One of my favorite stories
Something I found while searching for something else: The story of the Gimli Glider – a Boeing 767 plane that ran out of fuel at 46,000 feet and landed safely.
The story linked above tells the technical of just how the hell such a thing could happen – a badly soldered joint, a mistake in calculation measuring fuel the manual way with a stick – but it misses one important detail: the metric-driven screwup.
It seems that someone in the Canadian Parliament got the bright idea that all planes should be fuelled in metric units – litres, kilograms, and so forth – instead of the more familiar gallons and pounds. Ground crews were sent to school to learn the Metric system and came away with their heads swimming full of numbers. As long as all the automated systems continued to work, they did OK, but when manual measurements and calculations became necessary, they wound up with half as much fuel as needed. Only the pilot’s amazing skill and personal knowledge of gliders (see the link) saved the lives of everyone on board.
This kind of screw-up is by no means unprecedented; think of the Mars probe that crashed because American engineers weren’t using the same units of measurement that the European engineers were using. No one died but millions of dollars were lost and a scientific opportunity missed.
Disasters involving technology run this way: some crucial communication fails to move forward in the social process, or simple denial prevents the problem from receiving the attention it deserves. Think of the walkway at the Kansas City Hilton, which collapsed and killed 240 people – it turned out to be an error in logic that seems blindingly obvious in retrospect. Or, the Johnstown Flood, which killed 2,200 people and was preceded by the immortal words, “You and your people are in no danger from our enterprise.”