
I’m going to have to cover this topic with one metaphorical hand tied behind my metaphorical back, because some of the important details land in the realm of confidentiality.
Last week, one of my loved ones had a frightening experience, slowly becoming disoriented and confused regarding time, place and language, hallucinating, falling down an unlit staircase and only missing serious injury by pure luck, speaking nonsense, then gibberish, and finally being unable to speak at all. By the time the EMTs were summoned, I was worried that I was witnessing a stroke in progress, which is what the paramedics thought when they arrived.
But it wasn’t a stroke. In fact, the ER doctors couldn’t figure out what was going on. By then the patient was trembling, thrashing around (so much that an MRI was impossible), frightened, angry, aggressive, and talking incessantly but incomprehensibly. They thought it might be a tumor, or an infection, or bleeding, or an interaction of many factors. It was like a “House” episode.
The real reason for the symptoms was that the patient hadn’t filled a long-standing prescription for Levothyroxine, a very common drug ( also known as synthroid) used to treat an underactive thyroid. The weather had been bad and ice was everywhere, so the trip to the CVS was put off one day, then another, then another. An unremarkable few days off the drug, which had been taken regularly for decades with occasional short interruptions, stretched into a week. That, the doctors concluded, had caused it all. Once the drug was injected, complete recovery occurred overnight.
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I was very pleased to receive this Comment of the Day by Ryan Harkins on the post “Catching Up: Professional Ethics And The Challenger Disaster,” because it focuses on the ethics of risk, a great topic that EA hasn’t covered as well as it should.
I’ll have one brief note at the end.
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I was 4 and in preschool when the Challenger exploded. We watched the launch on TV before I went to school that day, and apparently it really disturbed me, because I bit another student and then hid under a table for the rest of the day.
Working at the refinery now, we get to revisit the Challenger explosion frequently (along with the Bhopal Union Carbide gas leak, the Texas City tanker explosion, the Texas City ISOM explosion, and a host of others) when discussing process safety. Michael West is absolutely right in that it isn’t simply a calculation of what the worst consequence is, but also the likelihood of that occurring.
Part of the reason the engineers’ concerns were dismissed was because the problem with the O-rings had been known and discussed for quite some time, and there had been numerous launches prior to this one that had been perfectly successful. In other words, NASA had gotten away with using the faulty O-rings before, so they saw no reason to be overly concerned this time around. Furthermore, the launch had already been delayed multiple times, and they were under intense pressure to launch. Why should they listen to the doom-saying of engineers when empirical evidence said the worst-case scenario was not going happen?
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