Head On Collision

“Head On Collision” by Damnsoft 09 at English Wikipedia. Licensed under CC BY 3.0 via Commons

Back in the late 80’s I fortunate to have the opportunity of attending a submarine design class held by Harry Jackson, CAPT, USN Ret. – perhaps the foremost American submarine designer of the second half of the twentieth century. While I still remember many of the principles of submarine design, the one thing that really stands out from that class was Harry Jackson’s claim that there had to be three mistakes made in order for someone to die.

Years later when the Columbia fell out of the sky, I mentioned to a coworker as we were setting up the Government Relations Office for the Columbia Accident Investigation Board that there were at least three mistakes made – a paraphrase of Jackson’s statement. Nearly two years later, I received a copy of the final report on the Columbia from this coworker along with a note that said, “When you said that there were at least three mistakes I thought you were crazy. But after reading the final report, I realized there were many more than three mistakes!”

Each day I read my local newspaper cover to cover – first the comics (required!) then the news. And in every copy there’s stories of someone dying in auto accidents, home fires, or in violent acts. I often try to think through how the deaths happened and what could have been done to prevent it. Often, a single act – preformed or avoided – would have eliminated the death that occurred.

It’s really remarkable when you think about it – after all, we are human and we do make mistakes – so it’s remarkable that more of us aren’t killed every day. Just think of how many people you see every week with a phone held to their ear while they are driving – I regularly see 2-6 every week. Yes, it’s illegal in the state of Washington. Yes, it’s distracted driving which people know is dangerous, but people are still doing it. That phone call or text may be important!

So how do we avoid making the three mistakes that will result in someone dying? It can be as easy as asking three questions:

1. What am I supposed to do?

Americans are known throughout the world as being obedient. We stop for red lights even when there’s no one else at the intersection. In other countries a red light means go before the other guy. So ask yourself what is the law, the rule or accepted practice? There’s usually a very good reason that it was put in place. As I was once told at Pearl Harbor Naval Shipyard, most of the rules were written in blood.

2. What if?

Just think about what could go wrong: What if that driver cuts in front of me while I’m distracted by my phone? What if an engineer notices something wrong but can’t get the information to me before the launch? What if – a simple question and one which often irritates people. But we Americans often assume the best and asking this question will expose where the problems may arise.

3. If I knew now what I’ll know later, what would I do differently?

The old saying that hindsight is 20/20 is true but can we apply it to the future? Consider what you would do if you had prospective hindsight – looking at something that might occur in the future as if it had already occurred. This takes practice and can be done in a premortem – you’ve heard of postmortems where you review what happened and identify the causes and actions that should have been done. A premortem is exactly the same except that you perform it BEFORE the event. If you’re having trouble visualizing what this would look like, then it’s time to call in a professional who can help you.

There’s one other thing that you will be required to have – an open mind. Because it is so easy for people to think that it’s never happened; I know what to expect; we’ll covered for that emergency – except that the emergency that arises is not from some totally new situation or circumstances – they arise out of what we’ve faced before and have become very accustomed to. It’s the old “the straw that broke the camel’s back” syndrome – everyone will focus on the last straw added to the camel rather than consider how they could have prevented the first straw. It’s the same with mistakes – we focus on the last mistake – but we could have prevented the accident by preventing any one of the mistakes involved.

A physicist by trade, author by choice, a born teacher, a retired veteran, and an adamant problem solver, Frank has helped the White House, federal agencies, military offices, historical museums, manufacturers, and over 250 technology startups get stuff done, communicate effectively, and find practical solutions that work for them. In his spare time, he makes sawdust and watches Godzilla movies.