the throes of some silent panic did not put the nose down He wanted the plane to climb away from a danger that did not exist The plane fell like a rock despite all systems go The captain – who had been on break – only figured out what his copilot was doing in the last seconds nearing 2000 feet without enough time to regain speed The copilot likely never understood that he had killed them all His last words were a uestion “But what is happening?” Air France Flight 447 crashed some eight years after the publication of James R Chiles’ Inviting Disaster Had it occurred earlier though or if Chiles had published his book later it definitely would have been studied in these pages It is a perfect example of so many of the topics that he discusses the difficulty of understanding unseen systems; the erosion of skill that comes with overreliance on technology; the complacency that attends our belief in redundancies and fail safes; and finally the horrendous conseuences that occur when the center is no longer holding Inviting Disaster is a survey of breakdowns that occur at the borderlands of the technological frontier where the complexities of our machines sometimes surpass our ability to control them Chiles undertakes this survey utilizing the case study method analyzing dozens of disasters and near disasters to tease out their lessons Some such as the sinking of the Thresher and the explosion of the Challenger are infamous Others are familiar if a bit unknown in the particulars the discussion on Three Mile Island for instance was uite enlightening And many have been mostly lost to history such as the Ocean Ranger drilling rig and the British submarine Thetis Chiles organizes these mishaps into thematic chapters that illustrate a certain point For example his account of Three Mile Island comes in the chapter on hidden systems demonstrating what can happen when a piece of technology becomes too big to comprehend with a single pair of eyes or even many pairs of eyes Here Chiles compares a 19th century engineer watching the pressure of his boiler with the reactor operators at TMI 2 who were unable to eyeball the maze of pipework that cooled the reactor and therefore believed that the water level was getting too high when in fact just the opposite was true Other chapters are devoted to the dangers of rushing technology to meet a deadline eg the Challenger; the trouble that comes from failing to perform proper tests; and the always present human element such as Eastern Air Lines Flight 401 that gradually lost altitude and crashed into the Everglades while its tunnel focused crew attempted to confirm whether the landing gear was down Thankfully it’s not all mayhem death and the rending of garments Chiles also covers near misses such as Apollo 13 and looks at the precautions and protocols followed by high risk industries such as explosive manufacturers and helicopter linemen that manage exceptional safety records Overall Chiles does a decent job in narrating the myriad crashes explosions and breakdowns He is focused on forensic examinations meaning that you will mostly have to look elsewhere for the human side of the story While the overall outline provided by the themed chapters is helpful Chiles tends to needlessly confuse things by jumping manically from one topic to the next Often he will start to make a point and – just as he’s almost there – start talking about something else I’m still waiting for him to finish his story about the Thetis At times Chiles is like an overexcited kid so eager to tell you everything he’s learned that he ends up creating a word salad I am not going to go so far as to say that Inviting Disaster is an important book though it clearly wants to be thought of that way It also did not entirely convince me that we are drifting into a machine fueled apocalypse Indeed I tend to think that future tech such as airplane autopilots and self driving cars are likely a good thing I’m worried about how late stage capitalism reacts to a significant portion of its workforce being made obsolete by robots Robotics is not mentioned at all That said Inviting Disaster did get me thinking a bit While reading this on a commuter train I couldn’t help but look around and attempt to spot all the stress points the danger zones the things that might snap or crack or fray or detach leading to the dreaded cascading failure No one ever went broke warning of an impending disaster Eventually it happens which is just in the nature of probabilities Most of the time however as Chiles acknowledges things do not go wrong With that said Chiles is not wrong to sound a note of caution I'd go so far as to say that parts of Inviting Disaster reads like prophecy His discussion of Aero Peru 603’s “static port sensor tube” problems which sent it into the Pacific in 1996 sounds a lot like Air France 447’s pitot tube malfunction His offhand mention of the space shuttle Columbia’s heat tile issue in 1981 “the critical tiles on the bottom of the shuttle stayed on so the craft was spared having a hole burned through its aluminum skin upon reentry” chillingly prefigures the craft’s death in 2003 along with all seven astronauts onboard It is easy to mock Cassandra while forgetting that Cassandra was right It is easy to forget that cutting edge technology can really cut Sometimes we forget right up to the point where a Boeing 737 MAX falls twice from the clouds or a GPS and radar euipped container ship like the El Faro sails right into a Category 3 hurricane At that point it is too late to start paying attention

  2. says:

    Accidents and disasters are often caused by simple random events or the change in a normal seuence of actions any one of which could affect the outcome Had the path of the Air France Concorde been slightly different or the piece of titanium not fallen off a DC 10 or the plane left a tad earlier or later or a sealant been used in the fuel tanks or any one of any other seemingly unimportant events taken place the plane's tire would not have struck the titanium and a piece of tire would not have opened a substantial leak in the plane's fuel tank and the passengers and crew would still be alive todayAnother related book worth reading is Normal Accidents by Charles Perrow Perrow had studied several major accidents and concluded that some forms of technology are open to chains of failure and that adding safety systems can actually lead to an increased likelihood of an accident because of the increase in complexity The systems become so tightly coupled that a failure in any part of the system almost inevitably leads to a chain of unmanageable and uncontrollable eventsChiles goes Perrow one further and makes recommendations as to how training and people can prevent the accidents by breaking one of the links in the chain It reuires that individuals throughout the organization be empowered to call decisions into uestion or to halt actions they believe to be of concern He observed several industries as air traffic control centers and aircraft carriers not to mention helicopter repair of high tension lines which have impressive safety records despite a high level of coupling and dangerIt's a fascinating book that examines why disasters happened and what lessons can be gleaned from those tragedies For example the explosion of the steamboat Sultana killed hundreds at a time 1865 when Americans were seemingly inured to disasters of all kinds between 1816 and 1848 233 explosions on American steamboats had killed than two thousand people Steamboats were constantly being destroyed by boiler explosions and despite industry objections the federal government had issued all sorts of controls and inspections In the case of the Sultana the captain was in a hurry he wanted to pack as many prisoners released from Andersonville prison on board as possible being paid per soldier and per officer The ship was way overloaded which contributed to the boiler explosion because when the ship turned its topheaviness caused the water level in the boiler to shift beyond safe levels In addition rather than have a crack in one boiler properly fixed the captain had insisted on a patch that normally would have been fine except that it was slightly thinner than the boilerplate on the rest of the boiler That would have been OK except that no one thought to change the setting on the emergency blowout valve to reflect the thinner metal of the repair so a seuence of decisions that individually would have been unimportant resulted in a seuence that killed far on a percentage basis than the 911 attacksIt is possible to conduct accident free operations but Chiles says that it means changing normal operational culture and mindset For example challenging authority becomes crucial in preventing aircraft crashes and other jobs where people have to work as a team The airlines have recognized this and no longer is there a pilot in command; the term now is pilot flying the plane with each pilot reuired to uestion the judgment of the other pilot if heshe thinks the pilot flying has made an unsafe move or decisionI learned about the extraordinary safety record of companies that use helicopters to make repairs on high tension electrical lines while the current is still on That would certainly loosen my sphincter The pilot hovers the craft within feet of the conductive lines while the electrician leans out on a platform hooks a device to the line that makes the craft and everyone on it conduct up to 200000 volts they have to even wear conductive clothing and makes repairs to the line They have never had an accident in twenty five years of doing this Safety is paramount they anticipate the unexpected and everyone is an eual partner in the team and expected to point out conditions that might be unsafe A good system and operators with good `crew resource management' skills can tolerate mistakes and malfunctions amazingly well Some call it luck but it's really a matter a resilience and redundancy Failing to have this resiliency can have tragic conseuences On December 29 1972 an L 1011 crashed on approach to Miami because a light bulb indicating whether the landing gear was down had burned out and the entire four man crew became involved in changing the bulb They did not notice that someone had bumped the throttle lever releasing the autopilot that was supposed to keep them at two thousand feet and the air traffic controller who noticed the deviation in altitude did not yell at them to pull up not wanting to annoy the crew but simply asked if everything was coming along The plane crashed killing everyone on boardAnother key element is that people must be clear in speaking and writing even if doing so necessitates asking people to repeat what you told them We know that people will try to avoid making trouble particularly any trouble visible to outsiders even though they are convinced that catastrophe is near Chiles sites numerous instances where committed individuals went outside normal channels to get additional perspectives or assistance and prevented catastrophe Those individuals always knew the leadership would back up their independent decisions even if they were wrongI have just scratched the surface This book should be recommended reading for everyone

  3. says:

    The author does a good job mixing older disasters with newer ones He covers a lot of ground and a lot of disasters The insights are powerful as are the stories told around each disaster The focus is often the integration of man and machine and the flaws inherentI found this book after watching Seconds From Disaster on the National Geographic channel due to my own interest in preventing catastrophe When I was in the Special Forces the Green Berets a key component of our planning was anticipating all the possible ways things could go wrong and planning as best we could to avoid that catastrophe and preparing as well as possible to survive it if it did occurThis led me to start a new series of books It Doesn't Just Happen The Gift of Failure While the author of this book does great detail on a wide spectrum of catastrophes I focus on only 7 in each book applying the Rule of Seven Looking at the six cascade events leading up to the final catastrophe As this author notes there is always an element of human error in every catastrophe Thus every catastrophe can be avoided if we find that cascade event often than one involving human error and eliminate it I go beyond engineering disasters though to such events as the Donner Party and social disintegration leading to disaster It's an interesting area everyone should learn about whether thought this book or a show such as Second From Disaster Because we all are a lot closer to such an event than we think

  4. says:

    Chiles offers a history of many disasters accidents misfortunes and contends that the increasing complexity of machines in the modern age has raised the likelihood of disasters happening He provides blow by blow descriptions of how the many disasters happened exactly what went wrong He notes that much misery might have been avoided by a true focus on safety uber alles but notes that in most instances other factors were at play Pushing to meet deadlines results in cutting corners forcing workers to work when they are over tired simple human screw ups What might have been unpleasant a hundred years ago now has the potential for mass misery When masters of machines for instance were housed in the same space there developed a sense on the part of the engineers of what sounds for example might indicate showing problems that gauges were not telling Today remote controllers who are physically removed from their charges do not have the opportunity to exercise that hands on touch and feel It bears mentioning that Chiles does not paint a completely black picture He cites instances in which corporations actually did the right thing at great cost He also notes that there are some that have established mechanisms for rewarding employees who speak upI found that while the details of the events noted here were interesting I had a hard time focusing It became a bit too dry a recitation of facts I suppose the book has value as a warning to be ever vigilant but did not move me much

  5. says:

    Disaster porn at it's finest This book is certainly not an in depth treatment of the subject but it does provide an interesting perspectives on the commonalities inherent in the failure of complex machinery

  6. says:

    On April 27 1865 as the Civil War was winding down the steamboat Sultana was carrying released Union POWs up the Mississippi River Just north of Memphis its boilers exploded killing some people with shrapnel or boiling water staring fires that burned or suffocated others and causing others to jump into cold water where they drowned According to different estimates 1100 1700 people died making it the worst maritime disaster in US history Why did it explode? The boat was grossly overcrowded even though its legal passenger capacity was 376 it was carrying approximately 2300 POWs making the boat top heavy and causing it list during turns beyond the angle it was designed to A few days before one of the boilers had developed a crack; the captain decided that repairing it properly would take too long so he had a patch riveted to the boiler The patch was thinner than regular boiler skin but the emergency steam release valve wasn't adjusted accordingly When the first boiler exploded the shrapnel hit the others and two of the other three boilers exploded too; there were no bulkheads between them preventing this The disaster did not have just have one cause; it had a cascade of multiple causes and no measures taken to prevent such a cascadeThis book is a catalog of technological disasters the explosion of space shuttle Challenger the explosion of Air France Concorde the Bhopal disaster and Systems that are vastly complicated than a 19th century steamboat fail just as spectacularly Chiles's solution for the future is keep in mind that a disaster can happen; put in features that prevent it from cascading into a greater disaster so that for example an explosion at a chemical plant does not send debris flying around and causing explosions; give the people who might see the telltale signs of the coming disaster the authority to prevent it

  7. says:

    You might not want to do what I did and read this on an airline flight A collection of technological disaster scenarios Chiles digs down to explore how bad design unintended conseuences and technology and people set at cross purposes resulted in disaster I've read a few technical journal articles on incidents mentioned in the book and while it's clear it is adapted from a TV series I wish there was a bit depth some of the incidents are described very summarily That being said it's well worth it As long as you're not in mid air

  8. says:

    An up close and human look at some infamous foul upsIf you want to know why the Concorde crashed or how things got so fouled up at Chernobyl or what went wrong at Three Mile Island this very readable book is a good place to start Chiles gives us diagrams step by step chronologies and a very human narrative to illuminate these and scores of other technological disasters in a way that makes it excruciatingly clear that most of them could have been preventedWhat these disasters have in common is human error of course but Chiles reveals that there were also foreshadowings and warnings of the horrors to come in the form of cracks sagging roofs parts that didn't uite fit maintenance shortcuts taken capacity limits reached etc that should have tipped off those in the know that something terrible was about to happen Additionally virtually all of the disasters happened because than one thing went wrongAmong the horror stories told in detail areThe harrowing tale of the sinking of the drill rig Ocean Ranger in a North Atlantic gale in 1982 a disaster caused in part because somebody forgot to close the shutters on portlight windows;The Challenger space shuttle blow up which Chiles compares with the crash of the British hydrogen filled dirigible R101in 1921 Both were megaprojects born out of great national aspirationsand both went forward despite specific written warnings of danger p 67;The Hubble Space Telescope fiasco in which a lens is incorrectly ground thereby partially blinding the telescope a multi billion dollar error that could have been prevented with just a little testing In this chapter subtitled Testing is Such a Bother Chiles shows how disasters happen because proper tests are simply not performed;An out of control police van that killed parade watchers in Minneapolis in 1998 when an off duty police officer not completely in the driver's seat inexplicably gunned the engine instead of hitting the brakes This accident was in part caused by an alteration to Circuit 511 that controls both the brake lights and unbeknownst to the mechanics an electric shift lock on the vehicle Chiles notes that The odds of pedal error go up when drivers are elderly and also when drivers turn around in the seat to back their cars up p 242;The explosion at the Union Carbide plant in Bhopal India in 1984 the worst chemical disaster of all time that killed thousands of people Chiles calls this a case of Robbing The Pillar a reference to the practice in coal minds of mining the coal pillars holding up the walls of the minesThis is a book for the engineer in your soul a treatise for the worry wart on your shoulder a recounting of responsibility for the accountant in your heart and cautionary tales for the fear monger in the pit of your stomach Chiles is gentle in focusing blame but he does indeed name names and point fingers He also gives us a prescription for preventing future disasters In addition to the need to perform regular maintenance and follow safety procedures to the letter etc he suggests how we might prevent cognitive lock the blinding sense that we've all experienced that insists that THIS is the problem and not something else or that such and such is what needs to be done when in reality something else will work He also advises that near misses ought to be reported and not swept under the rug p 202 and that redline running is dangerous and that under pressure we are sometimes apt to do the wrong thing and therefore procedures to follow during crisis should be spelled out in advance Dennis Littrell author of “The World Is Not as We Think It Is”

  9. says:

    Look This book is about technology and it's 20 years old But it's really about humans and our responsibilities when it comes to complex technology So in that way it is still very relevant And also it's not like plane crashes and sudden unintentional acceleration aren't still very much in the news But I imagine if this book was written today it would also include data breaches AI and the like The technology has evolved and will continue to do so but the lessons are relevant

  10. says:

    This type of book is my catnip so I wasn't surprised that I really enjoyed it I appreciated that it covered some lesser known incidents and near misses that I hadn't heard of before One lesson I took away from this book is to never ride a new submarine on its sea trials especially in the project is under pressure for being late You'll end up at the bottom of the sea basically guaranteed

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