“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.
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.
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.
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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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.
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.
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.
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.