Psychology preceding avoidable accidents and catastrophes
May 9, 2014 8:55 PM   Subscribe

Please point me towards more non-fiction accounts of fatalities that may have been avoidable had the people involved made different decisions earlier on. In particular I am looking for accounts that provide detail about these earlier decisions so the reader can perhaps surmise where the “tipping point” was reached.

Examples that come to mind are this NYTimes article about the avalanche at Tunnel Creek, some NIOSH firefighter fatality reports, and the NTSB report on the sinking of the tall ship Bounty during Hurricane Sandy. I’m interested in the psychology behind these types of (possibly) avoidable accidents, i.e. denial, groupthink, illusion of control, optimism bias, etc., but these need not be specifically pointed out in the report or account. Examples from any field would be greatly appreciated.
posted by tr0ubley to Grab Bag (39 answers total) 65 users marked this as a favorite
The Yosemite Search and Rescue site occasionally has after action reports that highlight good and bad decisions in deteriorating situations. I believe the Annals of North American Mountaineering does too.

In book form, John Krakaur's Into Thin Air, about the disastrous 1996 climbing season on Everest is an absolutely gripping read and gives a ton of insight into the dangerous conditions and thinking in extreme altitudes. There are many, many accounts of various expeditions going wrong in book form.
posted by foodmapper at 9:05 PM on May 9, 2014 [1 favorite]

I'm reminded of this Metafilter post about a family of tourists who died in Death Valley:
In 1996, a family of German tourists went on vacation in the desert Southwest of the US. They disappeared in Death Valley sometime late July of that year, and despite repeated searches, their remains were not found until 2009. Tom Mahood details how that happened.
posted by bleep at 9:05 PM on May 9, 2014 [4 favorites]

I work in forensic engineering. I have a thousand stories I could tell you involving every point you asked for. I too would be interested in these accounts.

In my experience a catastrophic accident is never "one thing". It's several things that people never connect the dots to. Either by complete inexperience (homeowners) or institutional ignorance (several people on shifts not knowing what others have done, or undoing what others have done, or redoubling what others have done.)
posted by sanka at 9:05 PM on May 9, 2014 [8 favorites]

I think you might be looking for this book: The Logic Of Failure: Recognizing And Avoiding Error In Complex Situations.

The author '...identifies what he calls the “logic of failure”—certain tendencies in our patterns of thought that, while appropriate to an older, simpler world, prove disastrous for the complex world we live in now.'

It's from 1997, though -- maybe there's something later.

Chernobyl is mentioned, and the table of contents mentions AIDS. Alas, I got it because of a recent recommendation on AskMe and haven't read it yet myself.
posted by amtho at 9:06 PM on May 9, 2014 [2 favorites]

A few starting points -

More from the human nature side -
The Unthinkable: Who survives when disaster strikes and why by Amanda Ripley

More from the engineering side -
To Engineer is Human: The role of failure in successful design by Henry Petroski
The Logic of Failure by Dietrich Dorner
posted by LobsterMitten at 9:07 PM on May 9, 2014 [5 favorites]

Got the second rec a bit garbled- the American Alpine Club publishes an annual compendium, Accidents in North American Mountaineering. A portion of their 2011 book is available on their site.
posted by foodmapper at 9:09 PM on May 9, 2014 [1 favorite]

(Thought being, those will lead to other similar titles and you can read a bit and see if they seem like what you're after)

...and the classic Young Men and Fire by Norman McLean.
posted by LobsterMitten at 9:10 PM on May 9, 2014 [1 favorite]

Second the Petroski book and the very similar Deep Survival: Who Lives, Who Dies, and Why by Laurence Gonzalez. I think a lot of people point to the Challenger disaster as one with a pretty obvious tipping point. I don't know if you're interested in epidemiology but the spread of smallpox and the very slow spread of knowledge of how to combat smallpox is an interesting tale of the psychology of problem solving or failure thereof. The Speckled Monster: a Historical Tale of Battling Smallpox is a great book to read on the subject.
posted by jessamyn at 9:17 PM on May 9, 2014 [4 favorites]

Megan McArdle's "The Up Side of Down: Why Failing Well Is the Key to Success" (this year) is all about that sort of thing-- how to really learn from failure rather than just reacting to avoiding it. Mostly it talks about familiar forms of failure, but one chapter is about the time she nearly lost her mother in a medical mishap. She does a post-mortem on the events as she saw them.
posted by Sunburnt at 9:22 PM on May 9, 2014

In the Heart of the Sea: The Tragedy of the Whaleship Essex is very much on point, and it's also an incredibly gripping read. I don't think you'll be disappointed if you pick up this book.
posted by Conrad Cornelius o'Donald o'Dell at 9:30 PM on May 9, 2014 [1 favorite]

Although there is some debate about its historical accuracy, the movie Captain Phillips is filled with moments like this where you second guess prior decisions.
posted by SpacemanStix at 9:36 PM on May 9, 2014

A Review of Criticality Accidents from Los Alamos National Laboratory covers nuclear accidents, many of which resulted in fatalities. (I was first linked to it on Metafilter!)
posted by sigmagalator at 9:36 PM on May 9, 2014

Case studies associated with Cultural Theory of Risk might be particularly interesting to you.

I'm on a phone so I can't link any specific cases. The general gist is that different cultures assign different levels of risk to different circumstances or items.

Mary Douglas was a pioneer in this area.
posted by bilabial at 9:39 PM on May 9, 2014

The incident reports from the Mount Washington Avalanche Center S&R make for fascinating (and terrifying) reading.
posted by rtha at 9:45 PM on May 9, 2014 [1 favorite]

Jumping on the wildfire wagon:

The South Canyon Fire (aka Storm King Mountain) is a classic example of several of the pyschological roles you mentioned. The USFS report is enlightening as its one of the last USFS reports where they get to, if you'll please please excuse my crudeness, "blame the victims for their own mistakes." Here's an article that sums up that report from Fire Engineering, and there's also the book Fire on the Mountain by John Maclean.

The Thirty Mile Fire is another classic example of how group think and poor communication led to 4 deaths. USFS report here.


Piper Alpha is an oil platform in the North Sea that exploded in 1988, killed 167 men, and is the worst oilfield disaster in history. The tipping point of the explosion is literally one.piece.of.paper. The wikipedia article has a pretty good run-down, with some other sources of information.

Columbine by Dave Cullen shows how people reacted rightly and wrongly to the shooting, and hauntingly shows how the police reaction probably led to at least one death and why shooting responses changed afterward.

Issac's Storm, about the devastating 1900 Galveston Hurricane, is a great example of the illusion of control and ignoring others because you think you know better than them. The tipping point is when the National Weather Bureau decides to ignore forecasters in Cuba for you can guess the myriad of reasons.

The Texas City Explosion (1947)

PEPCON Explosion (Nevada, killed 2)

I also came in here to suggest The Unthinkable - it does a nice job of showing how people react and why, includes a ton of examples - including the Halifax Explosion - will also give you a completely different idea of Hurricane Katrina and in general will make you feel better prepared for the world.

I have oodles and boodles of these and could just keep on goin'. I have at least 10 of the Accidents in North American Mountaineering if you're interested if going that direction; I'd be happy to comb through and find good ones and get you a digital copy of the reports. But one of the best examples of the "illusion of control" in these particular arena IMHO is Dan Osman, a bungee jumper or practitioner of "free-falling" who made a fatal & good "tipping point" error concerning his ropes. Here's an Outside Magazine article about the accident.
posted by barchan at 9:59 PM on May 9, 2014 [4 favorites]

Are you only interested in accidents or do diseases also count? Apparently Steve Jobs had a very treatable form of pancreatic cancer (unlike the death sentence that other types of pancreatic cancers are) but he refused treatment despite the insistance of his doctors and instead decided to take the holistic approach. It wasn't until the cancer spread that he finally decided to listen to them and get treatment, but by then it was too late.
posted by manderin at 10:10 PM on May 9, 2014

Go to YouTube and search for "lessons learned accident" and "lessons learned investigation". Some pretty epic stories as well as numerous lectures, training exercises, talks and videos to be found there.
posted by fshgrl at 11:05 PM on May 9, 2014

Diver Down has a handful of stories of fatalities and near-misses from scuba diving. I'm pretty sure the author also has a blog with even more of these case studies, but I can't seem to dig it up at the moment.
posted by ktkt at 12:28 AM on May 10, 2014

There is an excellent book called The Blame Machine you would like. The first 100 pages goes into detail about the various types of human error and how it can be modeled.

The next 150 pages is dedicated to in-depth case studies of various accidents (17 in total, some notable ones like Estonia, Clapham Junction, Royal Flight) , including a look at inquiry findings, math, legal outcomes / safety changes made after those incidents....
posted by xdvesper at 12:58 AM on May 10, 2014

Gary Klein's Sources of Power is a classic in this area, with case studies of firefighters, nurses, and other 'front-line' professionals who face major decisions all the time - and sometimes get them wrong.
posted by narcotizingdysfunction at 2:22 AM on May 10, 2014

Don't Panic: the Psychology of Emergency Egress and Ingress compares several case studies of crowd evacuation (often fires in crowded public places), looking at the differences between deadly and successful incidents.

It might lead you to further reading on specific cases, if you're interested (e.g. the Iroquois Theatre Fire, the Cocoanut Grove Fire, the Hartford Circus Fire, etc., which have very good popular books written about them.) It includes the earlier WTC bombing, but is from 1999 so of course doesn't have 9/11.

(And I didn't buy it from Amazon, ouch...I checked it out of the library.)
posted by theatro at 4:17 AM on May 10, 2014 [1 favorite]

Normal Accidents: Living With High Risk Technology by Charles Perrow.

Normal Accidents analyzes the social side of technological risk. Charles Perrow argues that the conventional engineering approach to ensuring safety--building in more warnings and safeguards--fails because systems complexity makes failures inevitable. He asserts that typical precautions, by adding to complexity, may help create new categories of accidents. (At Chernobyl, tests of a new safety system helped produce the meltdown and subsequent fire.) By recognizing two dimensions of risk--complex versus linear interactions, and tight versus loose coupling--this book provides a powerful framework for analyzing risks and the organizations that insist we run them.

The first edition fulfilled one reviewer's prediction that it "may mark the beginning of accident research." In the new afterword to this edition Perrow reviews the extensive work on the major accidents of the last fifteen years, including Bhopal, Chernobyl, and the Challenger disaster. The new postscript probes what the author considers to be the "quintessential 'Normal Accident'" of our time: the Y2K computer problem.

Friendly Fire: The Accidental Shootdown of US Black Hawks Over Northern Iraq by Scott Snook.

On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all.

With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation.

His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.

posted by NotMyselfRightNow at 5:42 AM on May 10, 2014

TheGoiânia accident in Brazil was the first thing that came to my mind.
posted by daisyk at 6:00 AM on May 10, 2014 [1 favorite]

Oh gosh Issac's Storm is perfect for this and a very readable book. I was coming back to suggest Dark Tide about the Boston Molasses Flood that killed a bunch of people and resulted in a big lawsuit which is analyzed extensively in the book. A more meta-analysis of this topic as it relates to medicine (more accidents and less catastrophes) is Internal Bleeding : The Truth Behind America’s Terrifying Epidemic of Medical Mistakes which talks about why things go wrong in a medical setting, from poorly written scrips to "I left a thing inside a patient" Good read.
posted by jessamyn at 6:22 AM on May 10, 2014 [1 favorite]

Derek Lowe's chemistry blog In the Pipeline (previously linked on the Blue), specifically the Things I Won't Work With section, has some of these stories, but regarding the often-disastrous discovery or use of many dangerous chemicals. It's definitely interesting to read his breakdown of various small chemical explosions, disasters, and deaths.
posted by limeonaire at 6:49 AM on May 10, 2014

Full episodes of Seconds from Disaster are available on YouTube. Much of it deals with engineering failures, but the shows frequently mention psychological contributors (generally hubris or greed, as in the Korean department store collapse).
posted by desjardins at 8:43 AM on May 10, 2014 [2 favorites]

The TV series Mayday/Air Crash Investigations (depending on the country it's aired in) does dramatic recreations of incidents in commercial air flight and then follows the investigating teams as they try to unpack what happened based on available evidence/eyewitness reports if there are any, etc. You can find a bunch of episodes on YouTube as well as Netflix.
posted by bettafish at 12:39 PM on May 10, 2014 [1 favorite]

Malcolm Gladwell chronicled the "ethnic theory of plane crashes" in "Outliers." Essentially, Korean cultural norms contribute to high rates of aviation mistakes. The theory was criticized by the blog "Ask A Korean," which also posted Mr. Gladwell's response.

I've only read Gladwell's original presentation. Assuming that it's not nonsense, it's what you're looking for.
posted by stuart_s at 1:33 PM on May 10, 2014

I really enjoyed "The Unthinkable" and "Deep Survival". You might also like "Inviting Disaster".
posted by rmd1023 at 3:03 PM on May 10, 2014

Young Men and Fire tells about a tragic loss of firefighters in a Montana forest fire.
posted by j_curiouser at 3:23 PM on May 10, 2014

What about Into Thin Air?

I recently read Comm Check and I think it fits too.
posted by secretseasons at 5:14 PM on May 10, 2014

If you can find them, episodes of "I Shouldn't be Alive" are almost exactly what you are looking for, except there are survivors (often by luck alone).
posted by procrastination at 5:33 PM on May 10, 2014

Perfect Storm by Sebastian Junger seems like a classic example of this to me.
posted by mon-ma-tron at 6:40 PM on May 10, 2014

This recent article on the disappearance of Michael Rockefeller was the first thing your question made me think of.
posted by kostia at 10:04 PM on May 11, 2014

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