The Lecture I Never Gave

I've probably given my last lecture on the subject matter of Inviting Disaster. But I can't complain: that totals over fifty talks between 2001 and 2018, taking me as far west as Hawaii and as far east as Greece. I met many interesting people with fresh insights into the machine frontier: engineers, scientists, nuclear-weapons-watchers, pilots, soldiers, forensic investigators, rescuers, and refinery operators. 

A partial list of topics I covered in eighteen years of keynotes and seminars:

• System fractures
• Living (and dying) with the NRTL, the narcissistic risk-taking leader
• The red zone: why people build their houses in areas of known hazard, and why they expect others to pick up the costs
• Disaster investigations as offering a window into normally opaque dealings
• Two centuries of heavy-rescue 
• Sinking of the Titanic
• Arthur Woods and his radical reforms to the NYPD
• Piper Alpha and the consequences of pencil-whipping problems
• A lesson from World War 2: the teachings of “Doctor Facts”
• High performance teams and the first technological rescue: the submarine K-13
• Electrical system mishaps and emergent behavior in control systems
• Precursors and warnings, aka red flags

Which prompts this look-back question: What topics did I not get around to covering in my Inviting Disaster lecturing days?

One would have been a lecture on the importance of learning from one's own errors, at the end of which I'd have made a rousing invitation for any and all to join the Mistake-Makers Club. I didn't give that particular talk, but I did write it as an oped column, so here it is, reproduced from the National Board's Winter 2018 issue.

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Lately I've been seeing a string of articles about the globe's most exclusive clubs. One for the one-percenters is Club 33, an unlabeled, members-only restaurant in Disneyland's New Orleans Square. The initiation fee is $25,000 and up, depending on privileges, and the yearly fee starts at  $12,500 (Note to the budget-minded: meals and drinks are extra). Even so, the waiting list to join the club is said to be 14 years long. Across the ocean, there's the famous A-lister huddle called the World Economic Forum in Davos, Switzerland. 

But nothing I've come across matches the exclusivity of Google Camp, sponsored by the Google founders. Invitations go out to just a few hundred of the world's VVIPs. This year's Google Camp was held at Verdura Resort on a Sicilian island. 

Meanwhile, traditional clubs like Kiwanis, Freemasons, Elks, Moose, and Rotary are desperate for newcomers to replace long-serving elders. The Elks' roster has dropped by half in 25 years, by a million members.

The solution to that problem probably isn't chartering yet another organization, but even so I have in mind a club with a potential eligibility in the billions, to wit, “anyone who has made the kind of goof-up that is vividly, and quickly, clear to the mistake-maker.” So I call it the Mistake-Makers Club. Even though it doesn't pander to the uber-wealthy, they're as welcome as anyone who's made a mistake.

Do the rich and famous make face-palming mistakes? Sure they do! One is Mark Zuckerberg of Facebook fame, who recently received a full measure of social-media scorn after he live-streamed a “really magical” virtual-reality tour that placed his cartoon self in the middle of hurricane-wrecked Puerto Rico. And there's Andy Rubin of Android fame, reportedly worth $100 million. He's eligible because his Essential smartphone company punched off an ill-conceived email to its customers asking for images of their personal identification, such as photo ID's and passports. Customers who replied later found that their images had gone not only to Essential, but every other customer on the list too. So there's a lesson in modern life: pre-checking a mass-distribution email is Essential. 

Errors come in many sizes and shapes. And the subject is evergreen. Here's an old one from the world of telegraphy, before Western Union customers learned the importance of verifying their messages. A solid citizen in San Francisco heard that a society lady in Los Angeles had lost all her cash. He helpfully filled out a telegram blank with the message “Assist Mrs. XXX immediately,” and had it transmitted to a legal associate in Los Angeles. He heard from the lady the next day. She was not at all indebted for his kindness; instead, she was in jail. Sloppy work at the telegraph key had sent a different message southward: “Arrest Mrs. XXX immediately.”

What kind of errors would I ask my club's members to tally in their private journals? Likely their simple and clear mistakes, not the Swiss-cheese, multi-factor variety that need an investigating board to unravel.  

As a charter member of the Mistake-Makers Club, and currently the only one, I'll explain. Having called out the importance of learning from other people's errors in Inviting Disaster, it occurred to me after giving a talk to NASA engineers that I might make a few mistakes in the future. Could I take action to avoid repeating them? I thought again of this passage from Lewis Carroll's Through the Looking Glass: 

“The horror of that moment,” the King went on, “I shall never, ever forget.”
“You will, though,” the Queen said, “if you don't make a memorandum of it.”

Psychology 101 supports the Queen's suggestion. Most of us (including me) like to regard ourselves as smart and reasonably careful. Recalling our own mistakes tarnishes that self-image, so we rinse our recollections, and we repeat our errors.  

In 2004 I began keeping a journal of my simple, obvious mistakes. The list makes reading that is three parts scary (the close-call ones) and one part funny (the really stupid ones). Many on my list have to do with cars. In November 2007 I started backing out of the garage without looking to see if there was another car behind me in the driveway. There was: my father-in-law's. Stopping two or three inches short of impact, I remembered I'd made the exact same mistake about ten years before. But the first time happened before I started keeping a mistake journal, and I credit my mistake journal with keeping me from doing that particular thing a third time. 

But the field of mistake-making is rich and varied, so the entries continued. The night before a trip to Japan, I drove by the cash machine. I put the bills in a traveler's pouch but foolishly left my debit card on the car's console. Using the same car, my wife dropped me at the airport. On the way home she saw my card. She figured I'd really need it, and called about a hundred times, but couldn't reach me because I was inside the secure area and I'd turned my cellphone off. 

I lost my wallet for the better part of a day and eventually found it in our garbage can by the curb. That earned this entry in the mistake journal: Never put wallet on a countertop overhanging the kitchen trash can. 

• Garage door: left that open all night two years ago.
• Gas grill: left that running all night.
• Concrete stairwell: tripped going down, started to fall, and would have broken something important except for a lesson I learned from a medic on an offshore oil rig: always hold the guardrail!  
• Stuff sitting on stepladders: Left a hammer on one which, in falling, beaned a relative (my mom).

Meeting Crisis No. 1: I arranged to meet John Flicker, the editor in charge of my helicopter book, who happened to be attending a conference in my home city of Minneapolis. He gave me his cellphone number and we arranged a time and day to meet by the main door of his hotel's lobby. I wrote his cell number on a slip of paper and somehow lost it on the way to the hotel. No problem! I arrived in plenty of time, and occupied a sofa commanding what clearly was the main entrance. A half hour past the appointed time, I began to wonder: could a hotel have two main entrances? It could! I found John and he was less than happy. What a way to warm up your boss!

Meeting Crisis 2: In the early days of Mapquest, I printed out the directions to the location of the conference center in Mankato, Minnesota, where I'd be giving a talk to a state group of emergency managers. Those directions sent me deep into an undeveloped and unlit industrial park. Now worried about being late, I started back to the main highway to get directions at a gas station. Distracted, I rolled through a stop sign on the way. Sure enough: bright and flashing lights in my rearview mirror. The officer walked up, pulled out his ticket book, and asked me what I was doing there. I explained and he laughed: “I'm on my way to hear your talk! Just follow me.” 

Simple. Avoidable. Painfully obvious. What mistakes like these have you been making in your home or line of work? Blush-inducing memories are vivid for a day or two but won't last. Write them down, and right away. If you scan your list whenever you add another, if you can laugh and learn, you have my nomination to join the Mistake-Makers Club. Oh: about that staircase into the clubhouse ... hold the  handrail. 

Felled by the Falcon: Harrison Ford's 2014 accident at Pinewood Studios

Watching Blade Runner 2049 on DVD, with Harrison Ford's return to the Rick Deckard role, reminded me to check on the last word about the Millennium Falcon mishap at the “M” Stage at Pinewood Studios on June 12, 2014. That's the incident that injured Ford's hand and leg. It happened during a dress rehearsal for The Force Awakens, Episode VII.

It's worth a second look because the initial news accounts understated how serious (and avoidable) it was. The first days of news reports, citing a Disney spokesperson, said simply that something had gone wrong with the Falcon set and Ford sustained a broken ankle. In the following days the public learned more about the full extent of his injuries, but as to the chain of events, even after the 2016 publication of a court judgment that fined the company responsible – Foodles Production (UK) Ltd -- news reports didn't lay out what happened. 

Fortunately, investigative reports have been released from the United Kingdom's Health & Safety Executive (HSE). HSE had jurisdiction because the set was a workplace, and Foodles was responsible for making it safe. The following photos are from the HSE reports. A press release is here:

http://press.hse.gov.uk/2016/star-wars-film-maker-fined-1-6-million-for-injuring-harrison-ford/

Q. What was the setting?

A. Unlike in the original Star Wars set, in which the Falcon's ramp door operated by a simple pulley arrangement with no power added, the curved door of the new Falcon was hydraulically powered, and moved much more quickly.

This set of pictures shows the door closing.  

 Q. What was the official outcome?

A. In the Aylesbury Crown Court, Foodles pled guilty to breaching its safety duties, and the court fined it about US $2 million. Ford also received a financial settlement. 

Q. How did the door on the newer Falcon operate?

A. The new Falcon's door was remotely controlled – opened or closed – by an operator at a workstation with a laptop, a control panel, and an emergency stop button. Here's the control setup:
 
From where he sat, outside the Falcon set, the operator didn't have a direct view of the door, so he had to rely on the feed from a video camera pointed at the door. Here's the view:

At the time of the mishap, the camera view was a narrow angle, showing little more than the upper part of the doorway and the prop button alongside the door frame that Ford would press in the scene. 

This prop button that Ford was to slap didn't control the door or anything else – it was strictly a dummy, to offer the operator a cue. The plan was that the operator would remotely control the door from his laptop when (via the video feed) he saw Ford hit the button, and after he heard a verbal okay from a supervisor. 

Q. Why did the safety agency conclude that the door was a workplace hazard?

A. Start with the safety mechanisms that are now standard in powered doors, such as, one familiar to many homeowners: the motorized, overhead garage door. The early generations of powered garage doors posed a risk of pinning people as they closed, so now they're sold with multiple built-in safety devices. 

I'll illustrate with the one we bought for our house three years ago. First precaution: the door comes down slowly enough that there's time to get out of the way without diving for cover. Second, there's an electric-eye beam just above floor level, spanning the doorway: if the beam is interrupted, a photoelectric sensor sends a signal to stop the door immediately. Third, the door stops when it hits something. Fourth, there's a red lanyard that another person can pull to disengage the door from the powered slide if, somehow, it pins a person despite the first three safeties. 

Q. Which of these safety measures were in place on the Falcon's door?

A. Basically, none of them. The door on the Falcon set was a single, steel-framed, curved panel that ran on curved tracks that were out of sight, above the set. It was powered by a hydraulic cylinder. It came down three times faster than UK regulations allow for powered doors. For safety it relied on two or three people equipped with emergency-stop buttons and who had a view (either direct, or via camera) of the doorway. The remote operator at his workstation had an e-stop button, as did a supervisor with a direct view of the door. 

Q  Why was it important to have any safety measure? Wasn't this just a prop?

A. Because this door had both power and speed. The investigators compared its force to that of a small car coming down. Unlike the manually-operated Falcon door in the original Star Wars series (Episodes 4-6), this one was hydraulically powered, and it moved faster, taking just one and a half seconds to cover the distance from ceiling to floor, which was about six feet eight inches. Since it had no switch to disable it upon hitting an obstruction, once activated, the hydraulics would attempt to force the door all the way to the deck unless somebody hit a control to stop it, or unless it stalled after hitting an obstruction it couldn't break through, like a solid concrete block. Testimony compared it to a “blunt guillotine.”

Q. What went wrong?

A. Harrison Ford was asked about the mishap on the Jonathan Ross TV talk show, and he said, perhaps jokingly, that somebody on the set was curious about the door-closing switch and decided to push it when Ford happened in the doorway. There's no support for this in the HSE files, but understandably he was angry, and talk shows aren't the place to explain a root-cause analysis anyway. 

According to the HSE reports, the cause of the mishap wasn't inadvertent activation of the door, rather a design that excluded key safety precautions, combined with a communication breakdown.

The chain of events was this. On the day of the mishap the cast was doing walk-throughs and then dress rehearsals of a scene in which the actors come up the ramp and into a passageway on the Falcon. Once inside, Ford would hit the dummy button and the door would close after them. 

In the run-throughs that day, the door wasn't used. 

Dress rehearsals of the scene followed. The court heard testimony that before these began, the crew and actors were told that the door would be “live,” meaning that when Ford hit the dummy door-closing button on the doorframe, and upon hearing a verbal signal, the operator on the remote control would activate the door to come down. 

But in the the first dress rehearsal, the door didn't come down after all, because the special effects crew “wasn't ready.” It may have been a control issue, because of the way the emergency-stop buttons worked: unless all of the e-stop buttons were in the open position (meaning not activated), the operator couldn't run the door up or down. Put another way, if any of the e-stop buttons were pressed, the operator couldn't move the door without resetting his system. Also, the operator had to have his foot on a dead-man pedal. 

The actors repositioned themselves on the ramp for the second dress rehearsal. As this was about to begin, Ford didn't know that the door was now live, and that the remote operator planned to close it after Ford hit the dummy button. 

As the second dress rehearsal came to a close, having hit the dummy button and entered the Falcon, Ford immediately turned around to go back through the doorway and down the ramp, in preparation for a third rehearsal. 

The problem: the door operator was primed to close the door. But he was able to see the doorway only with th video camera feed, which was now zoomed in on the dummy door button. He'd seen Ford hit the dummy button, but with the tighter camera angle, he couldn't see that Ford had turned to come back through the doorway on his way down the ramp.

The operator activated the door to close and things happened quickly. After it knocked Ford down and continued to close, one of the effects crew hit the emergency-stop button. The door finally stopped above his waist, about eight inches from full closure. It left Ford with a deeply gashed hand and it broke his left tibula and fibula bones. 

Q. What happened next?

A. The director, J.J. Abrams, rushed forward and tried to lift the door off Ford. He said later that this fractured his back. It was a nice gesture but the door wasn't going to move until it had either been unlatched from the hydraulic drive mechanism, or else after all the e-stop buttons released and the control panel reset. 

Q. Why didn't the main safety measure, the emergency-stop buttons, prevent the mishap?

A. An HSE investigator's report established that, even in ideal circumstances (an experimental setup to test reaction time, where someone knows exactly what's going to happen and what to do), nobody with an e-stop button could have reacted quickly enough to keep a mistakenly-activated, powerful, fast-moving Falcon door from hitting an actor in the head. As it was, the operators reacted pretty quickly under the shocking circumstances. 

Foodles was fined because Ford's injuries were foreseeable, and in fact the door could have killed him. In other words, it created an inherently hazardous situation. 

Q. What was the outcome as far as the movie goes?

A. The production ditched the hydraulic door and substituted a CGI door. 

Heads Up: Finally a good prospect for finding MH370

If the hulk of MH370 ever turns up, I'm convinced it will be soon. Perhaps within weeks, because a new subsea effort is underway and it's starting with much better information. We can hope it will bring finality to one of the all-time aviation mysteries. And no, the Boeing 777-200ER wasn't hijacked to a hidden base. 

For reasons still unknown it crashed into the Indian Ocean on March 8, 2014, taking 239 souls with it. I think a catastrophic electrical fire is on the short list of possible causes, but that's only speculation. 

The new search builds on four separate sets of information, which have now lined up: flight simulations by Boeing, signal analysis, back-tracking of debris from the plane (aka drift studies), and photos from a French reconnaissance satellite that were taken soon after the crash. The sat-photos show a cluster of floating objects that were likely artificial. 

Taken together, these point to one fairly small area north of the main track:

The area of interest, 35.6 South Latitude, 92.8 East Longitude, is on the left side, where the black dots pile up. The latest studies identify a few additional places to look, but this one takes first priority. 

Over the final year of the 120,000-km search, evidence started accumulating that the searchers had been looking in the wrong place. Still, Australia refused to confirm that sufficient "new data" existed to justify a changed or expanded search.

Fortunately, the company Ocean Infinity has offered to take one more look:

https://news.sky.com/story/revealed-city-tycoon-funds-final-search-for-doomed-mh370-11224409

It's doing this as a classic salvage venture, called "no cure, no pay," so Ocean Infinity will be out a lot of money if the search fails. If it succeeds, Malaysia will pay the firm up to $70 million, with the exact amount determined by the effort. 

And if successful, it will be more proof, as with commercial spaceflight pioneers Blue Origin and SpaceX, that the age of tycoons taking command is truly upon us.  

Anomalous: The interstellar object of October 2017

As readers might have guessed, I love the idea of humans crossing the interstellar void, even if it takes ten thousand years to get anywhere. My fan poster of the Interstellar movie is here:
http://disaster-wise.blogspot.com/2014/10/interstellar-ice-fan-poster.html

And I love books like Alfred Bester's The Stars My Destination (the audio version of which came out last month on Audible!). 

So I was excited to read about the object that passed through our solar system, first reported on October 19. The IAU had to invent a scheme to indicate interstellar origin: designated 1I/2017 U1, now it's known as 'Oumuamua, a Hawaiian word meaning scout from a distant land. Although no telescope captured its portrait, the blue circle marks what astronomers saw (image combined from ESO's Very Large Telescope, and the Gemini South instrument):

Here's a Nature article with the science. 

curve range is very unusual.

Authors in a conservative journal like Nature or Science don't label something as "very unusual" very often, but that label fits 'Oumuamua. Here's my take from journal articles to date, in FAQ format.

Q. Was it verified as interstellar?
A. Yes. That's based on its speed and the "hyperbolic" path, a hyperbolic path being one that doesn't close up into an ellipse. And it came in at too high a speed to be bound to our solar system. While it seems to have come from the star Vega, that belief doesn't account for how stars move through the galaxy over time, relative to the sun. Given the asteroid's (relatively) low speed, Vega wouldn't have been in that spot at the time when 'Oumuamua was in the area. We'd need a lot more information to figure out where it originated. Here's the trajectory, from SciAm. 

Q. Have astronomers seen any other interstellar objects passing through?
A. This is the first one confirmed. The problem is that interstellar visitors come in very fast. That makes them hard to spot, particularly the low-reflecting asteroids. And even interstellar chunks of ice would be hard to see unless they approach the sun. It's a tribute to modern science that 'Oumuamua was detected at all. 

Q. Is it likely we'll see more interstellar objects?
A. Thanks to the rise of vastly greater computing power and new telescopes, yes. It's a sure thing that lots have already passed through our solar system over the eons, because interstellar space must have lots of loose rocks. The reason is that stars regularly pass near enough to other solar systems -- even through them -- to toss out planets and asteroids. That must have happened many times around the Milky Way galaxy, given the passage of billions of years. 

Q. Did observations show any sign of alien works?
A. It was scanned by radio telescope for artificial emissions, but nothing turned up. That doesn't prove a great deal since we had so little time even to look at it, and when we did have the chance, it was already so far away we couldn't resolve details. Other than the trajectory, the information we have is from the color of the light reflected and the timing of how that light dimmed over time, cycling about every seven hours.

Q. Why did its light change over time?
A. Most likely because it was rotating.

Q. Is there anything really unique about it, other than its origin?
A. The inferred shape of 'Oumuamua is by far the most unique feature. A year ago, experts would have guessed that the first observed interstellar object should be a garden-variety hunk very much like the thousands we see in our neighborhood. 'Oumuamua didn't fit that expectation in at least one respect, its shape. Though we couldn't resolve details, evidence from the way its brightness changed with rotation points to it having the proportions of a cigar: about 110 yards in diameter, and two-thirds of a mile long. While we know of some narrow asteroids in our solar system, none has a ratio that extreme. That means 'Oumuamua is unlike any of the 20,000 solar-system asteroids about which we've gathered info on shape. Since we don't know how it was oriented compared to Earth, it's possible that the ratio is even more extreme than 10:1. So 'Oumuamua is a strange beast in that respect. 

Q. How about its surface?
A. Its color (apparently a dull red) is nothing special compared to local asteroids. The color points to it being an asteroid of rock or metal, but the surface could be a mineral crust over ice. The insulating properties of such a crust would explain why, even if the object contains lots of ice, the ice didn't off-gas like a comet would. Many astronomers would have dearly loved to get a close-up look at the surface. 

Q. Is there any chance of taking a closer look?
A. Not 'Oumuamua. It came and went, and won't be back. Its speed and distance mean that none of today's chemical-fueled rockets could catching up. But with more advanced technology, such as nuclear propulsion, we might be able to get a close look at future drop-ins. That's the plot of Arthur C. Clarke's Rendezvous with Rama, a novel about a spaceship that goes to explore a vast, dormant alien craft that's passing through the solar system. In a striking coincidence, Rama is also cylinder shape. 

Origin of the "Streisand Effect": Tales of the Chopper

Many articles came out last week about Michael Wolff's Fire and Fury book ...
http://nymag.com/daily/intelligencer/2018/01/michael-wolff-fire-and-fury-book-donald-trump.html

... and some are referencing the boost that can happen when an uber-celebrity's office threatens all manner of legal mayhem to shut down a publishing project, because it's such an invasion of privacy, etc.:
https://www.verdict.co.uk/publishers-rushing-tell-trump-book-huge-demand-despite-legal-warning/

Said Jimmy Kimmel: "Threatening the writer with legal action is literally the dumbest move you can make if you want to keep it on the down-low.”"

The White House refuses to blame itself for any of this, saying press coverage of the book is solely responsible. 

Such marketing bonanzas are now called the Streisand Effect.
https://en.wikipedia.org/wiki/Streisand_effect

It's named for this case: in 2003, celebrity Barbra Streisand sued to remove an aerial photo of her Malibu coastal estate linked to a public-interest website (the California Coastal Records Project). That website had been set up to host thousands of coastline photos. The intent was to harness citizen action to protect California shores from illegal development. Ms. Streisand considered it an invasion of privacy.

Ms. Streisand not only failed to win her $10 million suit and get the photo blocked, she had to pay her opponents' legal fees.

Worse, from her perspective, the suit transformed the offending photo into a worldwide phenom. As in: the photo had been clicked on only six times before the legal filing, and two of those hits were from Ms. Streisand's law firm. Within a month, hits on the photo exceeded 400,000. 
http://www.californiacoastline.org/streisand/slapp-ruling-tentative.pdf

World media picked up the story as well. This from Japan Times: "She would clearly have done better to say nothing." 

It's earned a place in the list of unwanted results.
https://en.wikipedia.org/wiki/Unintended_consequences

Here's the photo that caused all the buzz; it offended the plaintiff because she had selected her property for the seclusion it offered in those pre-drone days. It was essentially unviewable from the road, or from houses on either side.

The photographer was Kenneth Adelman, and along with thousands of other coastal photos, he took it from a Robinson 44 helicopter piloted by his wife.

In 2005, as part of my book on the social history of helicopters, The God Machine, I was writing a chapter about eyes in the sky. I came across the story, and got in touch with Mr. Adelman. Here's info from our email interview.

Q. Why use a helicopter? 

A: The helicopter is slower and more maneuverable than a light plane, and the removable door is a great help.

Q. What's a good setup for such photography? 

A. An altitude of 500 feet, and an airspeed of 50-60 knots, works well, with an occasional hover with a pedal-turn. 

Q. Did any other celebrities or coastal-estate owners sue him, or otherwise give him grief about taking photos of their property? 

A: No.