Price of poor instructions: the Cutter case

Subject: Price of poor instructions: the Cutter case
From: Stuart Burnfield <sburnf -at- au1 -dot- ibm -dot- com>
To: techwr-l -at- lists -dot- techwr-l -dot- com, austechwriter -at- freelists -dot- org
Date: Wed, 2 Aug 2006 13:01:36 +0800

People sometimes ask on the list for examples of inadequate technical
instructions that led to loss or harm.

"Development of the vaccines that eradicated polio from most of the
Western world was funded mainly by the March of Dimes. That charitable
foundation also oversaw the first field trials establishing the safety
and efficacy of Jonas Salkâs vaccine. It then handed the project to the
government, which licensed five private companies to produce the
vaccine. Although the government prescribed exactly how it was to be
manufactured, the instructions were not quite the same as those the
foundation had promulgated prior to the first trial. The Cutter Company,
the smallest of the five licensees, followed the governmentâs
instructions to the letter, but failed to kill all the virus in the
vaccine. Seventy thousand people suffered mild forms of polio. Two
hundred were paralyzed. Ten died."

I hadn't heard of this case till I read this article.


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