Thursday, December 6, 2007

To Err is Human

I have written previously about the professional way in which people employ the technologies in our daily lives (see Chatter in the Sky). Most of the time, we can depend on people to make the right decisions. Unfortunately, there are times when just the opposite happens.

This week is the anniversary of the Bhopal Disaster in India. Thousands of people were killed when methyl isocynate gas escaped from a holding tank at the Union Carbide facility during the early morning hours of December 3, 1984. The investigations and legal proceedings stemming from this disaster went on for years and led to the eventual sale of Union Carbide to Dow Chemical Company.

What caught my eye in reading about the disaster was the role of the people at the Bhopal plant. There was an audible external alarm that sounded when the gas leaked but the plant management quickly silenced the alarm so as not to panic the residents of the town. Many people continued to sleep while the toxic gas drifted over their homes. Even after the pulmonary symptoms developed, doctors were not informed of the nature of the leak so as to provide the correct care. Many people died unnecessarily.

It seems that the response in Bhopal is one that has happened enough times in other settings to be troubling. Examples abound of people who know the facts but withhold them for all the wrong reasons. Here are a couple more stories I have come across recently. In December of 1943, a German bomber sank an allied ship in the harbor at Bari, Italy. The ship, the SS John Harvey, contained a secret cargo of mustard gas that was being brought to Italy in case the Germans used this same poison on allied troops. Authorities on shore had no knowledge of the highly-classified cargo and as a result doctors did not know what was causing the resident's deadly symptoms. And they were not told. It is reported that the presence of the mustard gas was hushed up until after the war on the direct orders of Winston Churchill.

Here is another story. In September 1918, as many as 100 young soldiers were dying each day in Boston from the Spanish Flu. Despite the obvious pandemic, city officials refused to cancel the "Win the War for Freedom" parade through Boston thus exposing tens of thousands of people to the virus being shed by the young soldiers in the parade. The pandemic continued its rampage through the population.

Another more recent example is what took place in the Superdome in New Orleans in the aftermath of Hurricane Katrina. Tens of thousands of people were left abandoned for days in the richest country on earth.

Sometimes, intelligent people who can see a disaster unfolding fail us, why? Confusion during a crisis is one possible explanation. Pure incompetence is always has to be considered but I believe that most people who are in decision-making positions are not stupid. I suspect that it has more to do with denial and fear of the bad news coming back to roost with these decision makers, even more so when they know that they have been systematically compromising the very technologies they are there to manage. It is an all too human response. .

I doubt we can ever expect a change in human nature. But we can do more to provide fail-safe technology and adequate warnings when disasters do occur. The company I worked for had to provide a complete inventory of chemicals to both the federal and local authorities in the event of a fire or problem in one of our labs. But these inventories came as a result of fires in other labs in other companies. It is like airline safety - it is built on the graves of the dead. We may complain about the high cost of regulations and the costs of technology backup systems. But history teaches us that people are not always dependable in a pinch.

To err is human....

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