DRAFT: This module has unpublished changes.

Complexity & Failure:


Paraskevidekatriaphobia; a word which means morbid fear of Friday the 13th. It is unclear on how these superstitions emerged, but it is very clear that millions of people get pretty anxious when it comes around. The Great Pickle Works Wreck occurred on a Friday the 13th, which I believe is a pretty clever placement in the syllabus (intentional or not) since Friday the 13th is three days away. 


The two-headed Shetler Island Express was leaving Penn Station around 4:00 pm, headed to Greenport; carrying over 300 passengers. Unbeknownst to them, they would never make it to their destination.


Meanwhile, at the Golden Pickle factory in Calverton workers were getting ready to close shop early. It was unbearably humid, and of course; it was Friday! The boss decided to cut them some slack and let them go home at 5:00 rather than 6:00 pm. Along this pickle factory was a switch that led to a side track. This track allowed trains to divert and stock up with pickles that were to be distributed all over NY. 


Friday the 13th, 1926 as the Shelter Island Express raced the oncoming storm, it passed through the switch that directed the train either towards Golden Pickles, or merely straightforward. The train was estimated to be going over 70mph (DP, 2016) which is not a speed you would want to be going past a switch in the case it wasn't completed switched or if it had some sort of deficiency. Of course, the engineer and firemen on board did not know that; as we learned in our lecture 5, it is easy to judge and give our two cents when we already know the cause and outcome. But looking in retrospect it's a whole new ball game. 


These tracks, the switch; is what you could consider an open system. Many aspects influenced its efficiency. Open systems, as we've learned are complex systems because there are so many things interacting with the systems, that the risks become almost unpredictable.


Maintenance was the culprit in this case, or was it sabotage? We would never know for sure. According to the investigation that followed, the problem was a missing cotter pin in a bolt. This 3-inch pin took the lives of 6 people. The first car of the train passed with no problem, but as Professor Halada proved in his video, even slight movement can cause the castle nut to move from the bolt. He demonstrated that by simply shaking his hand. Now let's imagine the vibration of a passing train...tragic. That stormy night, the train crashed into the pickle factory.



So we know that maintenance can be even more vital than a poor design. This is where human factors, such as the design of the bolt and complex open systems like the effect of maintenance (or lack thereof) come hand in hand and show us yet, another tragic lesson.


Today, we have automated switches, and I am sure they still involve pins, bolts, the whole nine yards but they are very much more efficient. There is much less human interaction in regards to the mechanical parts. (MD MTA 2016) Before they'd have to get off and manually move the steel switch. Today, with a push of a button they are able to choose the track they want to go on. Of course, there definitely has to be maintenance involved, or we'll have another vegetable wreck but the standards, with every incident, become even more rigid.


Yes, there was a storm on that night of the crash, but the incident would have still occurred rain or shine. On the flip side, sometimes extreme conditions can magnify a flaw a system may have. Like in the case of the hurricane protection system in New Orleans. If it weren't for Katrina deciding to pay them a visit; we probably would still be oblivious to the fact that their system was in shambles.


Complexity and extreme conditions is a recipe for disaster. We know that the extreme condition was obviously Hurricane Katrina passing through the south-east of New Orleans at 125 mph causing approximately 70 billion dollars worth of damage (Wikipedia). But as Tainter and Patzek mention in Drilling Down there are losses that cannot be counted in money, and these cases are far more tragic. People lost a sense of who they were, their sense of belonging, not just a house, but their home. But I'll leave that for my psychology paper. Feelings aside, let's get to the complexity of this thing.


What made this system complex was the fact that there was no order, in every aspect you can imagine. There was a complex combination of structures, which were all maintained differently and also ran by different entities. Some structures even dated back to the 1800s (Lens 2014) There was an indistinct interface between all these different systems, and as we know things change. Environment changes, weather changes, culture changes, on a day to day basis. What worked one day; will not work tomorrow; let's not say a hundred years from now. All these factors made this open system complex as if a hurricane protection system made to withstand extreme conditions isn't complex enough.


Like always, many failure analyses followed this event. It was clear that their hurricane protection system failed.. miserably. The combination of complexity and extreme conditions proved to be deadly; almost everybody involved from the engineers to maintenance workers held some sort of accountability when it came to the protection systems failure.


New Orleans, is one of the most vulnerable cities in the US when it comes to hurricanes. It has an 11 percent chance of experiencing the impact of a hurricane in an average year. According to NOAA, a hurricane makes landfall within 50 miles of New Orleans about once every seven to 11 years (AccuWeather). So with hurricanes being almost culturally acceptable; they probably depicted floods are the norm. When in fact they should have taken this to inspect and improve their pumping stations since they were obviously not doing what they were supposed to. This is a great example of normalization of deviance. They came desensitized overtime to these floods and started accepting them as normal.


So how can we improve our systems to be able to withstand extreme conditions such as natural disasters? First thing is first, we already have most systems such as transportation, energy generation, infrastructures, etc in place. It would be extremely costly and unrealistic to demolish it all and start from scratch and replace it with state of the art equipment. Regular inspections is the first step we should be taking, not by just anyone willing to work; but by a licensed engineer; whose background gives him/her the credibility to know what the heck he/she is doing. Not only that, but if possible have two engineers, as one may have different experiences that can contribute and aid any potential malfunctions that the other may have overlooked. Two is always better than one. 


But the main question is how can it be designed to survive an extreme condition? Like the designer from the twin towers said, he would have never imagined that a plane (that didn't even exist at the time the buildings were designed) would crash into the towers. This is where all of those contradicting characteristics we read about in the first chapter of Lessons Amid the Rubble come into play because it is not black and white. The first step would be a cost analysis; take into consideration all of the possible combinations of meteorological conditions that are considered reasonably characteristics of the region where the product will be placed. You build something that can be able to survive the worst case scenario; of course, it is costly. But who is to say its failure won't be even more costly? Or having to repeatedly revamp it after mediocre condition damages; it'll eventually add up. 


In fact, the hurricane protection system in New Orleans got revamped (crowd chants: Move that bus!, Move that bus!... you wouldn't get that if you didn't watch Extreme Makeover: Home Edition) The US Army Corps of Engineers was given 14.5 billion to strengthen the city's hurricane protection system (QZ 2017) They have replaced the century-old pump stations and closure structures, not only that. But they have built safe houses for the employees to be able to control the different stations even in the midst of a natural disaster. They were built to sustain winds up to 250mph (NPC 2015)



Aside from that, they have made the levees much taller. Previously they were designed to withstand a category three storm, but some levees were never even built as tall as they were supposed, and many were even poorly built (Scientific American 2015) The crown jewel according to Miguel Llanos is the barrier at Lake Borgne Surg (shown above) which is two miles long and 26' tall (NBC News). All of these improvements have emerged because of the failure of past structures. There will never be a perfect plan, but we can definitely take precautions to reduce the risks.


What I've taken from this lesson is that is better to be overprepared (not that they were) than underprepared. It is impossible to calculate every risk one may encounter but it is possible to reduce the risk. The infrastructure system in Louisiana's name says it itself "Hurricane & Storm Damage Risk Reduction System" not risk prevention system. Each and every lecture has given us a puzzle piece to this jigsaw of engineering. So we only have 6 pieces so far out of the hundred thousand. But hey, we have to start somewhere right?





“The way to succeed is to double your failure rate.”

Thomas J. Watson










MTA MD https://youtu.be/7eHdb5XUh5E















DRAFT: This module has unpublished changes.