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iliana
@iliana

At 9:54 a.m. Pacific Standard Time, the operator finished pouring the hot water over the coffee grounds, placed the kettle back in its base, and left the pour to set. The operator then immediately began the "bagel section" of the operation, involving a wide-slot kitchen toaster, commonly used in the industry.

The toaster featured three inputs: Defrost, Bagel, Reheat, and a darkness selector. The darkness selector was a radially-adjusted knob that rotated over a 270-degree circle, with various points along the circle labeled 1 through 7. The knob was symmetrical in shape, and thus could inadvertently confuse an operator about the position of the knob; the manufacturer chose to include a white indicator dot on the chromed plastic to allow the operator to see the position of the darkness selector.

On the morning of the incident, light reflected on the chromed plastic of the darkness selector, making it more difficult to see the true setting of the darkness selector. In fact, the operator believed the darkness selector was set for its lowest possible setting based on its position. However, the darkness selector was set a bit higher than "4", a position 180 degrees opposite from the lowest setting. When the operator adjusted the knob to set it between "2" and "3", as per written procedure, they in fact set the knob to between "6" and "7", close to the highest possible darkness setting. The operator reported after the incident that they did not know the knob had started in an already-dangerous position prior to starting the bagel section of the operation.


 
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