Flirting with Disaster: Why Accidents Are Rarely Accidental [Paperback]

"Flirting With Disaster" starts with a great premise, and contains much good information. I have been a safety professional for much of my working life in both the aviation and chemical processing industries, and was very pleased when this book was published. I consider it to be a partial success. It covers an audacious amount of ground from the disaster response to Hurricane Katrina to the Vioxx scandal. I am always interested in disaster management, risk analysis, and hazard mitigation and look for correlations across industries; in that regard the book has the advantage of looking at numerous accidents (and a few intentional disasters, e.g. Enron) for patterns of causation. The general introduction to the Chernobyl accident (Chapter 5) is very good, and the discussion of the inherent risks of the RBMK reactor are excellent for people new to nuclear technology (these hazards are not present in western-designed plants.) The concept of flaws in the sociotechnical system is excellent, and the inclusion of James Reason's "Swiss cheese" safety model (a staple in every aviation safety course for over two decades now) is handled very well.

It is clear, though, that primary author Marc Gerstein is schooled in management and is not a technologist per se. Some of the technical details presented in the book are not absolutely correct and could have used vetting from specialists in their respective fields. I noticed the issue mostly in discussions of aviation and aerospace, but other technical professionals might notice things related to their fields of specialty. The general introduction to pilot error is quite well written, though not perfect. Gerstein discusses the evolution on aircraft automation, focusing of the Flight Management Systems (FMS) installed in modern aircraft, though many of the attributes of the aircraft he has issues with are actually wholly unrelated to the FMS. That isn't to say his conclusions are totally invalid, just that some of the technical basis for his conclusions have either been generalized for the reader or somewhat misunderstood by the author. A prime example is his discussion of the new "Fly By Wire" (FBW) A-320 series of aircraft. As a current A-320 Captain, I know something about these aircraft and their history (they have an excellent safety record and reputation with pilots who fly them,) and the presentation here is less than accurate. Gerstein discusses the 1994 China Air Flight 140 crash as an example of pilots being unable to grasp the vagaries of the FMS. In fact, China Air 140 was an older generation A-300 that was not equipped with FBW, and the accident concerned pilots not understanding autopilot functions; the FMS wasn't a factor. The model confusion is a rather gross error, and definitely would weaken the credibility of any conclusions drawn in aviation circles. This combined with the discussion much later in the book rehashing China Air 140 and American Airlines 587 (another A-300) as examples of why pilots train so rigorously for emergencies (it's true; we do) are not very germane illustrations. In both of those cases there was no emergency to respond to; they were primarily caused by the pilots initiating the emergencies. Of course no catastrophe of that magnitude ever has a single cause, and other factors (training, background, ergonomics, etc.) played roles in both of those accidents. As illustrative examples, these were not perhaps the wisest choices. Having said that, I actually was pleased overall with the handling of aviation and aerospace disasters. The technicalities might not be perfect, but the general concepts are solid.

Some of the other disasters discussed have been dealt with better in other books. I am not saying that it's not a worthy accident to study, but the "Challenger" accident was covered in much better detail, with much more rigor in Diane Vaughan's brilliant book "The Challenger Launch Decision." While Gerstein provides a good general analysis, there is nothing of note contributed to this case study that Vaughan didn't cover better and in much greater detail years earlier. This is also the first place in the book that the biases of Gerstein and coauthor Michael Ellsberg rear their head. Ellsberg is the son of Daniel Ellsberg (who writes the politically-charged and vituperative foreword and afterword here,) and they make it clear throughout the book their disdain for conservatives, taking all possible opportunities to meander away from the points of discussion to complain about everything from Reagan's role in pressuring for the "Challenger" launch based on testimony from one of Nancy Reagan's astrologers, to taking every possible potshot at the Iraq war, with particular disdain for Bush and Cheney. In the particularly nasty afterword Daniel Ellsberg discusses the wonderful series of checks and balances designed by men like "Tom Paine" (I guess he was on familiar grounds with the great man) and which are routinely disregarded in his worldview. In a particularly scathing passage Ellsberg writes "Checks and balances; investigative powers of Congress, with subpoenas; investigators with some degree of independence from the president; and independent judiciary. All of these things that you don't have in a dictatorship. They are institutions that leaders such as Vice President Richard Cheney, for one, openly disdain." He certainly never proves this accusation, but the larger question is why would I trust a man who (with the help of Senator Edward Kennedy's staff) copied and released 7,000 pages of top secret information to the press? Daniel Ellsberg likes to pontificate on how his conscience made him do it; the fact that he was charged (with an abundance of evidence against him) under federal espionage laws makes him a less than credible authority for ethics lessons, and the book is definitely lessened by the streak of left wing activism running through it. Ellsberg is a very intelligent man, but was highly involved with decision making on the Vietnam war in the Johnson administration; that he later became enamored with the anti-war movement is fine. That he purloined, copied, and distributed classified documents is not.

Besides the irrelevant recurring political opinion contained, the book features other closely related tragic flaws: pacing, the tendency to wander, and a decidedly off-putting writing style leads to case studies being much longer than necessary, and having the key points obscured with a frequently haughty writing style that makes sure to let the reader know how academically brilliant the authors really are. I laughed out loud reading Gerstein's praise of Michael Ellsberg in the acknowledgements: "He has an unerring nose for boredom, and ruthlessly cut away whatever we could do without...." Really? Did Michael read "When Countries Go Bankrupt," the ponderous chapter on monetary policy?

The book celebrates people at all levels having the ability to speak up and celebrates whistle blowers. Fortunately I work in an industry famous for critique and self-critique (I have worked in places where speaking up was decidedly not welcome as well.) I agree with the general conclusions reached by the authors and think the strongest chapter in the book is "Advice For Leaders," which prizes employee feedback and candor. Those are noble causes, and are policies that must be supported by engaged leaders at all companies which truly value safety. Unfortunately in the US, fear of legal ramifications if errors are made public leads frequently to concealment of problems, especially leading indicators of latent failures. For more insight into this, see any of the brilliant books by Trevor Kletz, notably "Learning From Accidents in Industry."

"Flirting With Disaster" contains some good information (though I would independently verify any technical analyses,) and most of the underlying concepts are very good. While it is ponderous and wordy (it could have easily presented the same material in half the length with more judicious editing) the general conclusions the authors reach are rather good. Sadly the book takes every opportunity imaginable to insert political opinion as allegedly relevant subtext, an effort that is both transparent and ill-suited to a work of this nature. There are better books available in the technical fields, and I would recommend this book primarily to people who have exhausted more authoritative and less opinionated works in their specific fields of interest. To technological generalists, this is a very general overview of the subject matter. It does have numerous strong points, but enough detractions for me to recommend it only with caution.

Flirting with Disaster covers the whys and causes of the Challenger & Columbia Space shuttles, Chernobyl Nuclear plant, Vioxx Medicine, Arthur Anderson accounting, Black Hawks friendly fire shoot down and a number of other disasters. The book just doesn't look at the mechanical, electrical or software reasons for the failure, but goes beyond into the human reasons for why the disaster was ALLOWED to occur. The author shows how in nearly all cases, the disaster was not an unforeseen "Act of God", but was rather an expected out come of poor management, poor communication and lack of training. I was truly shocked by how the author proved the point that most disasters are easily preventable and avoidable and never would have happened if everyone had worked together and had done their jobs properly. The "unforeseen unavoidable no ones fault" kind of disaster is a convenient myth used as a cover story to deflect responsibility from the guilty parties. I was amazed at how people knew what was going to happen, or at least knew what could happen, and yet failed to take action. The reasons for the failure to act is explained in the book and guidelines are given on to avoid being the next "buck passer" that fails to prevent the next disaster. The author also outlines changes that need to be made in management to prevent the human tendency to ignore or even silence whistle blowers who try to sound the alarm before it is too late.

On the downside, this book is part explosive disaster book, and part human engineering book. On the one hand it is exciting and on the other hand it can be a bit boring, but all in all, it is a good read that makes you think.