A DC-9 flown by ValuJet crashed in the Everglades on May 11, 1996, and resulted in the loss of life of all five crew members and all 105 passengers. Almost two years later, writer and pilot Bill Langewiesche wrote a highly intriguing article building on the work of sociologist Charles Perrow.
Toward the end of the article, Langewiesche draws his long knives:
The Lessons of ValuJet 592, the Atlantic, William Langewiesche, March 1998.
http://www.theatlantic.com/magazine/archive/1998/03/the-lessons-of-valujet-592/306534/
' . . . Flight 592 had been loaded with a potentially dangerous cargo of chemical oxygen generators . . . '
' . . . They inhabited a world of boss men and sudden firings . . . '
' . . . replacing oxygen generators . . . '
' . . "expired" . . '
' . . "expended," . . '
' . . . The two unfortunate mechanics who signed off on the nonexistent safety caps just happened to be the slowest to slip away when the supervisors needed signatures. . . '
Toward the end of the article, Langewiesche draws his long knives:
So, what if the theory of system accident had been better understood at the time of Enron (2001) and WorldCom (2002)?' . . . the creation of an entire pretend reality that includes unworkable chains of command, unlearnable training programs, unreadable manuals, and the fiction of regulations, checks, and controls. Such pretend realities extend even into the most self-consciously progressive large organizations, with their attempts to formalize informality, to deregulate the workplace, to share profits and responsibilities, to respect the integrity and initiative of the individual. The systems work in principle, and usually in practice as well, but the two may have little to do with each other. Paperwork floats free of the ground and obscures the murky workplaces where, in the confusion of real life, system accidents are born. . . '