Wired magazine is on our best 5 list here at CX, and a recent article by Ben Paynter resonated.
He points out that when the space shuttle Challenger burned up on reentry, the problem had been known for 79 previous missions. But it had not come together and created a disaster, so the rocket nerds didn’t know, or they just hoped and prayed. Essentially, the foam insulation had been peeling off the thing on launch, but no one had the gumption to imagine a clump could damage the heat tiles.
Hello? Where were the high paid scientists? Oh yeah, group think got in the way.
Just like no one thought the Indiana stage was unstable with a few lousy concrete barriers as ballast, sitting untethered on the ground, and the Radiohead stage would not crack up under a full tour load of excessive lighting and video crap.
A near miss is a near failure, says Paynter. He sites a study by business grad’s who surveyed NASA attitudes to a successful mission, and one with a near miss. In both cases the nerds ranked the missions as equally well done.
This CX writer was a licensed pilot for 12 years, and is hopelessly addicted to reading the reasons for aviation accidents. No surprise that cockpit resource management (CRM) is best performed in the developed world, and worst in emerging economies, where subservient culture overrides a first officer taking command when a captain is on a kamikaze mission (Garuda Flight 200) and clearly about to crash.
We see casualized crew come together and defer to the seniors who sometimes have it wrong – but without CREW RESOURCE MANAGEMENT (ie: a culture of questioning and a preparedness to take over) mistakes go unchecked. Line arrays get flown with pins out. Trusses go up with bad slings, on old unserviced motors.
“A more effective way to curtail disasters is to get better at spotting a near miss”, says Paynter.
We need to think about this, and CRM, next time we rig a live show.
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