87. Systematic regulatory failure

A global catastrophe, or any technogenic failure, may not be a result of any one fatal error, but the culmination of ten insignificant errors. Due to limitations in space and knowledge, for it is necessary to avoid too many regulations or instructions on trifles. Yet, small things—a smoldering cigarette butt, an open tank porthole, an improper start-up procedure, a restart returning a system to default settings—all these things can set the stage for a disaster. In disasters, there is rarely one “main thing” that causes critical failure, but a series of things. Running a system “by the book,” may not help, because the book may not have an entry for the mistake you have made.