Re: What are the worst things that have happened due to content mistake?

Subject: Re: What are the worst things that have happened due to content mistake?
From: "Peter Neilson" <neilson -at- windstream -dot- net>
To: techwr-l -at- lists -dot- techwr-l -dot- com
Date: Tue, 24 Apr 2018 07:53:40 -0400

Robert's referenced pdf from the DOE tells how flammable "organic" kitty litter was used instead of inert zeolite clay kitty litter. Some nitrates (one immediately thinks of KNO3) easily yield oxygen to things that want to burn. KNO3 is part of traditional gunpowder.

Undocumented changes to procedures for handling dangerous materials apparently occur frequently. Sometimes a person unskilled in chemistry corrects what seems to be a spelling error in a document, or substitutes a material that is presumably the same thing but is cheaper. My wife relates several occurrences at work, such as the substitution, by the purchasing department, of chopped newspaper instead of vermiculite and of trichloroethane instead of trichloroethylene.

The vermiculite and the chopped newspaper can both be used as "insulating material" in construction. Only the vermiculite is appropriate for packaging containers of certain reactive chemicals. My wife discovered the substitution through her careful attention to details. She have prevented some horrific tragedy.

The trichloroethylene was for degreasing the yarn for making the fabric brushes that were part of Xerox copiers. Trichloroethane does not do degreasing, and the result was several million dollars loss, after Xerox complained to the fabric supplier.

There are methods for preventing this sort of error, but they only work within a corporate culture where top management sees assurance of quality as a primary goal. The employee who discovers and reports a problem must not be pushed aside or fired.

"Faster, cheaper, better. Choose two. You'll never get all three."

Government agencies often seem to choose among "slower, costlier, worse" instead. They really can get all three.

The Department of Energy presumably has friction between actual scientists and political hacks. Did someone substitute "organic" kitty litter because the word "organic" somehow makes everything better and green?

On Tue, 24 Apr 2018 03:31:29 -0400, Robert Lauriston <robert -at- lauriston -dot- com> wrote:

https://www.energy.gov/sites/prod/files/2014/10/f18/DOE-IG-0922.pdf

On Sun, Apr 22, 2018 at 9:18 PM, yehoshua paul <ysp10182 -at- gmail -dot- com> wrote:
I will be delivering a short presentation on May 6 on some of the more
costlier mistakes that have occurred because of a mistake in the technical
content that was delivered.
The list I have compiled so far includes:
A deadly helicopter crash
https://www.timesofisrael.com/idf-confirms-steering-rod-
incorrectly-installed-causing-deadly-chopper-crash/
Radioactive waste turned into bomb
https://gizmodo.com/how-a-simple-typo-may-have-turned-a-
drum-of-radioactive-1662683094
Mars Orbiter mishap
https://en.wikipedia.org/wiki/Mars_Climate_Orbiter#Cause_of_failure
Toyota recalls sports cars:
https://blogs.wsj.com/drivers-seat/2012/06/09/toyota-subaru-
recall-sports-cars-for-misprinted-manuals/
NYC Subway map typo
https://www.upi.com/blog/2013/03/11/250000-Subway-typo-printed-on-NYC-maps/
8271363008323

Does anyone else have anything that could be added to this list (with
links)? I'm sure there have been similar threads in the past, but I
wouldn't know where and when to start looking.

Thanks,
Yehoshua
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