Managing YourSpecial 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:
An
active culture whose confirming feedback offered little resistance to
incremental deviation.
Production
pressures and scarcity of resources meant that ‘satisficing’
rather than optimizing cost, schedule and price became not only acceptable,
but quickly necessary.
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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