#3. The Herald of Free Enterprise Capsized Because of an Open Door
In 1987, the Herald of Free Enterprise, a ferry between Belgium and England, capsized, resulting in the deadliest accident a British ship has been involved in outside a war in almost 100 years. The cause? Someone forgot to close the door that allows cars to board the ferry.
"I don't understand. I left the screen door shut."
The Dumb Problem:
Hey, you know how in your car you have a little light that tells you when somebody's door or the trunk is open? Yeah, this ship didn't have that.
And even worse, in a car, even if you had no warning "ding," there's still a good chance you'd see that the door or trunk was left open. Not so on the boat -- its doors weren't visible from the captain's post, and the only system for making sure they were closed was called "assuming someone closed them." Unless the guy in charge of closing the doors came up to the captain and said, "Hey, by the way, I am currently asleep in my cabin and didn't do my job," the captain would start the ship and leave. Even if the doors were open and inviting in tons of seawater. Which is exactly what happened.
That's the gaping doorway on the left.
It's not like this type of technology was unheard of at the time; this was just 1987 here. Members of the Herald crew had actually asked management to install a door-position indicator on the bridge, but management dismissed the request, calling it "frivolous."
Although some crew members were clearly at fault here, the ensuing investigation found that the root of the problem was actually in the company's management for not listening to the crew members' concerns and not implementing a better security system. In the end, as punishment for the deaths of nearly 200 people, the company's owners were forced to ... change the company's name and repaint their ships (they were all acquitted).
Company after. The real victims here, people.
#2. The Kegworth Air Disaster Happened Because of a Digital Dial
In 1989, a Boeing 737 crashed into the side of the M1 motorway near Kegworth, England. The problems started when the jet began vibrating, indicating that one of its two engines was malfunctioning. Unfortunately, the pilots got the impression that the good engine was at fault and turned it off.
Without any functioning engines, the jet became a large piece of metal suspended in the air and did what large pieces of metal suspended in the air tend to do.
The Dumb Problem:
Some months earlier, the cockpit instrumentation in this type of plane was updated to give them a slicker-looking digital design, presumably because someone at Boeing finally got around to watching Back to the Future and thought the inside of the DeLorean looked cool. The remarkably inept new design wasn't the only reason for the crash, but it was by far the dumbest and most easily avoidable.
At one point during the Kegworth flight, the dial indicating the vibration in the left engine rose to the maximum and stayed there for three minutes -- but the pilots never saw it, because it was too small. The older model had a large, clearly visible mechanical pointer that was pretty hard to miss. Here's a picture:
With instruments like those, you could bull's-eye a womp rat, no problem.
You can read those dials, right? Even if you backed up from your monitor a ways, you'd see that all those on the left are pointing to the upper right. Now try to find the "needle" on the new dials:
If you're saying "They're just circles, they don't have needles pointing at anything," you're almost right. Here's a closer look:
This is actually a better view than they gave the people flying the fucking plane.
See those three little lines outside the dial? That's the entire "pointer." The dial itself was already hard to see, and on top of that it had a digital pointer that barely existed. Now add that to the fact that the whole place was vibrating at the time. In the confusion, the pilots never saw the dials. Yes, the information was there if they went looking for it, but making the dials look stylish instead of readable made them easy to miss.
#1. The Space Shuttle Columbia Burned Up Because of PowerPoint
Every disaster on this list so far happened in a matter of minutes or even seconds and involved people having to act fast and under pressure. Not this one: After a piece of debris hit the space shuttle Columbia during launch on January 16, 2003, NASA had two weeks to prepare it for re-entry. Engineers were called to assess the danger, and after reading their reports, NASA decided that everything was just fine.
Well, we all know how that turned out.
The Dumb Problem:
So how did the experts so badly underestimate the damage to the shuttle? Well, you know those danger-assessment reports we mentioned? The ones commissioned by the most advanced space agency in the world to decide what to do about a potentially huge disaster? They were done with the same tool a 14-year-old would use today to create a school presentation: Microsoft's PowerPoint. And, according to information design guru Professor Edward Tufte, that fact may very well have cost seven astronauts their lives.
"Hey! When you clicked the thing, a glowy thing happened!"
Why? Because this was an enormously complex engineering puzzle with tons and tons of data painting the picture -- it wasn't the kind of shit that can be conveyed by a pie graph and four bullet points surrounded by clip art. Trying to compress a complex problem into a PowerPoint slide inevitably leads to truncated or unintentionally misleading information. Sometimes that causes you to get a D in a community college business class, and sometimes that causes a space shuttle to blow up.
For example, Professor Tufte analyzed slides used in one of the reports and pointed out that the arbitrary bullet point hierarchy (an inevitable part of every PP presentation ever created) made some statements look more important than others. Like in this slide:
Every single word was programmed to spin in separately from off screen.
You see bold words like "overpredicted penetration of tile coating," which makes it sound like the damage wasn't as bad as they thought. But way down in the middle, in the tiniest of non-bolded print, you see the words "Test results do show that it is possible with sufficient mass and velocity," where "it" meant "total freaking disaster."
And see that nonsense phrase buried down at the very very bottom? "Volume of ramp is 1920cu vs 3 cu in for test"? Yeah, that actually meant that the debris that hit Columbia was 640 times bigger than the one they used for testing. But hey, at least the bullet point fit onto a single line.
"Rocket science isn't really rocket science, right?"
In a much more serious post-accident report, experts at NASA actually admitted that as the information in PowerPoint presentations moved to the top of the agency, key facts were filtered out. By the time it reached high-level employees, they were only seeing the good stuff. And let's face it: It's entirely possible that at least some of those guys just glanced at the headlines and thought "Well, that's a relief," then continued playing Minesweeper.
And stop by LinkSTORM to discover ancient videos of Y-chromosomal Adam and Eve totally doing it.
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