When life goes wrong, we ask the question “Why?” When we hear on the news as we did recently about someone taking a gun and shooting it into a crowd of people, killing innocent people that they didn’t even know, we ask, “How did this person get to the point of being able to do what he did?” For every effect, there is a cause and finding the cause of what went wrong is a worthwhile task, especially if we can find it and resolve problems before they turn into disasters that can’t be remedied. We can learn something about investigating these matters by observing the investigation of other kinds of disasters.
August 21, 1995 a small twin engine commuter plane with 26 people onboard was traveling from Atlanta Georgia to Gulfport Mississippi. Suddenly a loud crashing sound shook the whole plane and it began rapidly descending. Less than ten minutes later, after heroic effort by the pilots to maintain control, it crash landed in a field in the Georgia countryside. Miraculously everyone onboard survived the initial crash landing, but when jet fuel leaking from the airplane ignited, nine people perished and many more were severely burned.
As in any airplane crash, investigators are charged with discovering why the crash took place and what can be done to ensure that what went wrong on that airplane doesn’t go wrong again on any other airplane like it. Obviously the most destructive, traumatic and deadly part of this disaster was the fire. Although the fire was the climax of the disaster, it was merely a result of the crash. Investigators go much further back to discover why the airplane crashed in the first place. In this case, it was because a blade broke off one of the propellers causing the engine on one side of the airplane to break apart creating a great deal of drag on that side of the plane preventing it from being flown well on the one engine still running.
Why did the propeller blade break? Was it the speed of the rotation of the engine? Was it the kind of metal used to manufacture the propeller? Was it the engineering of the propeller blade? It turned out that none of these things were the primary cause of the breakage of the blade. The actual problem was the use of chlorine on a small piece of cork inside the hollow propeller blade. The chlorine reacted with the metal to corrode it and cause it to crack under stress. Many other steps could be taken to try to prevent the accident, but until the true cause of the accident was discovered, disasters like this would continue to take place.
As long and as complicated as the investigation might seem to have been, the end result was simple, and the solution to prevent a repeat of the disaster was simple. Not only is the solution simple, it is way easier to prevent a crash by not putting chlorine on the plug in the propeller than it is to prevent jet fuel from igniting after a crash. We could respond to the crash by focusing on fire prevention, durability of the aircraft on impact, ability to control a damaged aircraft, etcetera. All of these things are good areas of focus, but in focusing on all these things, we don’t want to miss the real cause of the accident. Sometimes when we see a big disaster, we have trouble connecting the magnitude of the disaster with the root cause and often overlook the real solution to preventing disasters in the future. After all, would have thought that the presence of a little bit of chlorine in the propeller would, over time, left unattended, lead to a tragic accident?
In this tragic accident, many people’s lives were changed forever. Unfortunately, tragedy like this is not limited to physical accidents. We have only to look around us to see tragedy, mass shootings, murder, suicide, children being abused, people ending careers in disgrace, marriages breaking up, and the list could go on. Like the impact of the airplane crash that broke bones and the fire that killed so many, tragedies such as school shootings, murders, and destroyed relationships, all demonstrate that something has gone terribly wrong. In our investigation of what went wrong, we need to go back to the very beginning where the seeds of disaster were planted, seeds that may appear benign or unrelated but which ultimately are the beginning of a chain of reactions that leads to pain, tragedy, brokenness and even death.
For an illustration of how this played out in real life, see part two of this blog post.