Failures in Technical Communications

I always liked this presentation for Technical Communication. My teammate and I decided to do it on failures of technical communication.

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Mars Climate Orbiter (Polar Orbiter)

This missing was going good until a thruster shot off wrong and the orbiter burned up in the atmosphere. It turned out that one of the groups gave its information in the standard system while everyone else was using the metric system. Oops.

Links

  1. Mission Background
  2. Findings


Phenergan (Promethazine HCL)

Phenergan

This drug was to help people with severe nausea. The only problem was that if it was injected wrong it caused gangrene. The instructions were so byzantine that even trained nurses couldn’t inject it correctly (see below.) The reason that the company didn’t update the instructions after people started to get hurt? Wyeth said the government wouldn’t let them, but that wasn’t a good enough reason for the courts.

Links

  1. A lawsuit that went to the supreme court
  2. What happens when the drug is injected incorrectly

Challenger Explosion

The Challenger exploded in 1986, the cause was likely group-think, found so often in government and larger companies. I cannot show the chapter from the Edward Tufte’s book Visual Explanations: Images and Quantities, Evidence and Narrative we used for copyright reasons.


Miscellaneous Information

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A recent study conducted at the Swiss federal Institute of technology in Zurich analyzed 800 cases of structural failure in which 504 people were killed, 592 people injured, and millions of dollars of damage incurred. When engineers were at fault, the researchers classified the causes of failure as follows:

Insufficient knowledge

36%

Underestimation of influence

16%

Ignorance, carelessness, negligence

14%

Forgetfulness, error

13%

Relying upon others without sufficient control

9%

Objectively unknown situation

7%

Imprecise definition of responsibilities

1%

Choice of bad quality

1%

Other

3%

From: M. Matousek and Schneider, J., (1976) Untersuchungen Zur
Struktur des Zicherheitproblems bei Bauwerken, Institut
für Baustatik und Konstruktion der ETH Zürich,
FrBericht No. 59, ETH.

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