Things go wrong. Murphy's Law prevails, or else Sod's Law does, or whichever law you prefer that predicts that failure is not only imminent but inevitable. In an operation with a hundred steps, or a thousand, or a million, sooner or later, one of them will be outside the safe limits. In some cases, that can lead to a cascade of disaster.
After the event, it is often easy, to pinpoint where an accident began, and
while that can be mildly amusing, there is a more serious task, looking at the
cases where the slip did not lead to
a cascade of disaster. Human endeavour, human greed, human ambition and human
hubris make it easy for things to go wrong, but human forethought can prevent
much of it.
It is a curious thing that so many management and self-improvement books
train their readers to prepare for success. It would be far more useful to
train them to recognise the seeds of failure, the nature of folly, and the
origins of truly awful copper-bottomed Grand Guignol folly. Most grand
successes begin with grand schemes, but so do most grand failures.
Grand schemes fail for many reasons. Many times, the hopes and ambitions of
the proponents flopped because the schemes were just too grand altogether, and
the planners were not prepared for the unexpected. Perhaps they underestimated
a hostile environment or an enemy's strength and ingenuity in a time of war, or
the amount of background research needed.
Fame is all too often the spur that sets somebody on the path to a fall.
Either fame or the pursuit of it, or its precursors, ambition and pride is
prominent in the causal chain. Many historic failures happened because people
played office politics and fought the enemy within, rather than the enemy
without. If the British Secret Intelligence Service (SIS or MI6) had devoted
less of its time to internecine squabbles with the Special Operations Executive
(also British) in World War II, both bodies might have achieved more and lost
fewer agents (and we will gloss over the problems both sides had with de
Gaulle's Free French, who were nominally on the same side).
Hand-in-hand with the pursuit of fame comes the pursuit of lucre, because
most people realise that being disgustingly rich can make one famous. The
Spanish Armada might have fared differently if either Drake or Howard spent a
little longer looting separated Spanish ships, or if Medina Sidonia had seen
what the English captains were doing, and sacrificed a rich-looking ship or
two, in order to delay them.
In some cases, people could not communicate their needs fast enough, or
there was some other breakdown in communications, or they were not given the
materials or funds and resources they needed to do the job. Related to this are
the failures where the players lacked an essential piece of information but pushed
ahead anyhow — or had the information, but ignored it.
Then there were the structural failures, where operations were expanding too fast, and everybody fell into a spiral of reorganisation, or people found themselves in an group or society which became ossified by tradition and bureaucracy, or in a situation where the leadership gave way to panic, or a mob took over.
At other times, the authorities, driven by activists, went too far
in the opposite direction, over-reacting and causing even greater problems.
Other structural failures involved actual structures, mainly dams, cathedrals
and bridges, falling down because they were not built properly.
True, some of the world's great failures were simple bad luck, but more
came about because people were either ungifted amateurs or plain stupid or
both. Of course, when you start to examine some of the most terrible failures,
you begin to realise that there were flaws all over the place, so that
identifying a single cause of failure is either pointless or impossible. It is
more a matter of wonder that anything does go right in this world, that success
is so common.
My favourite success is one in which I was involved, but can take no credit
for it. A perceptive and clever supervisor sent me out to talk to the 'old hands'
after I took over a politically sensitive operation. I was told to talk to
these people, tap into their experience, find out what had gone wrong and been
fixed, what had nearly gone wrong, and what might have gone wrong, but hadn't.
Thanks to a bunch of committed people, and for the price of a few beers and
coffees, I tapped into perhaps half a century of hard work, experience and
wisdom on dealing with vomit, bomb threats, theft, hysteria, locks that would
not budge, flood, fire, conspiracy and more, and I gathered in neat solutions
for most of them and work-arounds for the rest. When something did go wrong, it was close enough to one
of the scenarios that was in our Compendium
of Disaster Great and Small, and we narrowly avoided the cascade to disaster.
In many factories where safety and risk are key issues, the company will
keep a "black book". This lists past problems, their causes and their
solutions, all carefully recorded. In a few companies, young engineers are
encouraged to try to second-guess where failures may happen. Undergraduates in
engineering and architecture are commonly given course work on classic past
failures, which should mean they avoid repeating old mistakes, but what of
future disasters?
The failures I hate are those like Union Carbide's poison spill at Bhopal in India, where nobody had the good sense of my boss. No young engineers were sent out to look at similar factories, ranging from oil refineries to cement works to other insecticide plants, to get a sense for what might go, wrong, and how it could be fixed. Just one valve in the right place at Union Carbide's plant, and thousands of lives might have been saved.
Somebody might have thought of a better pathway that did not use toxic
methyl isocyanate to make the pesticide, or somebody might have questioned the
wisdom of a process where the toxic intermediate product was stored, rather
than being converted immediately.
My favourite failures are the ones where people ought to have known what
they were doing, and ought to have known that what they were doing was not a
good idea, but they went ahead and did it anyhow. And even when it turns out
that their preferred site for their proposed swimming resort was in a malarial
swamp with poison trees, deadly snakes, rabid bats and voracious crocodiles,
they will still smile ruefully and tell you that it had seemed like a good idea
at the time.
