Herzner Fred - What Did We Know? What Did We Do?

In July 1989, United Airlines Flight 232 crashed in Sioux City, Iowa. In total, 111 people lost their lives and numerous others were seriously injured. The accident was initiated by a small metallurgical defect in an engine rotating part. That engine was manufactured by General Electric Aircraft Engines and I was the engineering manager of the group responsible for that part.

This is not a book about the accident. Rather, it is broader than that. This is a story about big, catastrophic events, the decisions that lead up to them, and their resulting consequences. It is also about the things that influence people and organizations to do what they do.

I bring a unique perspective to this because, for several years before the UA 232 accident, I was part of a team that was working on the problem that initiated the event. That deeply affected me. It drove me to look back at what I and others knew prior to the accident to try to understand why this terrible event happened.

Of course, after the accident, there was a flurry of activity to prevent further incidents and determine the root cause of the failure. But what I wanted to know was what underlying factors influenced the people and the organizations to fail to break the chain of events which led up to it. I was particularly focused on my own experience because I felt that had I done something differently, I might have changed the outcome.

Six years after the disaster, I was named the chief engineer of GE Aircraft Engines. Part of that responsibility was to manage the Flight Safety Organization, which had an advisory role on product safety matters. This gave me an opportunity to help structure a formal product safety policy based on my retrospective look at the Sioux City experience.

Then, after my retirement from GE in 2003, I started to see numerous devastating events in the news. These included the BP oil spill, the Flint, Michigan, lead-tainted water scandal, the General Motors ignition switch issue, and the Volkswagen diesel emissions cheating event.

From what I could see and read in the media, these events seemed to have been influenced by some of the same factors that led to the Sioux City accident. But some of these events had influencing factors which were not present in the UA 232 case. In fact, some of those factors were things I had never even thought about during my work tenure.

This made me think that perhaps I could help other organizations benefit not only from what I had learned from UA 232, but also from those recent events as well. So, I examined them and added some of the lessons learned to a set of principles which organizations could use to hopefully avoid such disasters.

Events like these have grave consequences and change the lives of many people. All the organizations that were involvedGE, BP, and VW, among otherspaid dearly. Not only in financial terms, but also in loss of reputation. What I didnt expect was that the people inside those organizations who made the decisions also suffered consequences. I know I did because of my involvement with the UA 232 accident. Those consequences are still with me today.

This is what motivated me to begin writing. In this book, I have attempted to use what I learned from Sioux City and other recent events to propose a set of principles which others can use to avoid similar terrible outcomes. I also want this book to serve as a reminder and motivator for those who work in large organizations that what they do, and how they do it, is important to everyone: the people who use the products; the organizations that make the products and provide jobs; and last, but not least, the employees themselves.

Fred Herzner

Cincinnati

October 2017