21 Great Disasters from our past. The quotes that show our hubris, our failure to see what is coming, and how human error leads to catastrophe. We have to learn from the past.

2. Every catastrophe requires seven
things to go wrong.
Six Cascade events leading to the
7th event, the Catastrophe. At least
one of the Cascade events involves
human error. Thus most
catastrophes can be avoided.
Shit Doesn’t Just Happen

3. By studying past catastrophes we
can learn to avoid future ones.
Focusing on the Cascade Events and
how they can be stopped is key!
The Gift of Failure

4. The Titanic: Systematic Failure

5. "There is no danger that Titanic will
sink. The boat is unsinkable and nothing
but inconvenience will be suffered by the
passengers."
Phillip Franklin, White Star Line vice-
president, 1912
The Titanic: Systematic Failure

6. The Kegworth Plane Crash:
Trusting Experts

7. Passenger on British Midland Flight 92
reflecting on hearing the pilot announce
he was shutting down the right engine:
“We were thinking: ‘Why is he doing
that?’ because we saw flame coming out
of the left engine. But I was only a bread
man. What did I know?”
The Kegworth Plane Crash:
Trusting Experts

8. Custer and the Little Big Horn
Leadership Failure

9. “There are not enough Indians in
the world to defeat the Seventh
Cavalry."
George Armstrong Custer
Custer and the Little Big Horn
Leadership Failure

10. New London Schoolhouse Explosion:
Lack of Focus

11. “I did nothing in my studies nor in my life to
prepare me for a story of the magnitude of
that New London tragedy, nor has any story
since that awful day equaled it.”
Walter Cronkite
New London Schoolhouse Explosion:
Lack of Focus

12. The Donner Party: Social Disintegration

13. “I wish I could cry, but I cannot. If I could
forget the tragedy, perhaps I would know
how to cry again.”
Mary Graves.
Survivor, the ‘Donner Party’
The Donner Party: Social Disintegration

14. The Housing Bubble
Greed Overwhelms Reality

15. “Monkeys in contemporary 17th century Dutch dress
are shown dealing in tulips. A satirical commentary
on speculators during the time of Tulip Mania, an
economic bubble that centered around rare tulip
bulbs.”
The Housing Bubble
Greed Overwhelms Reality

16. Apollo 13: Successful Failure

17. “From this day forward, Flight Control
will be known by two words: 'Tough' and
'Competent.' Tough means we are
forever accountable for what we do or
what we fail to do. We will never again
compromise our responsibilities." Gene
Kranz; the Monday morning after the
Apollo 1 disaster; flight director for
Apollo 13.
Apollo 13: Successful Failure

18. The Challenger: Organizational Failure

19. “I am appalled by your
recommendation.” NASA
reference recommendation by
Thiokol engineers who designed
the boosters not to launch
Challenger
The Challenger: Organizational Failure

20. The Last Czar:
Leadership Failure

21. "I am not prepared to be a tsar. I
never wanted to become one. I
know nothing of the business of
ruling." Nicholas II, last Czar of
Russia.
The Last Czar:
Leadership Failure

22. The Sultana Explosion

23. “If we arrive safe at Cairo it would be
the greatest trip ever made on the
western waters, as there were more
people on board than were ever
carried on one boat on the Mississippi
River!” William J, Gambrel, first clerk
& part owner of the steamship
Sultana.
The Sultana Explosion

24. The St. Francis Dam: Engineering Failure

25. During the Los Angeles Coroner's Inquest
William Mulholland, chief engineer, Water
Department Los Angeles said: “The only
ones I envy about this whole thing are the
ones who are dead. Whether it is good or
bad, don't blame anyone else, you just
fasten it on me. If there was an error in
human judgment, I was the human, I won't
try to fasten it on anyone else."
The St. Francis Dam: Engineering Failure

26. The Sinking of the Kursk: Poor Training and
Maintenance

27. “It's dark here to write, but I'll try by
touch. It seems like there are no
chances, 10%-20%. Let's hope that at
least someone will read this. Hello to
everyone. There is no need to despair."
Captain Lieutenant Dmitri Kolesnikov,
commander 7th Compartment (turbine
room) Russian submarine Kursk.
The Sinking of the Kursk: Poor Training and
Maintenance

28. Pearl Harbor

29. “Should hostilities once break out between Japan and the
United States, it would not be enough that we take Guam
and the Philippines, nor even Hawaii and San Francisco. To
make victory certain, we would have to march into
Washington and dictate the terms of peace in the White
House. I wonder if our politicians (who speak so lightly of a
Japanese-American war) have confidence as to the final
outcome and are prepared to make the necessary
sacrifices.” Admiral Yamamoto, Commander Japanese
Navy.
Pearl Harbor

30. ALIVE! Uruguayan Air Force Flight 571

31. “It was repugnant. Through the eyes of our
civilized society it was a disgusting
decision. My dignity was on the floor
having to grab a piece of my dead friend
and eat it in order to survive. But then I
thought of my mother and wanted to do
my best to get back to see her. I swallowed
a piece and it was a huge step - after which
nothing happened.” Dr. Robert Canessa
ALIVE! Uruguayan Air Force Flight 571

32. Air France 447:
Human-Machine Interface Failure

33. Last warning from the flight computer:
“Pull up.”
Co-pilot yells: “We’re going to crash. I
don’t believe it. But what’s happening?”
Seconds later one of the co-pilots
exclaims “Fuck! We’re dead.”
Air France 447:
Human-Machine Interface Failure

34. The Fetterman Massacre:
A Failure to Communicate

35. "Give me 80 men and I can ride through
the whole Sioux nation.”
Boast allegedly made by Captain
Fetterman
The Fetterman Massacre:
A Failure to Communicate

36. Hillsborough Soccer Crush
Unintended Consequences

37. “There was no organised response
there at all... There was nobody in
charge, no plan, no organisation at
all... There was no resuscitation
equipment there... The scene was
just absolute chaos.”
BBC Commentator Des Lynam
Hillsborough Soccer Crush
Unintended Consequences

38. Operation Market Garden:
Strategic Blindness

39. “Many historians, with an ‘if only’ approach to the
British defeat, have focused so much on different
aspects of Operation Market Garden which went
wrong that they have tended to overlook the
central element. It was quite simply a very bad
plan right from the start and right from the top.
Every other problem stemmed from that.”
― Antony Beevor, Arnhem: The Battle for the
Bridges
Operation Market Garden:
Strategic Blindness

40. The Tenerife Airport Crash:
The Danger of Haste

41. “I knew what I had to do. I went back and
started pulling people away from the
airplane.”
Flight Attendant Dorothy Kelly
The Tenerife Airport Crash:
The Danger of Haste

42. Son of Sam:
The Explosion of Tabloid Journalism

43. “Hello from the gutters of NYC, which is filled with dog
manure, vomit, stale wine, urine, and blood. Hello from the
sewers of NYC which swallow up these delicacies when
they are washed away by the sweeper trucks.”
David Berkowitz
Son of Sam:
The Explosion of Tabloid Journalism

44. Deepwater Horizon:
Safety Lapses

45. “This company (BP) is - actually, has a
better balance sheet today than it had
before the spill.”
U.S. witness at the trial penalty phase.
Deepwater Horizon:
Safety Lapses

46. More Free Information
If you want to go directly to a document with live
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use your camera on this QR Code. Or copy and
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https://www.dropbox.com/scl/fi/vwgilkne2vsq4jrhkp
gic/GEAR-
LINKS.docx?dl=0&rlkey=i858w1e2zd3irup2lcvhvlb
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47. More Free Information
Since Slideshare no longer supports links,
I’ve also put all the links to free apps, gear and web
pages on my web site at
www.bobmayer.com
Use the pop up from the following image there and
scroll through for what you want:

51. New York Times bestselling author, is a graduate of West Point and
former Green Beret. He’s had over 80 books published, including the
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www.bobmayer.com