Wednesday, May 16, 2007

Think before you act

This morning I was fixing breakfast for my son. The flat griddle we use for cooking bacon and pancakes had been left on the stove and not put away after being washed the day before. I decided to use the griddle instead of getting out a frying pan to scramble some eggs. Being in a hurry I didn't wait for the griddle to get completely hot before pouring on the eggs.

The stovetop is not quite level. Because I didn't wait for the griddle to get completely hot the eggs didn't set quickly. There was time enough for the eggs to slowly flow to the edge of the griddle and then onto the stovetop making a big mess.

If I had taken the time to get the griddle hot so the eggs would set quickly, or if I had gotten out the frying pan, or if the stove had been level a big mess would have been avoided.

I recall from a class long ago that most catastrophes are not the result of a single failure but the consequence of a chain of minor events and decisions which culminate in a tragedy.

There is a story in a recent Design News column The Case of the Languid Latch of how an assembly error combined with some wear and careless use led to a fatality.

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