Saturday, January 07, 2006

Learning Lessons Learned

I always try to get to the subject of failures in my entrepreneurship classes, because even when we start businesses outside of the manufacturing sector, we can learn vital lessons of preparation and prevention by viewing the history of our most celebrated failures. Plus, any group of students can pick up those lessons easily, just by paying attention. And how can you not pay attention to the chronicle of people being killed, or millions of dollars lost, because of something that broke when it wasn't supposed to?

Here's what they learned from a brief discussion of the THERAC-25 incident:
  1. The operator should have a view of the patient.
  2. Error messages (e.g. "malfunction 54") should be explained in advance or self-explanatory. The operator should be trained in the error messages.
  3. The full duty cycle must be completed before new commands can be entered.
  4. The X-ray should be inoperable without the tungsten shield in place.
  5. The manufacturer should have had a representative on-site to diagnose the problem right away.
  6. There should be a "panic button" available to the patient.
...and as regards the Mars Climate Orbiter:
  1. Mission Control staff should be cross-trained so no discipline is ever un-staffed.
  2. Either run guidance, navigation, and control with new software that the current engineers know, or bring back the old guard as consultants to train the current engineers and possibly run Mission Control.
  3. Have multiple sets of eyes responsible for sanity checks.
  4. Have management switch from a timing-based system of judgment to a performance-based system, even if launch windows are jeopardized. It's more important to fly successfully than to fly on-time.
Really, it's amazing that young people are ready after the fact to see the secrets that seem to elude us grizzled veterans at the time that history happens.

Katrina damage to student apartmentLater on, one of these same students went to New Orleans to help his sister, a student at Xavier University there, whose apartment had been damaged by Hurricane Katrina. He created a nice -- well, maybe "nice" is the wrong word when pertaining to anything that touches Katrina -- animation describing the damage to his sister's apartment. There may be better, more professional pictures out there. But I think my student saw a chance to view first-hand what happens when things go wrong and we're not prepared. (OK, he really wanted to help his sister. So sue me.)

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posted by Ron @ 7:16 PM

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