Challenger Disaster: For Lack of an Effective Meeting?
Like many of you, I know where I was at the moment I first learned of the Challenger Space Shuttle disaster 25 years ago. It was a terrible, unexpected tragedy. In our shock we wondered how could this have happened? As subsequent research showed, it was avoidable. The risk of a failure in a key part (the now infamous O-rings) had been observed in previous flights under various conditions. It was possible that the engineers and managers involved in the launch decision could have used this information to arrive at a different, wiser decision. While they met on the night before the launch, the risk was not adequately considered and we know the result. Could it have been otherwise?
The meeting held on the night of January 27 has been well documented (see particularly The Challenger Launch Decision.) There was a teleconference between NASA, Kennedy, Johnson and Marshall Space Centers and contractor Morton Thiokol. It was the engineers from Morton Thiokol who would make the recommendation of whether it was safe to launch based on the risk of O-Ring failure at the predicted, unusually cold temperatures (27F) predicted for the next morning at Kennedy Space Center. There were 37 people on the call with a variety of hastily prepared and faxed charts for reference, some hand written, presenting various performance data.
People sat around the phones with respect to hierarchy, with those sometimes having information but not authority whispering their views to their superiors. Only more senior people actually spoke on the call. As one participant later reported, “I saw that John McCarty, my deputy laboratory boss was there, and since he would be the guy that I would support, he would be the voice. I went and sat right next to him so I could work with him.”
During the call, an apparent discrepancy in the data was noted as various people studied the charts. But Thiokol senior management concluded that on the basis of the engineering projections, they could not recommend launching at any temperature below 53F. This conclusion was challenged and the whole question of whether anyone, specifically Thiokol, had set criteria for safely committing to a launch. It was unusual for a contractor to make a no-launch recommendation and this took managers from Marshall Space Flight Center by surprise. It was clear to all that Thiokol had a weak argument based on the data presented. As Thiokol’s Jack Kapp said later, “Engineering, I think, was generally aware that a great deal of our recommendation and our supporting data was subjective and kind of qualitative, but nonetheless it was there, and the engineering judgment was there.”
Thiokol asks for a private conference and mutes the telephone. A senior Thiokol vice president, states that “we have to make a management decision. “ The engineers presented their views once again, but the final decision was made by the four senior managers present with one reluctant manager told to “take off his engineering hat and put on his management hat.” All four Thiokol managers then voted to go against their initial engineering decision and agree to the launch.
Once the teleconference resumed, Thiokol announced that they had reconsidered and now recommended a launch. Participants at Marshall and Kennedy centers, having not heard what happened during the off-line (muted) discussion at Thiokol, were unaware that anyone at Thiokol had still objected to the launch recommendation. And as the Thiokol engineer who advocated against launch said later, ”I left the room feeling badly defeated, but I felt I really did all that I could to stop the launch.”
One “side” lost the debate. One critical perspective (engineering) was not heard by all. A wiser decision considering other options (e.g., a launch later in the day) was available, but was precluded by a concern for making the right management decision. It is not that the management decision was wrong, any more than the engineers’ recommendation was right. Both views needed to be heard and balanced. But the hierarchy and organizational divisions did not allow for this. A better design for this meeting and particularly for how decisions were made across this group could have improved the wisdom of their decisions and possibly averted the Challenge disaster.
Elsewhere in the blog we have discussed the complex, systemic issues that contribute to safety (see Improving Safety by Taking More Risks), and how more effective meetings are essential to improving performance in chemical manufacturing, highway contracts, and, perhaps, future deep water oil well drilling (see Improving Safety, Quality and Productivity Together, and Bring Lawyers, Guns and Money, the Oil Has Hit the Sand: Avoiding Deep Water Oil Well Disasters). I believe a different kind of communication and decision-making among all the stakeholders in complex project decisions is possible and essential. Unfortunately, the lessons of the Challenger decision were not learned in time to avoid a similar decision situation where a wiser decision could have been made, but wasn’t, and the space shuttle Columbia and its crew were lost.
(For detailed information on the meeting summarized here, see The Challenger Launch Decision by Diane Vaughan, University of Chicago Press, 1996, from which is the source for all quotes.)