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Murphy's Law in Action

Scott Shappell

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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