Price of poor instructions: the Cutter case

[Stuart Burnfield]

People sometimes ask on the list for examples of inadequate technical
instructions that led to loss or harm.

   "Development of the vaccines that eradicated polio from most of the
   Western world was funded mainly by the March of Dimes. That charitable
   foundation also oversaw the first field trials establishing the safety
   and efficacy of Jonas Salk’s vaccine. It then handed the project to the
   government, which licensed five private companies to produce the
   vaccine. Although the government prescribed exactly how it was to be
   manufactured, the instructions were not quite the same as those the
   foundation had promulgated prior to the first trial. The Cutter Company,
   the smallest of the five licensees, followed the government’s
   instructions to the letter, but failed to kill all the virus in the
   vaccine. Seventy thousand people suffered mild forms of polio. Two
   hundred were paralyzed. Ten died."

   http://www.commentarymagazine.com/article.asp?aid=12201023_1

I hadn't heard of this case till I read this article.

Stuart