The Worst School Catastrophe in US History

New LondonNew London Schoolhouse Explosion: Lack of Focus

“I did nothing in my studies nor in my life to prepare me for a story of the magnitude of that New London tragedy, nor has any story since that awful day equaled it.” Walter Cronkite

Propane doesn’t smell. It’s odorless in its natural state. But if there is a leak, you smell a nasty odor.

Ever wonder why?

It would have been fortuitous if this had been done as more and more buildings began to use propane and gas for heating. But no one thought of doing it until they realized they had to.

Lessons learned that save lives later, often come at high cost.

The Facts

On March 18, 1937, a gas leak was sparked, causing an explosion that killed approximately 293 students and teachers at the New London School in New London, Texas. It is still the deadliest school disaster in U.S. History.

ShitDoesntJustHappenFinal(1)The Cascading Events DEFINITION:  An event prior to a catastrophe that contributes to the actual catastrophe, but by itself, is not catastrophic.

Cascade One

The school board overrode the architect’s plan for heating the school.

The original plan, as drawn up by the architect, called for the school to be heated by a boiler and a steam system. But the school board overrode that and insisted on a gas system in order to save money.

The New London Schoolhouse was located in Rusk County and despite the rest of the country being bogged down in the Great Depression; it was one of the richest areas in the country. Oil fueled the local economy. There were even 11 derricks located right on school grounds. The school was relatively new, having been built in 1932.

Despite a large amount of money spent on the construction, the decision was made to heat the school with 72 gas heaters, rather than the planned centralized boiler and steam system. The architect warned them that the building wasn’t designed to vent gas fumes, but they proceeded anyway.

Lesson

Experts are just that.

There are actually two problems here wrapped in one. First is ignoring the original plans for the building. A heating system is integral to such plans and in this case, the building had been designed for steam heat. Switching to multiple gas heaters ignored the basic construction of the building. And ignoring the warning that the building wasn’t designed to vent gas fumes was piled on top of that.

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Pearl Harbor: Anatomy of a Catastrophe

PearlHarbor_TN copyToday marks the 73rd Anniversary of the attack on Pearl Harbor.

While most people focus on the ‘surprise’ element of the attack, the reality is that the cascade events leading up to it were a mixed bag of obvious, and worse, miscalculations.  Both the Americans and the Japanese military seriously misjudged each other’s intentions and war plans.

In light of this anniversary, I’ve pulled the event and made it a .99 special on Kindle (free is you have Kindle Unlimited).  It’s short, but lists the six key cascade events that led up to seventh event, the actual attack.  This follows my Rule of Seven, where every catastrophe involving humans doesn’t occur in isolation.  There are always at least six cascade events leading up to the catastrophe and at least one (if not all) involved human error.  Thus many catastrophes can be avoided.

For Pearl Harbor, the six cascade events are:

Cascade One  Political misunderstanding and maneuvers that backfired.

Cascade Two  Military strategic planners in both countries seriously miscalculated each other.

Cascade Three  Warnings were ignored and/or not given to those who needed to get the warnings.

Cascade Four  Tactical considerations worked both ways.

Cascade Five  New technology was not used correctly.

Cascade Six  Timing is everything.

Here’s a curious fact:  did you know that the Japanese started the Russo-Japanese War in 1904 with a surprise attack on Russia’s Pacific Fleet at Port Arthur prior to declaring war?  Sound familiar?  A key to these shorts is to learn from history.  More shorts are following and will be focused on key dates.

More Writers Than Ever Are Earning A Living BUT . . . 10 Ways to Keep Doing it!

There’s always a but.

Not long ago an author loop I am on had a thread titled: “Quitting My Day Job.” Lots of people posted. I found it weird, since the content flood is leveling out sales, but then I thought about it. Most on the loop are indie authors. And indie authors make much more per sale than trad authors (although most of the bigger name trad authors live off advances, thus the relative lack of concern over paltry eBook royalty rates). But for the midlist author, making so much per copy sold equals greater income.

So, cool beans.

Then this past month, a new thread appeared: “Going Back to the Day Job.” How fickle is fate? And how fast the changes in the marketplace. Lot of people are blaming it on Kindle Unlimited. Which knocks down royalty per copy earned. But then you’ve got Authors United (Not) blaming Amazon for everything wrong in the world (yet still selling their books there). But I think the reality is that the content flood is really taking sales away from pretty much everyone as readers have so many more choices. Over 300,000 books uploaded to Kindle last year. Yes, most are schlock, but you know some are pretty good. Your hard core readers who pay our bills, thank you very much, have so many more choices.

So what’s a writer to do in order to keep making a living?

  1. Write
  2. Study craft so you can become a better writer
  3. Have mule-like stupidity, aka Terry Gilliam’s advice to film makers
  4. Understand that everyone else isn’t doing as great as they pretend they’re doing, so stop comparing yourself. You control your career, not anyone else’s
  5. Stay ahead of changes by studying the business and extrapolating
  6. Have a catastrophe plan (separate blog post)
  7. Accept that there will be ups and downs in all aspects; don’t get bogged in the downs; don’t go overboard on the ups
  8. Listen to, factor in whatever truths might be there, then ignore the naysayers
  9. Never, ever, think you have it made; the second you do, it’s over
  10. Write

Pilots Shut Down Wrong Engine– Plane Crashes. Kegworth

On 8 January 1989, a Boeing 737-400 crashed just short of the runway near Kegworth in the UK. 47 people were killed and 74 received serious injuries out of a complement of 126 on board.

Shortly after taking off and passing through 28,300 feet en route to a cruising altitude of 35,000 feet, a blade detached from the turboprop in the left engine. It resulted in a jolt and a bang. This was followed by a pounding noise, vibration, and smoke coming into the cabin. Several passengers near the rear of the plane noted smoke and sparks coming out of the left engine.

For reasons discussed below, the pilot shut down the plane’s right engine; the wrong engine. The vibration and smoke decreased and they descended to make an emergency landing at East Midland Airport.

Just short of the runway, the vibration and smoke returned as power was increased to the left engine for landing and that engine ceased operating. The crew attempted to restart the right engine using airflow, but because they were getting ready to land, the plane was flying too slow and too low for this to work.

The plane crashed a quarter mile from the edge of the runway.

Kegworth runway imageCascade Three

The pilot shut down the wrong engine.

As soon as they felt the vibration and received the report that smoke had begun to seep into the cabin, the pilot disengaged the autopilot and asked the copilot which engine was the problem. The copilot replied “It’s the le—no, the right one.”

There was no fire warning light from either engine, because the problem had not yet reached that stage.

What both pilots failed to realize is that they were relying on out of date data and training. In the version of the 737 they were used to, the left engine supplied air to the cockpit (where there was little smoke) while the right supplied the cabin with air. If it had been the left engine, there would have only been smoke in the cockpit. But since there was smoke in the cabin? Ergo, the smoky air in the cabin had to come from the right engine.

What they didn’t know was that in the upgraded 737-400, the left engine feeds the flight deck and the after cabin, while the right fed the forward cabin.

By itself, this still wasn’t critical, but their mistaken assumption was about to get reinforcement. The captain throttled back on the right engine and the vibration and smoke decreased.

Unfortunately, this was just a coincidence. When the plane went off autopilot they were no longer ascending and fuel was reduced to both engines. This reduced the fuel to the left engine also. The excess fuel, which had been burning, was gone, and the smoke was reduced. The speed of the blades reduced in that engine and thus the vibration was reduced.

But the pilot connected the reduction of smoke and vibration to his throttling back on the right engine. Combining that with what they thought they knew about the airflow via the engines, the decision was made that the right engine was the culprit and needed to be shut down.

Lesson

Any time equipment is upgraded or changed; the operators need to be thoroughly trained on all the changes. Even the tiniest change in details can have enormous repercussions. Here, the pilots made their initial estimate of the problem based on a previous version of the plane.

All versions of the books: It Doesn’t Just Happen: The Gift of Failure are available here.

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