Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Challenger, Sultana, St. Francis Dam, Kursk, Pearl Harbor and more

424 views

Published on

What can we learn from great disasters of the past to prevent future ones?

Book Two in the Stuff Doesn't Just Happen: The Gift of Failure Series by NY Times Bestselling Author, West Point Graduate and former Green Beret, Bob Mayer.

Covering the cascade events leading up to each disaster, why they happened, and how we can prevent similar disasters in the future.

THE CHALLENGER: ORGANIZATIONAL FAILURE
“My God, Thiokol. When do you want me to launch? Next April?” Senior NASA official on a conference call to the manufacturer of the solid boosters, when they recommended on the morning of the launch that it be postponed.

THE SINKING OF THE KURSK

THE SULTANA EXPLOSION

PEARL HARBOR

Mulholland & The St. Francis Dam

THE LAST CZAR
“I am not prepared to be a tsar. I never wanted to become one. I know nothing of the business of ruling." Nicholas II, last Czar of Russia.

Published in: Engineering
  • Login to see the comments

  • Be the first to like this

Challenger, Sultana, St. Francis Dam, Kursk, Pearl Harbor and more

  1. 1. Every catastrophe requires seven things to go wrong. Six Cascade events leading to the 7th event, the Catastrophe. At least one of the Cascade events involves human error. Thus most catastrophes can be avoided. Shit Doesn’t Just Happen
  2. 2. By studying past catastrophes we can learn to avoid future ones. Focusing on the Cascade Events and how they can be stopped is key! The Gift of Failure
  3. 3. Book II covers: Challenger Explosion The Last Czar The Sultana Explosion St. Francis Dam Failure The Sinking of the Kursk Pearl Harbor Uruguayan Flight 571 Alive!
  4. 4. The Challenger: Organizational Failure
  5. 5. “I am appalled by your recommendation.” NASA reference recommendation by Thiokol engineers who designed the boosters not to launch Challenger
  6. 6. The Last Czar: Leadership Failure
  7. 7. "I am not prepared to be a tsar. I never wanted to become one. I know nothing of the business of ruling." Nicholas II, last Czar of Russia.
  8. 8. The Sultana Explosion
  9. 9. “If we arrive safe at Cairo it would be the greatest trip ever made on the western waters, as there were more people on board than were ever carried on one boat on the Mississippi River!” William J, Gambrel, first clerk & part owner of the steamship Sultana.
  10. 10. The St. Francis Dam: Engineering Failure
  11. 11. During the Los Angeles Coroner's Inquest William Mulholland, chief engineer, Water Department Los Angeles said: “This inquest is a very painful for me to have to attend but it is the occasion of that is painful. The only ones I envy about this whole thing are the ones who are dead. Whether it is good or bad, don't blame anyone else, you just fasten it on me. If there was an error in human judgment, I was the human, I won't try to fasten it on anyone else."
  12. 12. The Sinking of the Kursk: Poor Training and Maintenance
  13. 13. “It's dark here to write, but I'll try by touch. It seems like there are no chances, 10%-20%. Let's hope that at least someone will read this. Hello to everyone. There is no need to despair." Captain Lieutenant Dmitri Kolesnikov, commander 7th Compartment (turbine room) Russian submarine Kursk.
  14. 14. Pearl Harbor
  15. 15. “Should hostilities once break out between Japan and the United States, it would not be enough that we take Guam and the Philippines, nor even Hawaii and San Francisco. To make victory certain, we would have to march into Washington and dictate the terms of peace in the White House. I wonder if our politicians (who speak so lightly of a Japanese-American war) have confidence as to the final outcome and are prepared to make the necessary sacrifices.” Admiral Yamamoto, Commander Japanese Navy. (Note that this quote was used extensively for propaganda purposes by the United States by leaving out the last sentence)
  16. 16. ALIVE! Uruguayan Air Force Flight 571
  17. 17. “It was repugnant. Through the eyes of our civilized society it was a disgusting decision. My dignity was on the floor having to grab a piece of my dead friend and eat it in order to survive. But then I thought of my mother and wanted to do my best to get back to see her. I swallowed a piece and it was a huge step - after which nothing happened.” Dr. Robert Canessa
  18. 18. Seven Ways to Prevent Catastrophes 1. Have a Special Ops preparation mindset 2. Focus by utilizing both big picture & detail thinkers 3. Conduct Special Forces Area Studies 4. Use the Special Forces CARVER formula 5. Have a “10th man” 6. Conduct After Action Reviews 7. Write and USE Standing Operating Procedures (SOPs)
  19. 19. Are you interested in a presentation about various catastrophes and how the cascade events could have been prevented? Events covered range from human-machine interface, to leadership, to communication, cost-cutting, engineering, group think, perseverance, systematic failure, and more? Catastrophes are cascade events culminating in disastrous chaos. War is chaos. Special Forces is the most elite unit trained for a variety of combat situations. What makes Special Forces elite is our mindset and preparation. Are you interested in a presentation on how to use Special Forces tactics, techniques and mental attitude to help your organization anticipate and prevent potential catastrophes? Please email bob@bobmayer.com Summary
  20. 20. More Free Information I constantly update free, downloadable slideshows like this on my web site for preparation and survival and other topics. www.bobmayer.com/workshops Also, I conduct Area Study workshops for those interested in properly preparing for their specific circumstances.
  21. 21. The guide on the left is the complete preparation and survival guide. The one on the right is a pocket-size manual with just the survival portion. Useful in your Grab-n-Go bag, car and kitchen drawer. SURVIVAL GUIDES
  22. 22. New York Times bestselling author, is a graduate of West Point and former Green Beret. He’s had over 80 books published, including the #1 bestselling series Green Berets, Time Patrol, Area 51, and Atlantis. He’s sold over 5 million books. He was born in the Bronx and has traveled the world. He’s lived on an island off the east coast, an island off the west coast, in the Rocky Mountains, the Smoky Mountains and other places, including time in East Asia studying martial arts. He was an instructor and course developer/writer for years at the JFK Special Warfare Center and School which trains Green Berets and also runs the SERE school: Survival, Evasion, Resistance and Escape. www.bobmayer.com

×