Murphy's Law in Action
The Atomic Chef and Other Trule Tales of Design, Technology, and
Human Error. Steven Casey. 286 pp. Aegean Publishing
Company, 2006. $29.
The Embryo Imbroglio," "Out of Synch," "Event
Horizon," "The Perilous Plunge," "Titanic's
Wake," "End Game": These may sound like the names of
amusement-park rides or science fiction movies, but they're actually
the titles of chapters in Steven Casey's latest book, The Atomic
Chef and Other True Tales of Design, Technology, and Human
Error.Casey, the author of Set Phasers on Stun (1993),
has once again vividly demonstrated how design and technology all
too often leave unwitting humans on the brink of disaster. Written
in the style of a thriller by Tom Clancy or Dan Brown, these
vignettes skillfully draw the reader into the world of human error
and design flaws. But Casey isn't writing fiction—these 20
stories and the characters involved are all too real, and some of
the facts he reports are chilling.
Consider "Rhymes and Reasons," the chapter in which Casey
explains what led to the tragic demise of singer-songwriter John
Denver at the controls of a state-of-the-art experimental aircraft
he had recently purchased. This high-tech plane, a LongEZ designed
by the legendary Burt Rutan, had unfortunately been modified by its
original owner, who had built it from a kit. A modified home-built
plane may sound unusual, but Federal Aviation Administration
inspectors come across them all too often in the course of
investigating real-world accidents.
The builder of the plane Denver bought had made a seemingly benign
alteration: He had moved a lever that controls the flow of fuel from
the aircraft's two fuel tanks. He shifted it from the front of the
cockpit, where it could be easily seen and manipulated with either
hand, to a somewhat awkward spot behind the pilot's left shoulder.
In the original design, the switch position was intuitive: Turning
the valve handle to the left drew fuel from the left wing tank,
turning it to the right drew from the right wing tank, and the
"off" position was straight back. But the changed location
and orientation of the valve meant that now the pilot was required
to engage the autopilot, let go of the control stick with his right
hand, twist around and reach over his left shoulder for the valve
handle, and then move it to the right to draw fuel from the left
tank, down to draw fuel from the right tank, or straight up to stop
the flow altogether. For a pilot of average height, such a design
might not have posed a great problem. But Denver's short stature
meant that to reach the rudder pedals he had to sit forward in the
pilot's seat and was thus even farther away from the valve. The
modification proved lethal: On only his second solo flight in the
aircraft, Denver plunged to an untimely death just off the coast of
Monterey, California, presumably while trying to switch to an
alternate fuel tank.
Not all of the chapters have tragic endings. Indeed, some are quite
humorous, such as the one involving an unsuspecting customer trapped
inside the glass enclosure of an automatic teller machine on
Thanksgiving. I won't spoil the story, but what made that particular
tale painfully funny to me was that something similar happened to a
close friend of mine on a U.S. Navy base in Pensacola, Florida.
Perhaps that is what makes this book a "must
read"—these short stories of design-induced error will
have you recalling similar situations in your own life and realizing
that if not for the grace of God and a little bit of blind luck, you
too might have become the subject of a cautionary tale.
There are lessons to be learned from all of these accounts, from the
chapter about a California freeway driver fed up with traffic to the
story of a near-catastrophic nuclear explosion. Casey doesn't offer
remedies for the design and technological flaws he presents. But
that may not be a failing at all—in some dark and twisted way,
leaving the reader to ponder how to fix things may make the book
even more compelling and useful. After all, real life doesn't hand
us easy solutions.
The Atomic Chef has something to offer readers of all
stripes. Everyone who wants to improve the safety of everyday life
should read this book—anyone from the generally curious to
professionals concerned with human factors, whether they work on the
shop floor or in academia. After all, do you really want Casey's
next volume to have a chapter devoted to some mishap of your own?
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