RS went on to show TS several three-dimensional bodies. Starting with a cube, he asked TS in which of the six cut-out holes it would best fit. “The square,” said a smiling TS, and that’s where RS dropped the cube. With RS then pointing to the rectangle, TS asked for it to be put in the rectangle hole. But RS dropped it into the square hole. At that point, RS held up a thin rectangle, and TS asked him to drop it into the rectangle hole. RS, though, dropped it in the square hole. He then asked TS about the cylinder shape. Although she answered, “round hole,” RS also put it into the square hole. As for the “semi-circle" shape, TS wanted it dropped into the semi-circle hole. However, as with the other shapes, RS dropped it in the square hole. The same sad scenario followed for the three-dimensional triangle and arch shapes.

Why have I taken the time to describe that frustrating hole-test here? Download the video for yourself by clicking on the above link. In my opinion, it offers a quick lesson on why catastrophic process-release events still occur 36 years after the disastrous 1984 event in Bhopal, India.

As one keen observer told me, “We design equipment to operate in very specific and safe ways. We think there's no chance of something going wrong. Only after an incident do we learn equipment can be operated differently from intended. Those faced with its performance in real life will discover alternative ways of operation to overcome a constraint, make it simpler, or more efficient, which ultimately proves more dangerous.” To that, I'll describe what happened when I recently operated a gas pump.

I inserted, then removed my credit card a second before inserting the filler nozzle in my car’s tank and squeezing the trigger, all while looking at birds circling overhead. When I heard a “click” coming from somewhere and saw a meter reading 14.98 gallons, I removed the nozzle, put it back in its place, but did not see a receipt. A nearby attendant pushed a button and generated one for me. It noted 14.98 gallons. Check!

Back on the road, I drove another 30 miles before noticing some troubling “dashboard signal activity.” As I coasted to a stop, protesting that I had done everything right, my wife urged me to compare the credit-card number on the receipt with the one on my card. Sure enough, the receipt belonged to someone else. Whodunnit? Whatdidit? Blame it on the birds, perhaps?

My point (and that of the referenced video clip) is that people and equipment can operate differently than intended. And trouble can follow.

heinzpbloch@gmail.com