Sunday, July 22, 2018

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.