Tuesday, December 05, 2006

Judgement calls in organisations

New Delhi: The Ulta Pul was a casualty waiting to happen. The foot overbridge that smashed down on top of a moving train on Saturday morning was a British relic - over 140 years old and beyond repair. Coach No. F-8 of the Howrah-Jamalpur Superfast Express was crushed under the weight of the Ulta Pul, which was being demolished - a new one having been constructed and already in use to replace it. Though all the passengers trapped inside the coach were rescued and taken to a district hospital, 33 of them succumbed to their injuries.

Source: IBNLive : Bhagalpur was waiting to happen!

Perhaps the full story would only emerge when the statutory enquiry is completed, but it appears that someone made a Himalayan error of judgement.

When is a structure that's been partially pulled down likely to tip over and fall? There is no straight forward way to predict this accurately. And if trains cannot be stopped to remove the structure first, someone would be forced to make that judgement call.

With perfect hindsight we now know that on Saturday it was unsafe to allow the train to roll under the last remaining arch. Not too long ago a group of highly trained engineers at NASA made an error of judgement when they allowed Space Shuttle Columbia to re-enter the earth's atmosphere, without repairing damage to its heat shield.

Perhaps, the risk to this train on Saturday should have been easier to assess than the shuttle's, but I wouldn't think it was a trivial matter. Structures are notoriously difficult to assess.

Am I suggesting that we accept such disasters or rationalize them away as having been sent from Heaven?

No. I only suggest that being forced to make judgement calls, when there are organizational pressures to accept one recommendation rather than the other makes it extremely risky. Think back to the Challenger disaster and Feynman's account of his investigations into it. (Appendix F, Personal observations on the reliability of the Shuttle, Report of the Presidential Commission on the Space Shuttle Challenger Accident.)

Many of us make judgement calls. Not about stock markets, but other peoples lives. Think doctors, for instance. Or military commanders. But engineering failures are kill many people in a single, visible incident. So they make news.


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