anatomy of a disaster

reading a USAToday article about the blackout today, it struck me again what
a consistent overall pattern there is to disasters:

a.. Early off-nominal indications are buried in surface noise
b.. System functions predictably in retrospect, but in a then-totally
unplanned combination of patterns
c.. There's no time to respond to the problem; by the time a response is
begun, it's way too late
d.. Safeguards put into place to prevent recurrence of the last disaster
either don't apply to the current scenario, have no effect or make it even
worse
e.. Communications protocols designed to prevent the accident are garbled
and unresponsive; turf battles and buck-passing hinder efforts to prevent or
limit the damage
f.. Hubris set in long ago; this sort of thing "can't happen these days"
g.. Nature finds a way in through the cracks regardless
h.. Immediately after the event, responsible parties are incommunicado and
"out of the loop"; most of the most crucial information during and
immediately after the event is acquired through trivial channels
i.. Many false, misleading and contradictory rumors are reported in the
media; this leads to a garbled public perception of what really happened
that can easily become part of the public mythos around the event
j.. Before the "what" is even understood, everyone is clamoring to know
the "why" and demanding that Something Must Be Done About It (that something
being their own pet project)
k.. People respond to the crisis by merely redoubling their efforts at
what they usually do anyway
l.. After the initial chaos has worn off, the leaders responsible for
preventing the accident shift into CYA and blamestorming mode; it's
everybody's fault but theirs
m.. People who screwed up the worst during the event will publicly flaunt
their "crisis management" in trying to overcome the problems they personally
failed to prevent
n.. People who were just doing their jobs the best they knew how are
scapegoated, with career-threatening repercussions
o.. Lots of people figure out how to make a fast buck out of the event
p.. Public officials fight each other to acquire oversight/legislative
authority over the affected industry, plus a few other not-so-affected ones
q.. The finger-pointing among the parties involved gets truly nasty
r.. After careful, objective sifting of the evidence, the cause is
determined to be a combination very, very tiny things that nobody even
considered, let alone thought likely
s.. Notwithstanding which, someone will come forward shortly after the
event with documented proof that they "predicted" the event but were ignored
or hushed up
t.. Consultant types get very rich off the remediation contracts
u.. Conspiracy theorists have a field day coming up with wild, convoluted
scenarios that all fail the Sniff Test Of Basic Human Behaviour
v.. Efforts to rebut the CTers are cited by them as proof of a cover-up
w.. The CTers turn the disaster into a little cottage industry, but they
never seem to actually make much money off it
x.. The people who learn the lessons from this event aren't around the
next time something similar happens
y.. Next i

--
Terrell Miller


"I think the significant thing is that whatever prodecure we use, we are not
prepared to handle what I would call a fluid bowel movement. That is where
we were very...lucky. I was deathly afraid of that."
-Wally Schirra, Apollo 7 mission debrief