The Lessons of ValuJet 592

[Stuart Burnfield <slb -at- FS -dot- COM -dot- AU>]

Wendy Christensen <christensen -at- CATLAS -dot- MV -dot- COM> said:
> . . . I recommend perusal of "The Lessons of ValuJet 592" in the
> March, 1998, issue of The Atlantic Monthly....touches upon technical
> writing and documentation as among the many vital elements of complex
> systems where failure, or a multiplicity of unpredictably inter-
> related failures, can kill.

> >     http://www.theatlantic.com/issues/98mar/valujet1.htm

I endorse Wendy's recommendation. This is a fascinating piece about
complex systems and the limits of safety procedures. Two snippets that
should particularly interest tech writers:


       . . .This required a gang of hard-pressed mechanics to draw
       a verbal distinction between canisters that were "expired,"
       meaning most of the ones they were removing, and canisters
       that were not "expended," meaning many of the same ones,
       loaded and ready to fire, on which they were expected to put
       nonexistent caps. Also involved were canisters that were
       expired and expended, and others that were not expired but
       were expended. And then, of course, there was the set of
       new replacement canisters, which were both unexpended and
       unexpired. If this seems confusing, do not waste your time
       trying to figure it out -- the SabreTech mechanics did not,
       nor should they have been expected to. The NTSB suggested that
       one problem at SabreTech's Miami facility may have been the
       presence of Spanish-speaking immigrants on the work force, but
       quite obviously the language problem lay on the other side --
       with ValuJet and the English-speaking engineers, literalists,
       who wrote the orders and technical manuals as if they were
       writing to themselves. The real problem, in other words, was
       engineerspeak.

[snip]

       Yes, a mechanic might have found his way past the ValuJet work
       card and into the huge MD-80 maintenance manual, to chapter
       35-22-01, within which line "h" would have instructed him to
       "store or dispose of oxygen generator." By diligently pursuing
       his options, the mechanic could have found his way to a
       different part of the manual and learned that "all serviceable
       and unserviceable (unexpended) oxygen generators (canisters)
       are to be stored in an area that ensures that each unit is not
       exposed to high temperatures or possible damage." By pondering
       the implications of the parentheses he might have deduced that
       the "unexpended" canisters were also "unserviceable" canisters
       and that because he had no shipping cap, he should perhaps take
       such canisters to a safe area and "initiate" them, according to
       the procedures described in section 2.D. To initiate an oxygen
       generator is of course to fire it off, triggering the chemical
       reaction that produces oxygen and leaves a mildly toxic residue
       within the canister, which is then classified as hazardous
       waste. Section 2.D contains the admonition "An expended oxygen
       generator (canister) contains both barium oxide and asbestos
       fibers and must be disposed of in accordance with local
       regulatory compliances and using authorized procedures." No
       wonder the mechanics stuck the old generators in boxes.

Regards
---
Stuart Burnfield                 "Fun, fun, fun
Functional Software Pty Ltd       In the sun, sun, sun. . ."
mailto:slb -at- fs -dot- com -dot- au