8. Murphy's Law

(How things go wrong, and how to make them go right.)

     Murphy’s Law: “If anything can go wrong, it will, and at the worst possible time.” (attributed to Major Murphy)

     Actually, Major Murphy never said that. What he actually said was, “If there’s more than one way of doing something, and one way will lead to disaster, someone will do it that way.”

     Discussion Question: What causes things to go wrong?

Most people would say, “Carelessness,” or, “Incompetence,” but let’s take a closer look at Murphy’s Law:

“If anything can go wrong, it will, and at the worst possible time.”

Really?

     Question: When are the worst possible times to get into a car wreck?

     Answers: In a heavy fog, in a heavy rain, during a typhoon, at night, and on a winding mountain road. Question: When are you most at risk of getting into a car wreck? Answer: In a heavy fog, in a heavy rain, during a typhoon, at night, or on a winding mountain road. In fact, the more of these conditions exist, the more likely you are of getting into a car wreck.

     Thus, Murphy’s Law is more correct than incorrect

     Suppose your car crashed on a winding mountain road one night during a heavy rain, and suppose you had had no choice except to be on the road at that time. Suppose someone else were driving on a straight stretch of road during a fair-weather day, and he didn’t get into an accident. Does that mean that he is more careful and more competent than you are?

     Why or why not?

     Question: Is it true that bread usually falls jelly-side down?

     Answer: When bread falls from a table, it slides from the table, tips over, and falls. This causes the slice of bread to turn as it falls. Most tables are of the same height as most other tables. For that reason, bread almost always turns 1 ½ times before it hits the floor. This phenomenon almost always causes a slice of jellied bread sliding from a table to land jelly-side down on the floor.

Normal Accident Theory

     Ah, now you’re beginning to realize that things often go wrong for reasons other than incompetence or carelessness. Small mistakes are often caused by incompetence or carelessness, yes. But big mistakes such as disasters are usually caused by poorly designed systems.

     We sometimes design systems that cause things to go wrong. Look at the table from which slices of bread fall jelly-side down. No one deliberately designs a table with the idea of causing slices of bread to fall jelly-side down. Nonetheless, it happens anyway; and it happens entirely because of the way tables are designed.

     It’s called Normal Accident Theory because of the systems that cause accidents. As a result of these systems, accidents are “normal.”

     You’ve often heard the following remarks:

1. “The crash was caused by human error.”

2. “The space shuttle disaster was an accident waiting to happen.”

     Let’s look at the first one: “The crash was caused by human error.” Whether it’s an airliner, ship, or a nuclear power plant, “human error” doesn’t mean that a highly trained, experienced technician suddenly became careless and incompetent. It usually means that a series of things went wrong in the system, and that a human at the end of the chain made the final error of judgment.

     In the case of the Three Mile Island nuclear reactor, a technician made a faulty temperature reading regarding the fuel rods. The technician would not have made the faulty reading if the system itself had not malfunctioned before the faulty reading.

     What about the similar diagnosis, pilot error? Some years ago, a Canadian flight crew faced a perfect storm of technical problems. Canada had just switched from gallons to liters; when the flight crew requested a certain number of gallons of fuel, they received that number of liters. Thus, they were dangerously low on fuel. Gauges showing faulty readings were another. They also suffered an engine fire. There were many other problems.

     They had many critical decisions to make, but they safely landed the plane. The airlines used that flight as a model for training pilots on computerized flight simulators. Fewer than 1% of all pilots taking the simulation were able to “land” the virtual airliner. Yet, if the plane in real life had crashed, the crash would probably have been attributed to pilot error.

     That’s right. The flight crew had many critical decisions to make in a very short time. If even one of those decisions had been wrong, the pilot’s wrong decision would have been the immediate cause of the crash. That’s the true meaning of the term PILOT ERROR.

     Now let’s look at the next one: “It was an accident waiting to happen.”

     The space shuttle Columbia disaster was, in many ways, a mirror image of the Challenger disaster two decades earlier.

     Every manager has to make judgments based on expectations of risk and reward. Since no two situations are alike, risk might be wise in one circumstance, and reward might be wise in another.

     Prior to the 1980’s the National Aeronautics and Space Administration preferred to “err on the side of caution.” As a result, NASA experienced no fatalities during a mission. When NASA faced budget cuts, they felt under greater pressure to show progress in the space program. This led them to take the path of erring on the side of the mission. As a result, they tended to downplay risks that would lead to the two space shuttle disasters.

     Getting back to the subject of business and marketing, it can be said that the Enron/Arthur Andersen business alliance was an accident waiting to happen. During the 1990’s, one of the world’s most respected auditing firms—Arthur Andersen & Associates—had Enron, another highly respected business, as one of their clients.

Then Enron hired Arthur Andersen & Associates to advise them on business investments. At the time, no one seemed to see anything wrong with it. The alliance between these two highly respected companies would later be called an accident waiting to happen.

     Question: What was wrong with a system in which the firm that audited Enron also advised them on business?

     Answer: The Arthur Andersen firm was advising Enron on their investment, which gave them strong reasons for wanting to show that the investments were paying off.

     The Arthur Andersen firm was auditing Enron’s success—which means that the Andersen firm was supposed to be giving Enron’s investors honest assessments on whether their investments were paying off.

     That became a conflict of interest. When Enron began lying to their investors, Arthur Andersen & Associates used creative accounting methods to help them get away with lying.

     Executive from both companies went to prison.

     Now let’s apply Normal Accident Theory to a marketing situation.

     Some years ago, Klutz Pharmaceuticals packaged two different medicines in almost identical packages. The medical staff at Magoo General Hospital saw that this would be a problem. Doctors and nurses often have to act very quickly and don’t have the time to carefully study a package to tell which medicine is which. They came up with a system to solve the problem.

     On medicine “A,” a tag would be placed, identifying it as medicine “A.” On medicine “B” a tag would be placed, identifying it as medicine “B.” Everyone had the responsibility to do this any time he saw one of the two medicines without a label. They knew that one mistake could be very serious, so they had to be careful.

     A mistake occurred anyway, and some patients died.

     Question: What was wrong with Magoo General Hospital’s system?

     Answer: There were several things wrong with their system:

     1. No one person was given the responsibility of placing tags on the medicines. As a rule of thumb, when everybody is responsible for one task, no one is responsible.

     2. There was no particular time to place the tags on the medicines. In a hospital in which everyone is busy, “no particular time” means that it sometimes won’t get done.

     3. If person knows he may be sued, fired, or go to prison for making a mistake, he’s less likely to reveal that a mistake has been made. The mistake will not be corrected and will continue to be made by others.

     There are many more airline flights today than 50 years ago, but far fewer fatal airline accidents. At the same time, there are far more lawsuits against doctors and hospitals for malpractice.

Why?

     Hospitals and airlines take different approaches when things go wrong. Hospitals look for someone to blame and punish. Airlines look for causes that they can correct.

How to Manage Murphy’s Law:

When designing your business and marketing system,

1. Try to identify everything that can go wrong; assume worst-case scenarios.

2. Listen to your critics. Even your enemies may tell you something you need to know.

3. Design your system to prevent each error, no matter how small the error may seem. After all, disasters usually begin with little mistakes.

4. Design a backup system in case something in #2 fails.

5. Have a contingency plan in case something goes wrong anyway. Either it’s a way out, a means of minimizing damage, or another plan.

6. Look for opportunities in problems. Most opportunities look like problems anyway.

A Final Word on Murphy’s Law:

     Although many things go wrong for reasons beyond our control, you’re still responsible for paying attention in class and doing your assignments.