Managing Your
Public Risk

                       Special Edition - 28 January 2000

Lessons Learned – Challenger Launch Decision

Fourteen years ago today, seven astronauts died in NASA's worst and most public tragedy to date. Failed O-rings caused the Shuttle to explode, but many organizational causes led to it.  Unless understood, these factors could cause another loss, and not just at NASA.  Identified by Boston College sociologist Diane Vaughan in her landmark 1996 book, Challenger Launch Decision, these factors are so important to any organization with safety responsibilities, they merit a special edition of MYPR.  

Major changes in organizational roles (in NASA’s case, from bold exploration to routine shuttle flights), coupled with severe resource constraints, added a new and higher level of risk.  More disturbingly, NASA persistently misread, misinterpreted and misused available safety warnings.

Vaughan believes the tragedy was further misdiagnosed during the subsequent investigation.  “Retrospective fallacy” is the imperfect reconstruction of an event, even with the luxury of history.  Despite usually having less information than investigators, participants are expected to have figured everything out at the time.  The politics of blame, so satisfying and so natural, are also self-blinding.

People in organizations are under great pressure to get along with each other – to conform, even if it means going against their better judgment.  Rules and regulations don’t yell at you when the project is running late or over budget, but the boss probably will.  The social and rational construction of risk includes assessing the probability and consequences of being caught.  This is classic behavior of the "Mark I Human Being"  and probably exists in your organization today, in one form or another.  Also of interest, NASA normalized its corporate deviance in ways that are common to most organizations:

  1. An active culture whose confirming feedback offered little resistance to incremental deviation.

  2. Production pressures and scarcity of resources meant that ‘satisficing’ rather than optimizing cost, schedule and price became not only acceptable, but quickly necessary.

  3. Restricted information flows, organizational structures, routine transactions, timid regulators, weak, mixed and censored signals that failed to challenge assumptions. Even the adversarial Flight Readiness Review process, commendably open and candid, required actors to follow roles that were essentially scripted. Ironically, the actors read their lines largely as expected.

In another irony, NASA was organized and managed around risk – with goals and systematic, formalized, regulated and openly negotiated assessments.  Theories, the essential building block of any learning process, were broadened incorrectly to embrace disparate data.  Before every launch, NASA engineers, too often in ignorance, “snatched certainty from the jaws of uncertainty.”  The situational complexity should have raised red flags.  Risky activity should never be routine.  Challenger also showed NASA’s obsessive trust in quantitative risk was misplaced. Moreover, its scientific and rational perception of risk and how to deal with it was deeply flawed.  

What are the lessons of Challenger? We need clear, consistent, unambiguous signals from the top of the organization about the priority attached to safety.  We need an organizational environment where people are willing to step outside their largely scripted roles to ask tough questions and continually challenge accepted paradigms, data and assumptions.  We need a process that does not rely only on regulations or procedures for safety, because alone, they give a false sense of security.  This is a major challenge for any organization with public risk.   Let us learn from the mistakes of others – we don’t have the time, money, lives or public goodwill to make them all ourselves.  A good start is Chapter 10 – Lessons Learned - in Diane Vaughan’s 575-page Challenger Launch Decision.

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Before founding CADMUS in 1997, Mike Murphy spent 17 years (78-96) with Transport Canada, his last five as Regional Director General, Aviation in Winnipeg.  Originally trained as a professional pilot, he is the author of an internationally acclaimed 500-page report entitled "An Evaluation of Emergency Response Services at Airports in Canada," currently in its second revised edition (August 1999) and is undergoing a  third major revision.  He is also the Chairman of the Air Passenger Safety Group (APSG) , a Director of Transport 2000 Canada,  a Director of the Ottawa Chapter of Christian Businessmen's Committee (CBMC) and the Secretary General of the Peugeot Club of North America (PCNA).  

One of his more interesting projects while at Transport Canada was to develop a launch authorization program for a Winnipeg-based international aerospace consortium that planned to use SS-25 rockets to launch commercial payloads into low earth orbits over the North Pole from an abandoned rocket range in Churchill, Manitoba.  This would involve these former Soviet ICBMs, being repositioned on their mobile launchers to a position now only 600 nautical miles from the US border and that country's ICBM sites in North Dakota.  The SS-25s would be fired, poleward, back towards Mother Russia!   Although it was an extremely risky business, technical, legal, international and environmental situation, Murphy knew his staff could develop an effective launch authorization program and on that basis assured the client that the project would not fail due to government red tape.   It was a promise kept.  Murphy headed an interdepartmental team that provided all operational, legal, security and environmental safeguards were in place.  Transport Canada's Launch Safety Office, headed by Ms Deborah Warren, developed, from scratch, arguably the most effective and efficient launch approval processes for commercial rocket launches in the world.  Although the project was ultimately terminated after five years, it died for business and not for regulatory reasons.

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