Customer Reviews

Inviting Disaster: Lessons From the Edge of Technology

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'Inviting Disaster' is a compelling and easy to read book. It is an introduction to accident theory for generalists, and is as interesting (perhaps more so) to nontechnical people as it is to engineers and the like. James Chiles discusses several major accidents (Challenger, Three Mile Island, Ocean Ranger, etc.) in well executed chapters with substantial background from previous precursor accidents or incidents. One reviewer seems to believe that this is a flaw, but I disagree. The reviewer seems to believe, for instance, that the R101 (a dirigible, not a blimp, as the reviewer wrongly states) is totally irrelevant to Challenger. In fact R101 was the Challenger of it's day, and the social, managerial and technological pressures that ultimately led to the R101 disaster ultimately led to Challenger as well. Chiles ties this theme together in a seamless manner in chapter after chapter.

This book is not a rigorous technical analysis of the individual disasters with the engineering and math associated with formal inquiries and technical (AAIB, NTSB, etc.) investigations. What it does better than any of the technical inquiries could ever do, though, is make a clear a compelling case for the problems that led to each of the accidents covered, treating man-machine interface issues with particular grace.

I have long been associated with the more technical aspects of accident investigation and safety systems, but have to say that while there are more technical accounts available for all of these accidents, if you are looking for an entry level (but complete) overview of accidents and systems safety, you can't go wrong with this book.

James Chiles' new book is a welcome addition to the pantheon of engineering disaster chronicles. You should already have read Perrow's Normal Accidents, Vaughn's The Challenger Launch Decision, and Sagan's Limits of Safety. If you haven't, go read them now, I'll wait. Ok, next you have to read Chiles' book.

Inviting Disaster covers some of the same incidents that are featured prominently in those others, and Chiles adds new insights and observations with his trenchant observations and outstanding writing. But where he really shines is his ability to spot near-misses, close calls that the public never knew about (but which still cause nightmares for those who wish they didn't.) There are many more near-misses than calamities, and access to some of them is a major addition to our overall engineering knowledge. This book's a great read.

If you were expecting to find technical understanding of how best to improve a plant, don't buy this book. If you want a qualitative understanding of why disasters occur, this is the book. For a quantitative, engineer's perspective, refer to "Managing Risk and Reliability of Process Plants," by Mark Tweeddale. I found this book very insightful and easy to read. After reading this book, I was encouraged to go on to more technical text. After reading this book I decided to make it a career goal NOT to be one of the engineers who designed an oil plateform where the controls could be shorted out by sea water with the fill-valves open on failure. Dumb!

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I have read many books and articles about the problems of technology that range from gee-whiz-techno-chearleader to back-to-the stone-age Luddite. Recently, I have become so familiar with the problems of urban sprawl or nuclear waste that I simply turn to the last thin chapter for the author's solution to the problem and the solution is always vague...such as "grassroots activism" or "better regulation and oversight". It's very rare to find an author that is willing to touch practical solutions to technological problems with a ten foot pole...it's more fun to scare people about disasters past, present, and future...it sells books!
James Chiles doesn't want to just feed our goulish interest in things that blow-up and crash, he's interested in disecting each disaster for a cause or in many cases the set of sequences that lead to a catastrophic failure and prescribing steps to prevent future disasters. He presents the reader with case after case of preventable disasters and finds common threads of causative factors.
Chiles believes that we are living on an expanding "frontier" of technology. He believes that in order to survive in this always new environment we need to be ever vigilant. Chiles has assigned the name "Homo Machina" to the Human beings who will be best adapted to existence on the technology frontier.
This book would be most usefull to engineers, but it is written for a general audience that would be interested in behind-the-scenes explanations for many historical and recent headline-grabbers.
I find this book refreshing in it's candor about the course of Technology. I agree with Chiles' methods and conclusions but as a sceptic, I wish he would take on environmental disasters that call into question whether technology is a short-term boon and a long-term curse such as the burning of fossil fuels and global climate change , the use of CFC's and Ozone Depletion , and the dangers of emerging technologies like genetic engineering ...perhaps Chile's will take on these future disasters in his next book.

"Many of the mishaps we prefer to regard as impossible aren't impossible at all--they just take longer." (pg. 286)

That line of the book sums up the theme for the entire work. Every chapter deals in issues of accidents and near misses with the increasingly complex technology with which we surround ourselves. Eventually, that technology, some of which we trust our lives to, comes crashing down and it is often difficult if not impossible to discover why, how, and if anyone could have prevented the failure.

As a hobby I read technical publications about structural and mechanical failure, and that is what originally attracted me to this book. After reading through it, I can say it is certainly interesting, but it is definitely aimed at the layperson that doesn't know, and probably doesn't want to know, what punching shear and other technical terms mean. Instead of focusing on the mode of failure, Mr. Chiles, investigates the human side of these various disasters and near-misses. This is important because often technical publications will omit or oversimplify human interaction with the failure, which leaves us with nothing more than an "operator error" statement and no other valuable information.

I would recommend this book to anyone who is interested in the complex and often obscured issue of human involvement in technological failure. This book is especially for those who have ever wondered just how often does the technology we rely on have "very bad days."

Inviting Disaster by James R. Chiles is required reading for the devout Luddite, devout technophile, and everybody else in-between. I make this statement in light of the fact that humanity will probably not return voluntarily to the stone age, nor do we want turn the planet into a cyberdesert, where humans subsist on synthetics and tend to the machines. Admitting that accidents will happen at the machine frontier, Chiles gives us a thorough look at engineering and machine disasters and near misses from the history of the machine age, showing us how we can learn from our mistakes and reduce the number of accidents to a minimum. Well-known disasters and near misses like Three Mile Island, Challenger, and Bhopal, and lesser known ones like the Citicorp Center and the R.101 airship, provide the real life lessons that, if heeded, will allow us to develop a society that can handle its own machine creations with a minimum of trouble. Normal folks who often find an engineer's desire to 'test to destruction' unsettling, should come away with a better understanding of how engineering-at-its-best works, and why engineers aren't sick puppies for pushing their creations to the limit. Chiles writes as a technical writer and not as an engineer, which lends to the readability of the text. He has done his homework, visiting the places he writes about, giving us firsthand accounts from the machine frontier. Many, many people should read this wonderful book, from the everyday Joe or Josephine who wants to understand the wider world of technology, to the Science, Technology, and Society class that is looking for a balanced view of this important subject. I highly recommend this book.

If you want to know why the Concorde crashed or how things got so fouled up at Chernobyl or what went wrong at Three Mile Island, this very readable book is a good place to start. Chiles gives us diagrams, step-by-step chronologies, and a very human narrative to illuminate these and scores of other technological disasters in a way that makes it excruciatingly clear that most of them could have been prevented.

What these disasters have in common is human error, of course, but Chiles reveals that there were also foreshadowings and warnings of the horrors to come in the form of cracks, sagging roofs, parts that didn't quite fit, maintenance shortcuts taken, capacity limits reached, etc., that should have tipped off those in the know that something terrible was about to happen. Additionally, virtually all of the disasters happened because more than one thing went wrong.

Among the horror stories told in detail are:

The harrowing tale of the sinking of the drill rig Ocean Ranger in a North Atlantic gale in 1982, a disaster caused in part because somebody forgot to close the shutters on portlight windows;

The Challenger space shuttle blow-up, which Chiles compares with the crash of the British hydrogen-filled dirigible R.101in 1921. Both were "megaprojects born out of great national aspirations"and both went forward "despite specific, written warnings of danger." (p. 67);

The Hubble Space Telescope fiasco in which a lens is incorrectly ground thereby partially "blinding" the telescope, a multi-billion dollar error that could have been prevented with just a little testing. In this chapter (subtitled: "Testing is Such a Bother") Chiles shows how disasters happen because proper tests are simply not performed;

An out of control police van that killed parade watchers in Minneapolis in 1998 when an off duty police officer not completely in the driver's seat inexplicably gunned the engine instead of hitting the brakes. This accident was in part caused by an alteration to "Circuit 511" that controls both the brake lights and (unbeknownst to the mechanics) an electric shift lock on the vehicle. Chiles notes that "The odds of pedal error go up when drivers are elderly, and also when drivers turn around in the seat to back their cars up." (p. 242);

The explosion at the Union Carbide plant in Bhopal, India in 1984--"the worst chemical disaster of all time"--that killed thousands of people. Chiles calls this a case of "Robbing The Pillar," a reference to the practice in coal minds of mining the coal pillars holding up the walls of the mines.

This is a book for the engineer in your soul, a treatise for the worry-wart on your shoulder, a recounting of responsibility for the accountant in your heart, and cautionary tales for the fear monger in the pit of your stomach. Chiles is gentle in focusing blame, but he does indeed name names and point fingers. He also gives us a prescription for preventing future disasters. In addition to the need to perform regular maintenance, and follow safety procedures to the letter, etc., he suggests how we might prevent "cognitive lock," the blinding sense that we've all experienced, that insists that THIS is the problem and not something else, or that such and such is what needs to be done, when in reality something else will work. He also advises that near misses ought to be reported and not swept under the rug (p. 202) and that "redline running" is dangerous and that under pressure we are sometimes apt to do the wrong thing, and therefore procedures to follow during crisis should be spelled out in advance.

Accidents and disasters are often caused by simple, random events or the change in a normal sequence of actions, any one of which could affect the outcome. Had the path of the Air France Concorde been slightly different, or the piece of titanium not fallen off a DC-10, or the plane left a tad earlier or later, or a sealant been used in the fuel tanks, or any one of any other seemingly unimportant events taken place, the plane's tire would not have struck the titanium and a piece of tire would not have opened a substantial leak in the plane's fuel tank, and the passengers and crew would still be alive today.
Another related book worth reading is Normal Accidents by Charles Perrow. Perrow had studied several major accidents and concluded that some forms of technology are more open to chains of failure and that adding more safety systems can actually lead to an increased likelihood of an accident because of the increase in complexity. The systems become so "tightly coupled" that a failure in any part of the system almost inevitably leads to a chain of unmanageable and uncontrollable events.
Chiles goes Perrow one further and makes recommendations as to how training and people can prevent the accidents by breaking one of the links in the chain. It requires that individuals throughout the organization be empowered to call decisions into question or to halt actions they believe to be of concern. He observed several industries as air traffic control centers, and aircraft carriers, (not to mention helicopter repair of high-tension lines!) which have impressive safety records despite a high level of coupling and danger.
It's a fascinating book that examines why disasters happened and what lessons can be gleaned from those tragedies. For example, the explosion of the steamboat Sultana killed hundreds at a time (1865) when Americans were seemingly inured to disasters of all kinds ("between 1816 and 1848, 233 explosions on American steamboats had killed more than two thousand people"). Steamboats were constantly being destroyed by boiler explosions, and, despite industry objections, the federal government had issued all sorts of controls and inspections. In the case of the Sultana, the captain was in a hurry, he wanted to pack as many prisoners (released from Andersonville prison) on board as possible (being paid [$] per soldier and [$] per officer). The ship was way overloaded, which contributed to the boiler explosion because when the ship turned, its topheaviness caused the water level in the boiler to shift beyond safe levels. In addition, rather than have a crack in one boiler properly fixed, the captain had insisted on a patch that normally would have been fine, except that it was slightly thinner than the boilerplate on the rest of the boiler. That would have been OK, except that no one thought to change the setting on the emergency blowout valve to reflect the thinner metal of the repair, so a sequence of decisions that individually would have been unimportant resulted in a sequence that killed far more, on a percentage basis, than the 9/11 attacks.
It is possible to conduct accident-free operations, but Chiles says that it means changing normal operational culture and mindset. For example, challenging authority becomes crucial in preventing aircraft crashes and other jobs where people have to work as a team. The airlines have recognized this and no longer is there a pilot in command; the term now is pilot flying the plane with each pilot required to question the judgment of the other pilot if he/she thinks the pilot flying has made an unsafe move or decision.
I learned about the extraordinary safety record of companies that use helicopters to make repairs on high-tension electrical lines while the current is still on. That would certainly loosen my sphincter. The pilot hovers the craft within feet of the conductive lines while the electrician leans out on a platform, hooks a device to the line that makes the craft and everyone on it conduct up to 200,000 volts (they have to even wear conductive clothing), and makes repairs to the line. They have never had an accident in twenty-five years of doing this. Safety is paramount, they anticipate the unexpected, and everyone is an equal partner in the team and expected to point out conditions that might be unsafe. "A good system, and operators with good `crew resource management' skills, can tolerate mistakes and malfunctions amazingly well. Some call it luck, but it's really a matter a resilience and redundancy." Failing to have this resiliency can have tragic consequences. On December 29, 1972 an L-1011 crashed on approach to Miami because a light bulb indicating whether the landing gear was down had burned out and the entire four-man crew became involved in changing the bulb. They did not notice that someone had bumped the throttle lever releasing the autopilot that was supposed to keep them at two thousand feet, and the air traffic controller who noticed the deviation in altitude did not yell at them to pull up, not wanting to annoy the crew, but simply asked if everything was coming along. The plane crashed killing everyone on board.
Another key element is that people must be clear in speaking and writing, "even if doing so necessitates asking people to repeat what you told them. . . We know that people will try to avoid making trouble, particularly any trouble visible to outsiders, even though they are convinced that catastrophe is near." Chiles sites numerous instances where committed individuals went outside normal channels to get additional perspectives or assistance and prevented catastrophe. Those individuals always knew the leadership would back up their independent decisions even if they were wrong.
I have just scratched the surface. This book should be recommended reading for everyone.

Chiles gives a vivid journalistic account of various accidents and disasters. The writing style is easy and popular -he clearly intends to reach a broad audience. He generally does this job well.
The main weakness of the book is the absence of an overarching framework, or theory if you like, that could help the reader assimilate all this information, structure it, identify some concepts or themes that recur. Or at least explain to the reader why Chiles found this particular selection of accidents so interesting that they deserve mention in his book. Chiles is quite candid about this lack of purpose: "When I began this project some friends asked what anybody could boil out of the huge variety of technological disaster we've seen. I didn't know." (p277).
Therefore, the title's promise of "Lessons [learned?] from the edge of technology" never really materialises. The stories are told well, but the lessons remain fragmented and fuzzy. The book is not particularly useful in actual accident prevention work.

While generally well written, at times, particularly in the second half of the book, Chiles goes an association or two too far. More than once, I was left in a mild state of confusion. Other reviewers have also mentioned this problem.
The book gives a fragmented account of various disasters. If you prefer depth over breadth, you won't like this book. If you are interested in a popular account of various disasters, you may enjoy it.

But why not spend your time better reading truly fantastic books on the subject of learning from [bad] experience. Read Henry Petroski's To engineer is human, Aaron Wildavsky's Searching for safety, Daniel Maurino's Beyond aviation human factors, or some of the books by James Reason, Trevor Kletz or perhaps Scott Sagan. There is plenty to choose from.

Every engineer or scientist should put this title on their "must read" list. Chiles' interesting explanations and descriptions of accidents waiting to happen often sent chills up my spine. Readers can see trouble brewing. Too bad the participants didn't.

The book suffers, though, from poor illustrations. There's not a photo in the book that shows either the components involved in the various disasters or the aftermath of these disasters. The lack of photos makes the various events seem almost surreal. The simple 2-D line drawings don't convey much information. The figure showing the Three Mile Island reactor, for example, describes a condensate valve and relief valve, but the illustration doesn't point them out.

The book has a couple of minor technical errors. The author refers to Sevin and Temik as herbicides. Actually, they're insecticides. He also mentiones cleaning a gunky trimer out of a pipe. Unless you know what a trimer is--three molecules of the same substance--this unexplained term may leave you scratching your head.

Overall a very good book. I recommend it highly