“Roger, go at throttle up”
Commander Dick Scobee, last transmission from Challenger
Despite all the talk of O-rings and pushing the boundaries to space, the explosion of the space shuttle that morning 30 years ago was primarily a failure of humans and not machines. By 1986, NASA knew the design of the solid rockets was faulty. They knew the O-rings were vulnerable to burn through. They had even ordered a new generation of solid rocket boosters with a different joint design. But until the new boosters came online, they’d fly the old.
The engineers at the company building the boosters, Morton-Thiokol, were deeply concerned. Their team had already documented that the O-rings stiffened in colder weather. Evidence of O-ring damage occurred in a previous launch at 52 degrees. On the morning of January 28, 1986 the thermometer plunged to a low of 29.
The night before launch, Thiokol engineers, led by Roger Boisjoly, were warning NASA; ‘Don’t do it….DON’T DO IT.’ But every previous flight went OK, so NASA eventually got Thiokol management to overrule its own engineers. The result was history.
“Success is a lousy teacher. It teaches smart people they cannot lose” – Bill Gates
The Nissan Sentra had a leaky master brake cylinder. Just a drip or two. My friend’s mechanic said no option but to replace it and do it now as it could completely fail at any time. Two hundred dollars to make it right. But he was a poor college student back then and a couple hundred bucks was a stretch. It would take a week or so to scrape up the money, but in the meantime my friend drove around as normal. After all, the brakes worked. And they did work, right up to the afternoon they didn’t. Fortunately enough he was in a near empty parking lot and only took out a light post.
The question for you is this: Was the cause of the accident the brakes failing or my friend minimizing first order issues? Did the Challenger explode due to O-rings, or because of something else?
At one time I lived down the street from a member of the National Transportation Safety Board’s GO TEAM. This elite group are always on standby for when a plane crashes down inside the United States . This particular investigator was a great systems thinker and would go on and on about the Chain Of Failure. Planes seldom crash because of ‘X’. Instead, it’s usually a part of “V-W-X-Y-Z”. In 95% of the cases, one of those links is a human being who has the information needed to change the outcome.
“Is he not clear then, the PanAm?”
KLM Flight Engineer Willem Schreuder to Captain Jacob VanZanten as their jet began takeoff down the foggy runway at Tenerife. Fourteen seconds later the KLM 4805 slammed into PanAm 1736 resulting in the single deadliest accident in history – 538 dead.
It’s far easier to engineer the Two Dimension world of parts, equipment, supplies. It’s the 3D world of people which continue to plague reliability, efficiency, and effectiveness. In other words, we must understand how to support the work of our personnel and empowering them to act upon basic first order questions which threaten the existence of the organization. This is the essence surrounding the study of human factors and it is more than just adding on another policy or institute more training.
Human Factors Failure Analysis is an intriguing field which focuses upon organizational rather than technical systems. While the majority of failures have multiple causes, the people aspect can most often be attributed to management structure and organizational culture. It certainly plagued NASA, which 17 years after Challenger would see its senior management ignore equally disastrous concerns about the space shuttle Columbia. Edward Tufte explored how first order information was buried under a series of PowerPoint bullets. The engineers understood the potential catastrophe, but could not effectively convey the seriousness of the problem to senior leaders. They overlooked it and in February 2003 we had another seven dead astronauts.
Situations such as this arise in nonprofits all the time. For the past 15 years I’ve worked as either staff or a contractor for funding agencies. Part of my expertise is to sift through nonprofits in financial distress looking for how it went wrong. Invariably, my analysis spots red flags all over the place. In the vast majority of cases, these problems were identified by someone inside the nonprofit but the issues did not get the attention needed. In one human service agency the financial reports revealed the organization had been hemorrhaging cash for 18 months. When I inquired of the finance director, she noted that all the information was in the monthly reports which went to the board, but they never acted upon it. When I inquired of a board member who was a CPA, she too noticed the shaky fiscals, but the staff did not seem too alarmed so it did not rouse her to action.
Coupling Human Factor Failure Analysis with whole enterprise evaluation is powerful when using techniques for considering the risks in most organizations. These include risks from poor communication, weak supervision, rigid hierarchies, low levels of organizational learning all of which lead to high rates of human error.
One of the best advancements in human design coming out of the airline industry is Crew Resource Management. Before CRM the Captain of an airliner had dictatorial rule over all the crew. His was the word of God. It was this overriding human element which led the captain of KLM 4805 to ignore the question from his engineer thus rolling his 747 head on into the Pan Am sitting on the runway. Since being first implemented in the aviation industry, CRM combined the various concepts known about employees in the workplace, into a training and management system for flight crews. CRM enables subordinates to challenge and overturn catastrophic inaction by their leaders. The results have been so successful that other high-risk outfits – hospitals, nuclear power plants, petroleum tankers – have undertaken CRM for their production and maintenance crews.
But these procedures are equally needed in seemingly low hazard situations in which poor decision making can wreck human lives.
Notation in margin of a 1999 memo written by Penn State VP Gary Shultz questioning a report of football coach Jerry Sandusky showering with kids in the Penn State locker rooms. Sandusky was arrested in 2011 by which time scores of other children were raped.
The molestation of young children over a decade plus at Penn State, leading to the firing of legendary football coach Joe Paterno, highlights what can happen when subordinates cannot challenge the dominate culture. As early as the late 1990s, reports were surfacing that Sandusky was being ‘inappropriate with children in his charity, The Second Mile. When one of those reports hit the desk Gary Shultz, his recommendation was to call the police. For reasons still not clearly explained, the university president Graham Spanier and/or Paterno overruled Shultz. Children paid the price.
In a world with empowered employees working in a healthy culture:
- Gary Shultz would have called the police.
- Willem Schreuder would have halted the KLM takeoff
- Roger Boisjoly would have grounded Challenger.
Their senior management and organizational culture kept them from breaking the chain. What keeps you from breaking the chain?