To err is human
Humans are more prone to error than we imagine. Why is this? One explanation is that we think the rules don’t apply to us – others need to stop at stop signs, but we are the exception. Another explanation is that we get lazy and cease to follow commonly accepted guidelines of best practices. Oddly, another failure mode is when we follow the commonly accepted guidelines without question – and the guidelines are wrong. Or perhaps we are working on something so complex there are few rules to even follow.
We will look at three examples over the last century, starting first with maritimers, examining groupthink and overconfidence failures with the Titanic and Exxon-Valdez, and then venturing to space, observing how arguably some of the most intelligent human beings, NASA engineers, can make colossally stupid human errors.
Titanic vs. Iceberg (1912)
The story of the unsinkable Titanic is instantly recognizable. On its maiden voyage from England to the United States, the Titanic collided with an iceberg on Sunday, April 14, 1912 at 11:40 p.m. and sunk two-and-a-half hours later, resulting in over 1,500 deaths. The shipbuilding costs totaled $7.5 million, with an inflation-adjusted price of $168 million.
Picture credit - http://www.titanic-nautical.com/RMS-Titanic.html
Groupthink and Overconfidence are Dangerous
Icebergs were not regarded as threats and the Titanic had inadequate lifeboats for all passengers and crew. These two main drivers caused the loss of life. At the time, however, the Titanic’s crew and captain were abiding by principles and standards that the majority of maritimers would have agreed with. And herein lies the rub, the Titanic failed not because rules were broken, but because the wrong rules were followed.
A United States Senate inquiry concluded with ruling the disaster an “act of God”. Other liners of the time had rammed icebergs without causing catastrophic damage, and ice warnings were seen as advisories, not meriting speed reductions. It was not mandated that ocean liners carry enough lifeboats for all passengers, as lifeboats were viewed primarily as a means of transporting passengers to another close-by vessel, as opposed to providing standalone support. While Captain Smith was quoted as saying in 1907 he could not “imagine any condition which would cause a ship to founder . . . modern shipbuilding has gone beyond that”, his confidence was likely the result of groupthink and shared by the vast majority of shipbuilders and seamen. Ultimately, the best efforts of mankind were not enough.
Had Captain Smith doubted the strength of the vessel and reduced the speed in areas of heavy ice, it is likely the catastrophe would not have occurred. But Captain Smith would have had to justify this position, as it was the exception at the time. The general belief was ice posed little danger to large vessels. General beliefs can be wrong, commonly accepted practices can fail, and “acts of God” happen. The Titanic crew was not prepared for any of these.
Exxon-Valdez vs. Prince William Sound (1989)
On March 23, 1989, Captain Joe Hazelwood took irresponsibility to its highest level while operating the Exxon-Valdez. Initially on his way to California, he crashed the Exxon oil supertanker ashore Bligh Reef, which is a part of Prince William Sound off the coast of Alaska. As much as 760,000 barrels – 11 million gallons – of crude oil spilled into the Alaska coastline. The cleanup and repairs cost over $4.4 billion, thus becoming the costliest spill to-date, causing 1,300 miles of damaged shoreline and hundreds of thousands of dead wildlife.
Source: Chris Wilkins / AFP – Getty Images
Overconfidence is Still Dangerous
So what caused the unexpected crash? Captain Hazelwood allegedly had five vodka mixed beverages the evening of the incident and had been drinking earlier that day, starting around 1:45 pm. His blood alcohol level (taken 10 ½ hours after the accident) was 0.06, lower than the Alaskan driving limit but higher than Coast Guard regulations for operating a commercial vessel. Captain Hazelwood was charged with a felony, second-degree criminal mischief, and three misdemeanors: operating a vessel while intoxicated, reckless endangerment and the negligent discharge of oil.
Hazelwood knew that he should not have been drinking, and that it violated laws. He thought that he was the exception, however, and could perform his duties even while intoxicated. Many of us think that we are the exceptions to the rule, just like Hazelwood. While we may not break laws in the process, our behaviors show that we think some of the rules do not apply.
The Lost Space Orbiter (1999)
Lockheed Martin collaborated with NASA’s Jet Propulsion Laboratory (JPL) on a project to build the Mars Climate Orbiter, formerly known as the Mars Surveyor ’98 Orbiter. While Lockheed Martin engineers produced software for the ground systems that used the English unit of pound-force, the flight system software aboard the Orbiter took instructions using metric Newtons. To explain simply, the software on the earth told the software on the Orbiter to “move 10″. Instead of moving 10 feet, as the ground system was trying to tell it, the Orbiter moved 10 meters. Simple, huh? The navigation disaster occurred on the day the spacecraft was expected to enter Mars’ orbit, and resulted in the Orbiter disintegrating in the atmosphere of Mars.
Complicated Systems Thwart Even Our Brightest
No one has accepted blame for the orbiter failure. According to Tom Gavin, the JPL administrator, NASA came out with a document several years prior to the incident that established the metric system for all measurement units. Lorelle Young, president of the U.S. Metric Association, blames Congress for reducing NASA’s budget, and removing resources for unit conversion. Most surprising is that at least two navigators noticed the discrepancy in units and had their concerns dismissed.
Our best and brightest – engineers from NASA and Lockheed Martin – produced an error that freshman collegiate engineers could have caught. At the level of sophistication of a NASA project, there are often so many moving pieces that even simple errors can exist. And this error was found by navigators, only to be dismissed. The systems, procedures, and processes of NASA were not successful in either (i) preventing the error or (ii) incorporating navigator input so that a solution would be produced.
Conclusion: Prepare for Disaster
Most of us don’t intentionally decide to commit tragic mistakes that will haunt us for the rest of our lives, or end our lives. Accidents or “acts of God” are viewed as unpreventable occurrences. Based on what was known at the time, the Titanic sinking was unpreventable; the overwhelming majority of captains would have piloted the ship just as Smith did. Abiding by best known practices is not enough to prevent mistakes or errors.
Experience, such as that possessed by Captain Hazelwood, is not enough. He made a personal judgment mistake and operated the vessel while impaired. He was clearly not abiding by best known practices and it was costly, for not just him, but wildlife and the entire planet. Training and licensing was not enough. Experience and responsibility was not enough. He failed. Sometimes there aren’t even a set of best known techniques to abide by.
The NASA and Lockheed Martin teams worked on integrating disparate software systems on a complicated project, probably with government oversight & documenting expectations. There probably were not hard and fast rules that they needed to abide by, due to the novelty and complexity of the project. The end result: smart people made a mistake. And when the mistake came to light, no one took responsibility and fixed it.
Mistakes and errors happen in all sorts of conditions: when rules are followed, when rules are not followed, and when no rules exist. CodeGuard exists because humans have made and will continue to make errors. Rather than wait until an error occurs, why not put something in place so that when the inevitable happens, you already have a solution in place?
Special thanks to Stefania Lee for researching and composing the majority of this!