We often look at narrow escapes or near misses as ‘fortunate’ events where disaster was averted; indeed, we get to the point where we normalize near misses. Instead, we need to look at these ‘fortunate’ events as cascade events where we came close to catastrophe and were simply fortunate that we didn’t hit the final event. Relying on luck is a very dangerous mindset yet we immerse ourselves in it on a daily basis. We often call it ‘dodging the bullet’ forgetting that when a bullet hits, the results are catastrophic to the target.
We need to focus on cascade events, see their negative potential, and reduce their occurrence. A cascade event that doesn’t lead to a final event we will label a delusion event. A cascade event and delusion event are exactly the same: the only difference is that a delusion event doesn’t result in a final event.
Delusion events lead us into delusional thinking: that we will continue to dodge the bullet by doing nothing. In fact, a delusion event, where something goes wrong, but doesn’t lead to the final event, reinforces our complacency to do nothing about correcting a delusion event and increases our risk of a final event, a catastrophe. We take the delusion event as the status quo, not an aberration. Delusion events lead to the normalization of unacceptable risk. For a very simple example, the further you drive with the check engine light on in your car, the more you think it’s normal for that light to be on. This is called normalization by Diane Vaughan in her book The Challenger Launch Decision.(1) We’ll discuss this catastrophe as one of our seven in the second book in this series, focusing on organizational thinking about delusion events.
How many times have you been in a hotel or restaurant or store and the fire alarm goes off? How many times did you hurry to the exit? Rather, didn’t you, and everyone around you, with no smoke or fire noted, stand around, and wait for someone to actually announce what’s going on? We’ve been desensitized by false alarms to the point where the alarm serves little purpose any more.
The Harvard Business Review did a study in 2011 (2) and found that delusion events (multiple near misses) preceded every disaster and business crisis they studied over a seven-year period. Besides delusional thinking leading to normalization, the other problem is outcome bias. If you flip a coin six times and it come up heads six times, even though statistically rare (1 chance in 64 attempts), you will tend to start focusing on the result, believing all coin tosses end up heads. While we know this isn’t true, we tend to base our probabilities of future occurrences not on the statistics of reality but on our experiences.
This is called heuristics and is at the root of many disasters. Hueristics is experience-based techniques for learning and problem solving that give a solution which isn’t necessarily optimal. We generalize based on the things we value most: our own experience and information related to us from sources we trust. Think how many ‘truths’ you have heard that turn out to be nothing more than an urban legend or a superstition. Yet we base many of our daily and emergency actions around these.
A small example from The Green Beret Survival Guide: every so often there is a news article about someone in a desperate survival situation who claims drinking their urine helped them make it through. That’s absolutely the wrong thing to do. But it’s one of those stories that gets repeated enough, until we believe it to be true. Because we only hear from survivors, who lived in spite of doing the wrong thing.
It is human nature that we focus on successful outcomes much more than negative ones. It’s irrational, but that’s part of being human. In the same way, managers and leaders are taught to plan for success, not failure, since it’s believed planning for failure is negative thinking. In fact, I would submit that many people are part of a cult of positive thinking that often excludes reality.
The good news is we tend to be predictably irrational and understanding our tendency to make a cascade event a delusion event, is the first step in correcting this problem.
“In wartime, truth is so precious she must be attended by a bodyguard of lies.” Winston Churchill.
Who polices the world of covert operations? That was the idea from which this book sprung forth.
The Cellar: Bodyguard of Lies is the Daily Deal today on Kindle. It’s the first book in the Cellar series (Lost Girls is book 2) and then the Cellar series merges with the 2nd book of my Nightstalker series, The Book of Truths.
When Bodyguard of Lies first came out there was a lot of Hollywood interest in it, with one director believing it should be the next Mission Impossible movie. Alas, those of you who know Hollywood, know its amazing anything gets made.
My grand plan, 25 years in the making, of merging various series is coming to fruition. Hannah & Neeley from the Cellar are with Scout and Moms and the rest of the Nightstalkers. And early next year, the Nightstalker run into the Time Patrol which is dealing with the concepts from my Atlantis series and meet Amelia Earhart, Dane and the concepts of parallel worlds and time travel and a Big Bad that’s trying to screw with our time line.
Well, it sounds good to say that was the grand plan; actually it’s something I became aware of about a year or so ago. It occurred to me that since all these books came out of my warped mind, there had to be common links. And there are. I blogged about my four pillars of story back in January and these books all touch on those:
Write what you know (yep, done a lot of time travel). Actually the military angle is there.
Write what you want to know: myths and legends! I have valkyries and kraken and more in Atlantis and now in Nightstalkers. Oh my.
Write what interests you: History. Bodyguard of Lies is based on history.
Write what is your passion: The power of the mind is key. In Bodyguard, the mental manipulations, in essence almost gaslighting, that various characters employ are central to the plot.
So today, for only $1.99, the Kindle Daily Deal is Bodyguard of Lies!
“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.
The sinking of the Sultana was the greatest maritime disaster in United States history, yet most people have never heard of it. Even at the time of its occurrence the headline was buried because John Wilkes Booth had been killed the day before the ship went down. In fact, the entire month of April was full of headlines: On the 9th of April 1865, Lee surrendered to Grant at Appomattox Courthouse. On the 14th, President Lincoln was assassinated.
The Facts: On 27 April 1865, three of four boilers on board the Sultana exploded, killing approximately 1,800. This was a greater loss of life than the Titanic. Most of those killed were Union soldiers, who were former prisoners of war returning home.
This occurred on the Mississippi River, roughly eight miles north of Memphis in the middle of the night.
21 April 1965: Sultana departs New Orleans.
24 April 1865: Sultana arrives at Vicksburg; boiler is ‘repaired’. The boat is overloaded, mostly with former Union POWs.
26 April 1865: Sultana docks at Memphis.
27 April 1865: Sultana explodes.
DEFINITION: Cascade Event: An event prior to a catastrophe that contributes to the actual catastrophe, but by itself, is not catastrophic.
CASCADE THREE: The boat was grossly overloaded.
With a legal capacity of 376, it is estimated there were roughly 2,400 people on board the Sultana.
While part of the reason was the intense desire for the former POWs to make it back home, the fault lies with the greed of both the ship owners and the Army Quartermaster in charge. We’ve already seen how the ship captain’s rush to make it to Vicksburg prevented him from adequately repairing the boiler. The system was that for each enlisted man he carried he would receive $5 and for every officer $10. And, the captain made an under the table deal with the quartermaster to kick back $1.15 for each soldier carried, an unfortunately rather common practice on the river.
Such was the nature of this scheme that another steamboat already docked at Vicksburg, Lady Gay, received not a single passenger from the Army even though it was larger than the Sultana and leaving before her. Lady Gay left Vicksburg without a single former POW on board.
Even when another steamboat arrived, the Quartermaster, Reuben Hatch, refused to divvy up the prisoners, insisting they all go on the Sultana.
The overcrowding had a direct impact on the explosion of the boilers because it made the boat top-heavy. As it went up the river, every time it took a turn in the Mississippi, the boat would tip. The four boilers were all interconnected and with each tip, water would run out of the high side boilers and into the low side. It’s believed that the water level got so low, that the high side would get almost completely drained.
When the water rushed back in to the hot boiler, the one with the patch finally blew, setting off two other boilers.
LESSON: The lure of ‘easy’ money and a kickback scheme set the stage for disaster. Regulations, concern for safety, common sense all disappeared as the ship’s captain and the quartermaster jammed every person they could aboard the Sultana, viewing each soul as cash.
The quartermaster clearly violated Army regulations in his greed.
Available at all platforms via this landing page.
Available at all platforms via this landing page.
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
“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.
THE SULTANA EXPLOSION
“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.
“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 purposed by the United States by leaving out the last sentence)
Mulholland & The St. Francis Dam
During the Los Angeles Coroner’s Inquest, William Mulholland 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.” In later testimony, after responding to a question, he added, “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.” William Mulholland, chief engineer, Water Department Los Angeles
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.
“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