From the Rogers Commission to reading Dr. Diane Vaughn’s book The Challenger Launch Decision took me 17 years.
For all those years I had learned the wrong lesson about the loss of Challenger. The sound-bite explanation kept me in ignorance. You know, that a rogue manager for venal motives suppressed the concerns of good engineers and true when they tried to stop the launch.
As Dr. Vaughn more correctly analyzed the decision “It can truly be said that the Challenger launch decision was a rule-based decision. It was not amorally calculating managers violating rules that were responsible for the tragedy. It was conformity.”
The sound-bite explanation was satisfying, easy to live with, and wrong. It failed to ask the more penetrating questions. But even more importantly, it failed to spur specific action. Just feeling anger at a bad decision or sadness at the loss is diffuse and unmotivating. It is imperative that we learn the proper lessons from history and use those to inculcate specific actions and behaviors that will result in safety for our people — and success for our missions.
So, ten years after Columbia, what are the lessons we should have learned and should practice every day? Here are my thoughts especially for those who work in dangerous and risky endeavor
1. It can happen to you.
Just because you are younger or smarter and read history lessons, don’t think that you won’t make mistakes and that events can’t get away from you. Nobody is smart enough to avoid all problems. That sliver of fear, the knowledge that the universe is out there waiting for the least lapse in attention to bite, is motivation that just might help you avoid catastrophe. Or perhaps not. Let’s hope that Dr. Perrow was wrong and that accidents in complex systems are not simply ‘normal’. Better yet let us all work to prove him wrong. The first principle of a successful high reliability organization is to be “preoccupied with failure.” Do that.
2. Focus.
“To always be aware that suddenly and unexpectedly we may find ourselves in a role where our performance has ultimate consequences” Or even better: “Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity, or neglect. “— Captain A. G. Lamplugh, RAF. Life happens, distractions mount. The probability is that only one critical decision will come to you in your career. It will come on a day when you least expect it, when you are most distracted. The organization will fill your time with busy work and bureaucracy. Keep focused on the important issues.
3. Speak up.
Better to ask a foolish question than to allow a mistake to be made. What is the worst that could happen to you? Lose your job? Lose the respect of your peers? Miss out on a promotion? Letting a mistake go unchallenged has other consequences: funerals, program shutdown, and life-long regret. Make your choice wisely — speak up rather than remain silent. If the organization can’t stand that, it’s the organization that needs to change.
4. You are not nearly as smart as you think you are.
Remember your mother’s teaching: “God gave you one mouth and two ears so that you should listen twice as much as you talk.” Defer to expertise rather than leaders. Check your ego at the door. Too many people are so busy passing out their point of view that they fail to hear the warnings that are coming at them. Listening is not enough; comprehending and acting are also required.
5. Dissention has tremendous value.
“If we are all in agreement on the decision — then I propose we postpone further discussion of this matter until our next meeting to give ourselves time to develop disagreement and perhaps gain some understanding of what the decision is all about.” — Charles E. Wilson (GM CEO circa 1950). If you don’t have dissention, then you haven’t examined the problem closely enough. If there is not a natural troublemaker in your group, appoint a devil’s advocate. Make sure the ‘devil’ is smart and articulate – just like the namesake. Draw people out; make them participate; don’t let them get away with silence.
6. Question Conventional Wisdom
“People in groups tend to agree on courses of action which, as individuals, they know are stupid.” We were told that flying in the space shuttle was just as safe as flying in a commercial airliner, so we denied the crew parachutes and pressure suits. Patently and obviously wrong to the most casual observer, such a belief can only be called stupid. We were told the shuttle was a mature flying vehicle with few surprises left. We believed it even though the truth was right in front of our eyes. This is, and always will be, risky business. Challenge conventional wisdom at every chance, look past it for the truth.
7. Do good work.
People thought Gus Grissom was inarticulate. I think he got to the crux, the nub, and said it very simply and perfectly: Do good work. There is no room for half hearted efforts or second best. Do it well or don’t do it at all. Don’t cut corners and don’t let your so-called leaders try to bully you into doing less than the best. Don’t accept excuses from others, either.
8. Engineering is done with numbers
Dr. David Aikin’s Laws are true: “Engineering is done with numbers. Analysis without numbers is only an opinion. Not having all the information you need is never a satisfactory excuse for not starting the analysis. Space is a completely unforgiving environment. If you screw up the engineering, somebody will die (and there’s no partial credit because most of the analysis was right).” Remember the motto of the Mission Evaluation Room: “In God We Trust, All Others Bring Data.” Don’t be persuaded with arm-waving or specious arguments lacking foundation in first principles.
9. Use your imagination
Frank Borman said that the Apollo 1 fire was the result of a failure of imagination. They just couldn’t imagine that a ground test could be hazardous. Keep your eyes fresh and your imagination active so that you can see the possibilities — good and bad — and work accordingly.
10. Nothing worthwhile was accomplished without taking risk.
“Where do we get such men?” — James Michener, The Bridges at Toko-Ri No, it is not black and white. At some point you have to leap off into the unknown without knowing everything that you should. Just because we are afraid, or focused on the possibility of failure, we cannot be paralyzed into inaction. These endeavors are not for the faint of heart.
And spend some days in wonder: where do we get such people? People who put everything on the line for the cause. We are fortunate to be in their presence. Make their risk as small as you can, then go forward. “They did not think their sacrifice a vain or empty one, and we will not debate their profound wisdom at these proceedings.” — David Buchner
As I get older, the world seems more and more inhabited with ghosts from the past; people places and things that no longer exist. Relatives that have passed, buildings that have been demolished, machines that have been scrapped; all of these are alive and new in memory. After the age of 50, this process seems to accelerate with frightening speed. And without passing the lessons and memories on to the next generations, important lessons will inevitably be lost. And mistakes will be repeated. Don’t let that happen.
Be sure to take solemn pride in the accomplishments. Don’t forget those either.
Originally posted Jan. 31, 2013 on Wayne Hale’s Blog. Used with Permission
