Mistakes at work

[matthewb0051]

Most recently thought I was emailing a colleague directly. Turned out to be the entire defense bar in our county. Fkcu. Wouldn't have been so bad but it dimed out someone that had done some shady stuff to both of us.

[matthewb0051]

Also made the mistake of talking with a reporter last December after a client died in the county jail. Told him I was only giving him background. MFer quoted me. He is on the top of the dodo list.

[A930Rocket]

Originally Posted by john70t

I've heard of a mall foundation pour being oriented in the wrong direction.

Easy fix… Change the building from left hand to right hand. Or vice versa.

[DonDavis]

Installing an MRI, we had the magnet ramped and I was getting set up to perform SuperCon Shimming. That process makes the magnetic field Homogeneous which essentially means "make the field more smooth" by manipulating the several coil currents.

I was on top and began inserting the shim lead down into the vessel. I did not realize the vessel pressure had gone just a smidge below atmosphere and it pulled room temp air into the mix.

Heard an ever-so-slight air woosh and then the burst disk popped. Helium does not like being liquid and tries to be gas whenever it can. That exchange rate is roughly 800-1 meaning 1 liter of liquid becomes 800 liters of gas within seconds. I was sitting on about 2,000 liters of liquid.

**side note*** As soon as a magnet is physically put in place, we install the venting which vents to the outside. It's 12" diameter stainless steel the entire path.

The magnet quenched. "Oh s***" and the system began rumbling as the helium exited to outside. I scrambled down and met responders at the door stopping them from rushing in.

That one really sucked, but the convo with management was really great. A crucial step was not performed the day prior. Not my fault.

I still felt crappy, tho.

If that had been billable, it would have topped $100k without blinking.

[jcwade]

[masraum]

Originally Posted by matthewb0051

Most recently thought I was emailing a colleague directly. Turned out to be the entire defense bar in our county. Fkcu. Wouldn't have been so bad but it dimed out someone that had done some shady stuff to both of us.

Yikes. I sent an email to my old boss 4-5 years ago that "a 'customer' was doing XYZ, blah, blah, blah." It wasn't that bad, I didn't say the customer was a dumbaß or anything like that, but it certainly wasn't something that I would have said to the customer directly. But my boss forwarded the email thread to the customer who had scrolled down enough to see my statement and actually responded to it. It was a learning moment. Don't send anything in email that you don't want potentially anyone else to see even if you think the audience is "safe."
Another time years ago, I wanted to gripe about a coworker and chatted my gripe to another coworker, except that I chatted it to the coworker that I was griping about.
Fortunately, in both cases, the language was matter of fact, not particularly inflammatory, and in both cases, while I'd have preferred to NOT have my statements seen by the folks they were seen by, I was comfortable standing behind both statements if push came to shove.

Originally Posted by matthewb0051

Also made the mistake of talking with a reporter last December after a client died in the county jail. Told him I was only giving him background. MFer quoted me. He is on the top of the dodo list.

Yikes! Never trust the media!

[rattlsnak]

Originally Posted by jcwade

Not too bad. Just grab 3-4 guys and pick up the backend and swing it over..

[masraum]

Originally Posted by DonDavis

Installing an MRI, we had the magnet ramped and I was getting set up to perform SuperCon Shimming. That process makes the magnetic field Homogeneous which essentially means "make the field more smooth" by manipulating the several coil currents.

I was on top and began inserting the shim lead down into the vessel. I did not realize the vessel pressure had gone just a smidge below atmosphere and it pulled room temp air into the mix.

Heard an ever-so-slight air woosh and then the burst disk popped. Helium does not like being liquid and tries to be gas whenever it can. That exchange rate is roughly 800-1 meaning 1 liter of liquid becomes 800 liters of gas within seconds. I was sitting on about 2,000 liters of liquid.

**side note*** As soon as a magnet is physically put in place, we install the venting which vents to the outside. It's 12" diameter stainless steel the entire path.

The magnet quenched. "Oh s***" and the system began rumbling as the helium exited to outside. I scrambled down and met responders at the door stopping them from rushing in.

That one really sucked, but the convo with management was really great. A crucial step was not performed the day prior. Not my fault.

I still felt crappy, tho.

If that had been billable, it would have topped $100k without blinking.

Yikes! But thank goodness for small miracles!

In a couple of the situations that I was party to, I didn't create the failure. The failure was a pre-existing bad/wrong situation that was waiting for a trigger. I just happened to be the trigger. So I didn't cause a problem, I just exposed a pre-existing problem.

In the way back days of networking, you'd have a circuit to connect 2 locations, but to save cost, rather than have 2 circuits, you'd have 1 circuit and the ability to dial a phone line and use that dial up in case the main circuit went down. I know of one instance where a guy was fired because he'd made a mistake configuring the dial up circuit which caused an enormous telephone bill, I think in the thousands or possibly even 5 digits. I have actually seen a phone bill that on printer paper was probably 3-4" thick because of that same sort of issue.

[masraum]

So often at work after an incident, mgmt is out looking for someone to place blame on. And yes, there's often a final triggering event that "causes" an incident, but in complex systems, there's usually a perfect storm of issues and failures before an ultimate failure, so there really is no single person that was the "root cause". The real root cause is more like - system A was in a bad state, system B had an error condition, system C had been disabled, and finally, Bob hit the button in system D that caused the whole thing to come crashing down. But if the first 3 conditions in systems A, B, and C hadn't existed, then Bob hitting the button wouldn't have been a problem or would have been a much different, smaller (non-catastrophic) issue.

https://how.complexsystems.fail/
(note, the following is not the full text of the link, but is excerpts of each of the points)

How Complex Systems Fail

(Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)
Richard I. Cook, MD
Cognitive Technologies Labratory
University of Chicago

1 Complex systems are intrinsically hazardous systems.
All of the interesting systems (e.g. transportation, healthcare, power generation) are inherently and unavoidably hazardous by the own nature.

2 Complex systems are heavily and successfully defended against failure
The high consequences of failure lead over time to the construction of multiple layers of defense against failure.

3 Catastrophe requires multiple failures – single point failures are not enough.
The array of defenses works. System operations are generally successful. Overt catastrophic failure occurs when small, apparently innocuous failures join to create opportunity for a systemic accident.

4 Complex systems contain changing mixtures of failures latent within them.
The complexity of these systems makes it impossible for them to run without multiple flaws being present.

5 Complex systems run in degraded mode.
A corollary to the preceding point is that complex systems run as broken systems. The system continues to function because it contains so many redundancies and because people can make it function, despite the presence of many flaws.

6 Catastrophe is always just around the corner.
Complex systems possess potential for catastrophic failure.

7 Post-accident attribution to a ‘root cause’ is fundamentally wrong.
Because overt failure requires multiple faults, there is no isolated ‘cause’ of an accident. There are multiple contributors to accidents. Each of these is necessarily insufficient in itself to create an accident. Only jointly are these causes sufficient to create an accident.

8 Hindsight biases post-accident assessments of human performance.
Knowledge of the outcome makes it seem that events leading to the outcome should have appeared more salient to practitioners at the time than was actually the case.

9 Human operators have dual roles: as producers & as defenders against failure.
The system practitioners operate the system in order to produce its desired product and also work to forestall accidents.

10 All practitioner actions are gambles.
After accidents, the overt failure often appears to have been inevitable and the practitioner’s actions as blunders or deliberate willful disregard of certain impending failure.

11 Actions at the sharp end resolve all ambiguity.
Organizations are ambiguous, often intentionally, about the relationship between production targets, efficient use of resources, economy and costs of operations, and acceptable risks of low and high consequence accidents.

12 Human practitioners are the adaptable element of complex systems.
Practitioners and first line management actively adapt the system to maximize production and minimize accidents.

13 Human expertise in complex systems is constantly changing
Complex systems require substantial human expertise in their operation and management.

14 Change introduces new forms of failure.
The low rate of overt accidents in reliable systems may encourage changes, especially the use of new technology, to decrease the number of low consequence but high frequency failures. These changes maybe actually create opportunities for new, low frequency but high consequence failures.

15 Views of ‘cause’ limit the effectiveness of defenses against future events.
Post-accident remedies for “human error” are usually predicated on obstructing activities that can “cause” accidents.

16 Safety is a characteristic of systems and not of their components
Safety is an emergent property of systems; it does not reside in a person, device or department of an organization or system.

17 People continuously create safety.
Failure free operations are the result of activities of people who work to keep the system within the boundaries of tolerable performance.

18 Failure free operations require experience with failure.
Recognizing hazard and successfully manipulating system operations to remain inside the tolerable performance boundaries requires intimate contact with failure.

[masraum]

Originally Posted by jcwade

[jcwade]

Glad I'm retired and don't have to worry about this kind of stuff anymore.

[David]

All the time and I think I remember everyone of them even as I forget more and more of the good things I accomplish. I would like to think my profit to loss ratio is pretty high though.

[GH85Carrera]

This is from today's newspaper. Someone made a very expensive mistake. A contractor was preparing the site for a shopping center and they struck a large diameter crude oil pipeline. The shut off valve was a ways away, and 88,000 gallons of crude spewed out. It looked like an old time gusher for a while. It was spewing many feet into the air.

The good thing is the heavy equipment crew that caused it, started building temporary dikes to contain the mess. The contractor is 100% responsible for the cleanup, and the loss of oil. I hope is insurance is paid up, and has good limits.

More important, I am glad I am not responsible for that whoops.

[masraum]

Originally Posted by GH85Carrera

This is from today's newspaper. Someone made a very expensive mistake. A contractor was preparing the site for a shopping center and they struck a large diameter crude oil pipeline. The shut off valve was a ways away, and 88,000 gallons of crude spewed out. It looked like an old time gusher for a while. It was spewing many feet into the air.

The good thing is the heavy equipment crew that caused it, started building temporary dikes to contain the mess. The contractor is 100% responsible for the cleanup, and the loss of oil. I hope is insurance is paid up, and has good limits.

More important, I am glad I am not responsible for that whoops.

Someone paid the ultimate price for this one.

https://www.smh.com.au/world/texas-gas-explosion-leaves-one-dead-20100608-xr8a.html

A work crew has ruptured a high-pressure natural gas pipeline, triggering an explosion and massive fireball that left one person dead and at least seven more injured.

Cleburne Fire Chief Clint Ishmael said all 13 workers on the crew at the site when the blast took place were accounted for and that one was dead, CNN reported on Monday.
This aerial photo shows the wide area of land affected by the natural gas line explosion in Cleburn.

This aerial photo shows the wide area of land affected by the natural gas line explosion in Cleburn.Credit: AP

The blast occurred about 2.30pm local time on Monday afternoon about five kilometres south of Pecan Plantation, a 5000-resident gated community in nearby Hood County.

Officials said the fire, with flames shooting about 200 metres skyward, raged for about two hours.
Flames shoot into the air after a natural gas line exploded in Cleburne.

Flames shoot into the air after a natural gas line exploded in Cleburne.Credit: AP

The body of a man was found about 200 metres from the blast site about 7.45pm local time, Johnson County Sheriff Bob Alford said.

Authorities said workers with C&H Power Line Construction Services of Dewey, Oklahoma, were boring a hole for a power line pole when an auger hit a 36-inch natural gas transmission line.

[Rusty Heap]

I was in my 20's, working at a Home Improvement shop,, carpet, paint, and such.


Driving a forklift, hit the brakes too hard and spilled 35 gallons of latex paint in the parking lot.........

[matthewb0051]

Originally Posted by Rusty Heap

I was in my 20's, working at a Home Improvement shop,, carpet, paint, and such.


Driving a forklift, hit the brakes too hard and spilled 35 gallons of latex paint in the parking lot.........

I worked at a CO-OP one summer with wife's cousin. After I left the job and moved on... one particular day the cousin was loading feed bags on a truck via fork lift. In a pure genius move, cousin backed the fork lift right off the loading dock (about 5 feet above the parking lot. Luckily he was not hurt.