Learning Experiences

July 2005 Issue

For Want Of A Nail: Learning Experiences 07/05

We have all heard the story of how a horseshoe nail was lost, leading to the loss of the horse and its rider, and the message he carried into battle. Because the message was never received, the battle and the war was lost. It’s as apocryphal today as when it was written. Examples include the shuttle Challenger tragedy—caused by a defective O-ring—and the Eastern Airlines Lockheed L-1011 that crashed in the Florida Everglades because someone nudged the autopilot switch “off” while working on a simple landing-gear problem but didn’t notice it.

The point is that accident chains usually start from very simple events, pick up steam from other links in the chain and then snowball out of contro...

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