21 Great Disasters from our past. The quotes that show our hubris, our failure to see what is coming, and how human error leads to catastrophe.
Size: 19.57 MB
Language: en
Added: Feb 14, 2022
Slides: 51 pages
Slide Content
Every catastrophe requires seven things to go wrong. Six Cascade events leading to the 7 th event, the Catastrophe. At least one of the Cascade events involves human error. Thus most catastrophes can be avoided. Shit Doesn’t Just Happen
By studying past catastrophes we can learn to avoid future ones. Focusing on the Cascade Events and how they can be stopped is key! The Gift of Failure
The Titanic : Systematic Failure
"There is no danger that Titanic will sink. The boat is unsinkable and nothing but inconvenience will be suffered by the passengers." Phillip Franklin, White Star Line vice-president, 1912 The Titanic : Systematic Failure
The Kegworth Plane Crash: Trusting Experts
Passenger on British Midland Flight 92 reflecting on hearing the pilot announce he was shutting down the right engine: “We were thinking: ‘Why is he doing that?’ because we saw flame coming out of the left engine. But I was only a bread man. What did I know?” The Kegworth Plane Crash: Trusting Experts
Custer and the Little Big Horn Leadership Failure
“There are not enough Indians in the world to defeat the Seventh Cavalry." George Armstrong Custer Custer and the Little Big Horn Leadership Failure
New London Schoolhouse Explosion: Lack of Focus
“I did nothing in my studies nor in my life to prepare me for a story of the magnitude of that New London tragedy, nor has any story since that awful day equaled it.” Walter Cronkite New London Schoolhouse Explosion: Lack of Focus
The Donner Party: Social Disintegration
“I wish I could cry, but I cannot. If I could forget the tragedy, perhaps I would know how to cry again.” Mary Graves. Survivor, the ‘Donner Party’ The Donner Party: Social Disintegration
The Housing Bubble Greed Overwhelms Reality
“Monkeys in contemporary 17th century Dutch dress are shown dealing in tulips. A satirical commentary on speculators during the time of Tulip Mania , an economic bubble that centered around rare tulip bulbs.” The Housing Bubble Greed Overwhelms Reality
Apollo 13: Successful Failure
“From this day forward, Flight Control will be known by two words: 'Tough' and 'Competent.' Tough means we are forever accountable for what we do or what we fail to do. We will never again compromise our responsibilities." Gene Kranz; the Monday morning after the Apollo 1 disaster; flight director for Apollo 13. Apollo 13: Successful Failure
The Challenger: Organizational Failure
“I am appalled by your recommendation.” NASA reference recommendation by Thiokol engineers who designed the boosters not to launch Challenger The Challenger: Organizational Failure
The Last Czar: Leadership Failure
"I am not prepared to be a tsar. I never wanted to become one. I know nothing of the business of ruling." Nicholas II, last Czar of Russia. The Last Czar: Leadership Failure
The Sultana Explosion
“If we arrive safe at Cairo it would be the greatest trip ever made on the western waters, as there were more people on board than were ever carried on one boat on the Mississippi River!” William J, Gambrel, first clerk & part owner of the steamship Sultana . The Sultana Explosion
The St. Francis Dam: Engineering Failure
During the Los Angeles Coroner's Inquest William Mulholland, chief engineer, Water Department Los Angeles said: “The only ones I envy about this whole thing are the ones who are dead. Whether it is good or bad, don't blame anyone else, you just fasten it on me. If there was an error in human judgment, I was the human, I won't try to fasten it on anyone else." The St. Francis Dam: Engineering Failure
The Sinking of the Kursk : Poor Training and Maintenance
“It's dark here to write, but I'll try by touch. It seems like there are no chances, 10%-20%. Let's hope that at least someone will read this. Hello to everyone. There is no need to despair." Captain Lieutenant Dmitri Kolesnikov, commander 7 th Compartment (turbine room) Russian submarine Kursk. The Sinking of the Kursk : Poor Training and Maintenance
Pearl Harbor
“Should hostilities once break out between Japan and the United States, it would not be enough that we take Guam and the Philippines, nor even Hawaii and San Francisco. To make victory certain, we would have to march into Washington and dictate the terms of peace in the White House. I wonder if our politicians (who speak so lightly of a Japanese-American war) have confidence as to the final outcome and are prepared to make the necessary sacrifices.” Admiral Yamamoto, Commander Japanese Navy. Pearl Harbor
ALIVE! Uruguayan Air Force Flight 571
“It was repugnant. Through the eyes of our civilized society it was a disgusting decision. My dignity was on the floor having to grab a piece of my dead friend and eat it in order to survive. But then I thought of my mother and wanted to do my best to get back to see her. I swallowed a piece and it was a huge step - after which nothing happened.” Dr. Robert Canessa ALIVE! Uruguayan Air Force Flight 571
Air France 447: Human-Machine Interface Failure
Last warning from the flight computer: “Pull up.” Co-pilot yells: “We’re going to crash. I don’t believe it. But what’s happening?” Seconds later one of the co-pilots exclaims “Fuck! We’re dead.” Air France 447: Human-Machine Interface Failure
The Fetterman Massacre: A Failure to Communicate
" Give me 80 men and I can ride through the whole Sioux nation. ” Boast allegedly made by Captain Fetterman The Fetterman Massacre: A Failure to Communicate
Hillsborough Soccer Crush Unintended Consequences
“ There was no organised response there at all... There was nobody in charge, no plan, no organisation at all... There was no resuscitation equipment there... The scene was just absolute chaos .” BBC Commentator Des Lynam Hillsborough Soccer Crush Unintended Consequences
Operation Market Garden: Strategic Blindness
“ Many historians, with an ‘if only’ approach to the British defeat, have focused so much on different aspects of Operation Market Garden which went wrong that they have tended to overlook the central element. It was quite simply a very bad plan right from the start and right from the top. Every other problem stemmed from that. ” ― Antony Beevor, Arnhem: The Battle for the Bridges Operation Market Garden: Strategic Blindness
The Tenerife Airport Crash: The Danger of Haste
“ I knew what I had to do. I went back and started pulling people away from the airplane .” Flight Attendant Dorothy Kelly The Tenerife Airport Crash: The Danger of Haste
Son of Sam: The Explosion of Tabloid Journalism
“ Hello from the gutters of NYC, which is filled with dog manure, vomit, stale wine, urine, and blood. Hello from the sewers of NYC which swallow up these delicacies when they are washed away by the sweeper trucks .” David Berkowitz Son of Sam: The Explosion of Tabloid Journalism
Deepwater Horizon: Safety Lapses
“ This company (BP) is - actually, has a better balance sheet today than it had before the spill .” U.S. witness at the trial penalty phase. Deepwater Horizon: Safety Lapses
AMAZON
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AMAZON
New York Times bestselling author, is a graduate of West Point and former Green Beret. He’s had over 80 books published, including the #1 bestselling series Green Berets, Time Patrol, Area 51, and Atlantis. He’s sold over 5 million books. He was born in the Bronx and has traveled the world. He’s lived on an island off the east coast, an island off the west coast, in the Rocky Mountains, the Smoky Mountains and other places, including time in East Asia studying martial arts. He was an instructor and course developer/writer for years at the JFK Special Warfare Center and School which trains Green Berets and also runs the SERE school: Survival, Evasion, Resistance and Escape. www.bobmayer.com