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

Superb. May I send it to a small circle of associates, with what
attribution?


"Terrell Miller" wrote in message
...
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

"Terrell Miller" wrote in message
...
snip really neat summary

How long did it take you to type that...?

Regarding point R: Sometimes the causes have been seen before, but in the
disaster they've come in a new and lethal combination with other factors. In
my understanding causes are hardly ever single-point failures, but multiple
failures or chains of events that come together in a bad way. Note also that
in both Shuttle disasters, the root causes were known and dismissed as
insignificant and/or buried long before they got lethal.

I think point S could also be fleshed out a little... Whenever something
goes wrong there are always two or three "I Told You So's" who come out of
the woodwork and take advantage of the situation to get some TV time. They
don't always have "documented proof", but they do always have an axe to
grind. One example is the fellow who got time on one of the networks to harp
on how he was supposedly fired after he tried to convince "them" to put
XB-70-style ejection capsules in the Shuttle.

There's also the negative doom-sayer types, usually from think-tanks, who
make the rounds and say the equivalent of "Yeah well, the program totally
sucks in reality and (disaster) is really no surprise, because everything
(agency or group) has ever done is really a failure. No success is possible
in the future either." John Pike from globalsecurity comes to mind... That
guy is on TV everywhere and I have yet to hear him say anything positive
about anything. I think these are the people called "Beltway Bandits" but I
might be wrong.

Remarks in some other post about the ascent angle on Challenger and it got me
thinking about the multiple factors that worked together.

1) The used SRB casing was way out of round. Don't recall if it was even in
spec. The poor assembly guys had to put a winch on it to force it into round so
that they could join it to the next section. The O-rings would have failed to
seal regardless of temperature (maybe.)

2) Launch temp far outside of experience. Cold hardened rubber O-rings
wouldn't seal/slow response.

3) Highest winds aloft.....put torque on SRB seals.

4) Highest launch payload. Overall higher stress on structures?

Yes, that is much as i see it, but its also how catastrophe theory would see
it, only of course the below the noise aspects would be abstract and not
named.

Brian


--
Brian Gaff....
graphics are great, but the blind can't hear them
Email:
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There was a book written a few years back, can't remember the name of
the author, but it was called "Normal Accidents" and made essesntially
the same points. What we think of as an accident is usually a
combination of factors, most of which in themselves would be
inconsequential.

Best
Keith

On Wed, 20 Aug 2003 00:27:37 GMT, "James Oberg"
wrote:

Superb. May I send it to a small circle of associates, with what
attribution?


"Terrell Miller" wrote in message
.. .
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





------------------------------------------------------------------
Keith Soltys -- -- http://www.soltys.ca/
------------------------------------------------------------------
Once in a while you get shown the light in the strangest
of places if you look at it right - Grateful Dead/Scarlet Begonias

On Wed, 20 Aug 2003 16:00:39 +0000, Lynndel Humphreys wrote:

Way off topic here but isn't there a megawatt version of a power surge
protector?

Sure, for any power you can produce you can build an appropriate
varistor set.... for a fee.

Multiply said fee by however many millions of junctions....

--
Chuck Stewart
"Anime-style catgirls: Threat? Menace? Or just studying algebra?"

A probabilistic loading-dependent model of cascading failure
and possible implications for blackouts
http://certs.lbl.gov/pdf/Dobson_1.pdf




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"Terrell Miller" wrote:

"Keith Soltys" wrote in message
.. .
There was a book written a few years back, can't remember the name of
the author, but it was called "Normal Accidents" and made essesntially
the same points.

aha, snagged a copy on Amazon, thanks for the heads-up!

It's a damm good read, *much* food for thought.

D.
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Corrections, comments, and additions should be
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