“For want of a nail, the shoe was lost; For want of the shoe, the horse was lost, For want of the horse, the rider was lost, For want of the rider, the battle was lost, For want of the battle, the kingdom was lost, And all from the want of a horseshoe nail…”
This parable, known of by most, yet followed by too few – who tend to achieve success in their endeavors – has its origins in many cultures going back several centuries. The primary idea is that a minor overlooked detail – or several – can lead to unanticipated, sometimes tragic outcomes. Variations on this theme have been referred to as “The Camel’s nose” (under the tent), “A stitch in time saves nine”, and “A little neglect may breed mischief.”
The thing about small details, is that if they are noticed and acted upon in time, they may contradict a developing narrative so that nothing untoward takes place. In other words, a successful outcome. If not, the significance of each deficit builds until they collectively reach contagion, wherein a tragedy becomes all but guaranteed. Unfortunately by definition, such a chain of causality cannot be seen until much later.
“Overlooked small details.”
Look no further than the 1986 Space Shuttle Challenger disaster which took the lives of 7 astronauts, and set back the program by almost three years. Initial “small details” like an unusually cold temperature at the launch site, along with the fact that O-ring seals used in the joint were not designed to handle the temperature, began the process toward irreversible systemic failure.
Then, as chronicled in Wikipedia, “The seals’ failure caused a breach in the SRB joint, allowing pressurized burning gas from within the solid rocket motor to reach the outside and impinge upon the adjacent SRB aft field joint attachment hardware and external fuel tank. This led to the separation of the right-hand SRB’s aft field joint attachment and the structural failure of the external tank. Aerodynamic forces broke up the orbiter.”
Additionally, governmental investigative findings indicated the O-ring issue had been known about for a number of years, but neither the company producing them nor the administrative body at NASA had seen fit to rectify the situation ahead of time.
All projects are likely to contain one or more “overlooked details”. The key lies in recognizing them during the process – ideally correcting them soon after discovery, during evolution of the prior-to-launch production cycle.
“Small” has a way of becoming “Large”
If one overlooked detail combines with another, a potentially much larger issue can arise. At some point, the “minor” O-ring situation became the issue, which first facilitated, then allowed the internally-pressurized burning gas to leach through into the fuel tank, creating an explosion. In hindsight, what may not have been apparent at the time, now tends to look quite obvious.
Tenerife -“…a chain of improbable errors and failures, together with a stroke or two of really bad luck.”
As recounted a year ago in the Travel section of The Telegraph, an incident in 1977 when two Boeing 747’s collided on a foggy runway in West Africa’s Canary Islands at Tenerife, remains to this day the deadliest commercial air disaster in history.
A Pan Am and a KLM 747 (among others) are diverted to a smaller less capable airport after a bomb explodes in a flower shop at the primary set-down airfield; one 747 takes on extra fuel at the last minute, delaying takeoff for both until fog has shrouded the runway; each plane taxis on the runway at the same time, invisible to each other and to the control tower (which has no ground tracking radar); one misses its assigned turnoff, placing both facing each other; overlapping radio signals cause “route clearance” to be read as “take off clearance”; The KLM attempted take-off fails as it slices off the Pan Am 747’s top and craters along the runway, killing all 234 aboard, plus killing 326 of 380 passengers on the Pan Am flight. Improbable errors and failures, along with a stroke of really bad luck, costing 583 lives…
Sometimes common sense can anticipate “small details” that, if not dealt with could lead to systemic failure. As in Social Security. As in Medicare. As in Student loans. As in subprime auto loans.
Social Security reportedly has $3 trillion in assets, yet pays out $1 trillion yearly. In 1940, 160 contributing workers supported 1 retiree; in 1960, 5; in 1990, 3.4; in 2013, 2.8. Has this trend been obvious for awhile? The solution? Tax increases and currency debasement.
Truly, the devil is in the details!
And some people wonder why there is an increasing groundswell – around the globe – for a return to what for four millennia has been sound, honest money – the peoples’ money…silver. Only now, digitalized on the blockchain. Cryptographic silver, redeemable on demand for real physical silver – anywhere in the world. A Project on the way which is paying attention to details, both large and small. Stay tuned…