Bob Mayer - Shit Doesnt Just Happen II: Challenger, Czar, Sultana, Mulholland , Kursk, Pearl Harbor, Alive!

IT Doesnt Just Happen II

THE GIFT OF FAILURE

(Challenger, Czar, Sultana, Mulholland, Kursk, Pearl Harbor, Alive)

The Challenger Explosion; The Fall of the Czar; The Sultana Explosion; Mulholland & The St. Francis Dam; The Sinking of the Kursk; Pearl Harbor; The Andes Plane Crash

by

BOB MAYER

ICONS USED IN THIS BOOK

I use icons in this book to focus on specific parts of the book. They are:

Definitions.

Timeline of each catastrophe.

Asides: When you see the sign below, it means Im giving you bonus information either based on my personal experience during my time in the military and as a Green Beret or information regarding a similar disaster/event/catastrophe.

Three Reasons to Read This Book

REASON ONE

FALSE ASSUMPTIONS

What is a catastrophe ?

The final event of the dramatic action, especially of a tragedy

An event causing great and often sudden damage or suffering; a disaster

Utter failure

We are usually surprised when a catastrophe strikes. There is a tendency to believe that a catastrophe is something that is unexpected, always happens suddenly, and is caused by a single thing going wrong.

These are false assumptions. The vast majority of catastrophes can easily be predicted with some attention and focus. If predicted, they can often be planned for and averted. If unavoidable, they can be planned for and their results blunted and minimized. Catastrophes occur suddenly only in terms of the final event, the catastrophe itself; however, the buildup, via a series of what we will term cascade events , can be very long in the unfolding. And at least one of these cascade events involves human error. Thus most catastrophes can be avoided.

I will go through seven well-known catastrophes, showing the six cascade events leading to the seventh and final event . I will list the events, pointing out how each could either be noted (knowledge often can prevent the cascade of events that lead to #7, the final event) or corrected. The key for us to focus on is what was learned and changed because of each, saving the lives of countless others afterward.

REASON TWO

A CATASTROPHE IS CLOSER THAN YOU THINK

While you might not have personally been in a catastrophe or a tragedy, I can assure you that we have all come close more often than we realize. Many times weve been to a #4, #5 or #6 cascade event and not gone into the final event; therein lies one of the key deceptions that lulls us into complacency.

As we will see in the seven examples, there are many places along the cascade of events where a single person saying or doing something, could have stopped the cascade and prevented the catastrophe. Or, at the very least, minimized the effect of the final event. Thus, its very important for us to understand how seemingly innocuous events can play a tragic role if left unchecked. This book is also about the gift of failure : how we can learn from past catastrophes in order to avoid ones in the future. The aviation industry works off the gift of failure in that practically every safety innovation introduced is developed in response to a plane crash.

Ultimately, its about gaining the proper catastrophe mindset, which goes against our natural instincts because...

REASON THREE

DELUSION EVENTS FOOL US

We often look at narrow escapes or near misses as fortunate events where disaster was averted; indeed, we get to the point where we normalize near misses. Instead, we need to look at these fortunate events as cascade events where we came close to catastrophe and were simply lucky that we didnt hit the final event. Relying on luck is a very dangerous mindset yet we immerse ourselves in it on a daily basis. We often call it dodging the bullet forgetting that when a bullet hits, the results are catastrophic to the target.

We need to focus on cascade events, see their negative potential, and reduce their occurrence. A cascade event that doesnt lead to a final event we will label a delusion event . A cascade event and delusion event are exactly the same: the only difference is that a delusion event doesnt result in a final event.

This time.

Delusion events lead us into delusional thinking: that we will continue to dodge the bullet by doing nothing. In fact, a delusion event, where something goes wrong, but doesnt lead to the final event, reinforces our complacency to do nothing about correcting a delusion event and increases our risk of a final event, a catastrophe. We take the delusion event as the status quo, not an aberration. Delusion events lead to the normalization of unacceptable risk. For a very simple example, the further you drive with the check engine light on in your car, the more you think its normal for that light to be on. Diane Vaughan calls this normalization in her book The Challenger Launch Decision. (1) Well discuss this catastrophe as one of our seven in the second book in this series, focusing on organizational thinking about delusion events.

How many times have you been in a hotel or restaurant or store and the fire alarm goes off? How many times did you hurry to the exit? Rather, didnt you, and everyone around you, with no smoke or fire noted, stand around, and wait for someone to actually announce whats going on? Weve been desensitized by false alarms to the point where the alarm serves little purpose any more.

The Harvard Business Review did a study in 2011 (2) and found that delusion events (multiple near misses) preceded every disaster and business crisis they studied over a seven-year period. Besides delusional thinking leading to normalization, the other problem is outcome bias. If you flip a coin six times and it comes up heads six times, even though statistically rare (1 chance in 64 attempts), you will tend to start focusing on the result, believing all coin tosses end up heads. While we know this isnt true, we tend to base our probabilities of future occurrences not on the statistics of reality but on our experiences.

This is called heuristics and is at the root of many disasters. Heuristics is experience-based techniques for learning and problem solving that give a solution, which isnt necessarily optimal. We generalize based on the things we value most: our own experience and information related to us from sources we trust. Think how many truths you have heard that turn out to be nothing more than an urban legend or a superstition. Yet, we base many of our daily and emergency actions around these.

A small example from The Green Beret Survival Guide : every so often there is a news article about someone in a desperate survival situation who claims drinking their urine helped them make it through. Thats absolutely the wrong thing to do. But its one of those stories that is repeated enough, until we believe it to be true. Because we only hear from survivors, who lived in spite of doing the wrong thing.

It is human nature that we focus on successful outcomes much more than negative ones. Its irrational, but thats part of being human. In the same way, managers and leaders are taught to plan for success, not failure, since its believed planning for failure is negative thinking. In fact, I would submit that many people are part of a cult of positive thinking that often excludes reality.

The good news is we tend to be predictably irrational and understanding our tendency to make a cascade event a delusion event, is the first step in correcting this problem.