7 ms·

The official report has more details https://www.jag.navy.mil/library/investigations/IWO%2520JIMA%252090.pdf https://www.jag.navy.mil/library/investigations/IWO

The official report has more details https://www.jag.navy.mil/library/investigations/IWO%2520JIMA%252090.pdf https://www.jag.navy.mil/library/investigations/IWO%2520JIMA... The accident is an example of the rare cases where the tolerance for error is tiny to prevent catastrophic consequences. Usually systems are designed with multiple lines of defense but this is not possible with a steam valve. The process to ensure that the correct fastenings were used was not in place. Ideally in these cases engineers should use poka yoke where the device can't be assembled incorrectly e.g. using an unusual thread size or marking all low strength fasteners in an obvious way to indicate low strength

weaksauce 5y ago
having done some steam work before... that's the one thing that terrifies me in industrial settings. so much pressure and heat with little margin for error. having worked with the people that install things like that is no comfort at all.
- deleted 5y ago
  [deleted]
- quickthrowman 5y ago
  I’m not sure what you have against union pipefitters, they’re probably one of the highest skill building trades. They’re generally at the top of prevailing wage scale, they do clean looking work, and pipefitting is still pretty much exclusively union labor. I’m on the commercial side, so maybe industrial is different?
  - wahern 5y ago
    I have a relative who is a boilermaker, though now he supervises. Listening to his stories, there's never any shortage of idiots. A good team requires some veterans and some good supervisors, all whom need to constantly keep an eye on the idiots, lest they kill or maim themselves or someone else. Also, AFAIU, there are often rules requiring a minimum percentage of local union members on a project. So the number of idiots on a project is both a function of the quality of the local membership, as well as how many reliable veterans the national union and contractor can put on a project, assuming a project will even have non-local union members. While much less physically exhausting, he doesn't much like his new job supervising, which entails alot of walking around and exclaiming, "WTF!?"
khazhoux 5y ago
Ha, I looked up "poka yoke", and found this Medium article: https://medium.com/@bhavyamangla/error-proofing-poka-yoke-fool-proofing-mistake-proofing-1be0bd22f82d https://medium.com/@bhavyamangla/error-proofing-poka-yoke-fo... but the jigsaw pieces with the words "Poka" "Yoke" can be connected in seven incorrect ways :-)
dctoedt 5y ago
>poka yoke In an online legal forum, a lawyer said (paraphrasing), "I keep trying to make my master services agreements more and more idiot-proof, but they keep coming up with better and better idiots."
- wcoenen 5y ago
  That seems to be based on a quote from the book "The Wizardry Compiled" by Rick Cook: Programming today is a race between software engineers striving to build bigger and better idiot-proof programs, and the Universe trying to produce bigger and better idiots. So far, the Universe is winning.
Aloha 5y ago
Does this link work for you?
- gwern 5y ago
  Me neither. Looks like he over-escaped the URL somehow ('%2520' is escaping the '%' in what should be the space-separated URL's '%20'), and that's why you're getting that access-denied error (because the over-escaped URL doesn't correspond to an existing file). If I go to https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2090.pdf https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2... directly, or try out a IA version like https://web.archive.org/web/20110716095835/https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2090.pdf https://web.archive.org/web/20110716095835/https://www.jag.n... then it works.
- taneq 5y ago
  Yep, looks like it's fixed now?
taneq 5y ago
Interesting, I've never run across this term before but that's how we design electrical connectors. Ideally it should be physically impossible to connect a cable to the wrong place, via deliberately varied pin counts, polarity, keying etc.
- krisoft 5y ago
  There is this spectacular rocket failure: https://youtu.be/ycRVAcZC5R4 https://youtu.be/ycRVAcZC5R4 According to the reports it happened because a technician installed the innertial measurement unit upside down. It was supposedly designed to be impossible to do that, but the technician found a clever way to bend the PCB :)
  - taneq 5y ago
    It’s a race between engineers inventing more and more foolproof devices…
    - c_o_n_v_e_x 5y ago
      Any time someone designs a fool proof device, someone goes out and designs a better fool.
  - gambiting 5y ago
    What I'm surprised by here is that the rocket didn't self destruct as soon as it started tilting - it could have easily flown towards the crowd. Is self destruct not a thing most rockets have?

weaksauce 5y ago

having done some steam work before... that's the one thing that terrifies me in industrial settings. so much pressure and heat with little margin for error. having worked with the people that install things like that is no comfort at all.

deleted 5y ago
[deleted]
quickthrowman 5y ago
I’m not sure what you have against union pipefitters, they’re probably one of the highest skill building trades. They’re generally at the top of prevailing wage scale, they do clean looking work, and pipefitting is still pretty much exclusively union labor. I’m on the commercial side, so maybe industrial is different?
- wahern 5y ago
  I have a relative who is a boilermaker, though now he supervises. Listening to his stories, there's never any shortage of idiots. A good team requires some veterans and some good supervisors, all whom need to constantly keep an eye on the idiots, lest they kill or maim themselves or someone else. Also, AFAIU, there are often rules requiring a minimum percentage of local union members on a project. So the number of idiots on a project is both a function of the quality of the local membership, as well as how many reliable veterans the national union and contractor can put on a project, assuming a project will even have non-local union members. While much less physically exhausting, he doesn't much like his new job supervising, which entails alot of walking around and exclaiming, "WTF!?"

khazhoux 5y ago

Ha, I looked up "poka yoke", and found this Medium article: https://medium.com/@bhavyamangla/error-proofing-poka-yoke-fool-proofing-mistake-proofing-1be0bd22f82d https://medium.com/@bhavyamangla/error-proofing-poka-yoke-fo... but the jigsaw pieces with the words "Poka" "Yoke" can be connected in seven incorrect ways :-)

dctoedt 5y ago

>poka yoke In an online legal forum, a lawyer said (paraphrasing), "I keep trying to make my master services agreements more and more idiot-proof, but they keep coming up with better and better idiots."

wcoenen 5y ago
That seems to be based on a quote from the book "The Wizardry Compiled" by Rick Cook: Programming today is a race between software engineers striving to build bigger and better idiot-proof programs, and the Universe trying to produce bigger and better idiots. So far, the Universe is winning.

Aloha 5y ago

Does this link work for you?

gwern 5y ago
Me neither. Looks like he over-escaped the URL somehow ('%2520' is escaping the '%' in what should be the space-separated URL's '%20'), and that's why you're getting that access-denied error (because the over-escaped URL doesn't correspond to an existing file). If I go to https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2090.pdf https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2... directly, or try out a IA version like https://web.archive.org/web/20110716095835/https://www.jag.navy.mil/library/investigations/IWO%20JIMA%2090.pdf https://web.archive.org/web/20110716095835/https://www.jag.n... then it works.
taneq 5y ago
Yep, looks like it's fixed now?

taneq 5y ago

Interesting, I've never run across this term before but that's how we design electrical connectors. Ideally it should be physically impossible to connect a cable to the wrong place, via deliberately varied pin counts, polarity, keying etc.

krisoft 5y ago
There is this spectacular rocket failure: https://youtu.be/ycRVAcZC5R4 https://youtu.be/ycRVAcZC5R4 According to the reports it happened because a technician installed the innertial measurement unit upside down. It was supposedly designed to be impossible to do that, but the technician found a clever way to bend the PCB :)
- taneq 5y ago
  It’s a race between engineers inventing more and more foolproof devices…
  - c_o_n_v_e_x 5y ago
    Any time someone designs a fool proof device, someone goes out and designs a better fool.
- gambiting 5y ago
  What I'm surprised by here is that the rocket didn't self destruct as soon as it started tilting - it could have easily flown towards the crowd. Is self destruct not a thing most rockets have?