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Saturday, January 30, 2016

Institutional Failure


30 years ago, the Space Shuttle Challenger broke apart 73 seconds into the flight. 


In true governmental fashion, committees were formed along with an additional government agency to oversee safety. However, the immediate response was a frenzied search for a scapegoat.


Six months before the disaster, several Morton Thiokol engineers warned their superiors about a known issue. In cold weather, flexible O-rings became ridged and would not maintain a seal. 


On the morning before the Challenger launch, Roger Boisjoly and Bob Ebeling desperately tried to stop it. The NASA representative refused. "I am appalled by your recommendation. My God, Thiokol, when do you want me to launch — next April?" Both the agency and manufacturer ordered employees to not speak with reporters. 


That night, Ebeling told his wife, Darlene, "It's going to blow up."


To increase interest in the space program, the NASA crew included a first ever civilian astronaut. Christa McAuliffe, a high school schoolteacher, was chosen out of 11,000 applicants to participate in the flight and schools across the country tuned in to watch a teacher go into space. 


After the catastrophe, the engineers were called to participate in the presidential commission evaluating the situation. They became increasingly ostracized at work and eventually resigned. “NASA was trying to discredit us. The company was treating us like black sheep. It got to be very personal, very uncomfortable.” 


The commission found fault with the management at both Morton Thiokol and NASA and an organizational restructuring for NASA was recommended  


Estimates of reliability offered by NASA management were wildly unrealistic, differing as much as a thousandfold from the estimates of working engineers. For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.
- Richard Feynman, theoretical physicist, appointed to assist the Rogers Commission


Failures in communication ... resulted in a decision to launch 51-L based on incomplete and sometimes misleading information, a conflict between engineering data and management judgments, and a NASA management structure that permitted internal flight safety problems to bypass key Shuttle managers.
— Rogers Commission Report


The congressional committee disagreed.


The underlying problem which led to the Challenger accident was not poor communication or underlying procedures as implied by the Rogers Commission conclusion. Rather, the fundamental problem was poor technical decision-making over a period of several years by top NASA and contractor personnel, who failed to act decisively to solve the increasingly serious anomalies in the Solid Rocket Booster joints.
- U.S. House Committee hearings


Thiokol forfeited a $10 million incentive fee without admitting liability. The organizational restructuring at NASA was largely superficial.


17 years after Challenger, the Space Shuttle Columbia disintegrated over Texas. A piece of foam insulation broke off from the external tank and struck the left wing of the shuttle. 

NASA limited the investigation, reasoning that the crew could not have fixed the problem if it had been confirmed. However, the resulting commission concluded, "The institutional failure responsible for Challenger have not been fixed."


Don't despair, last year Ted Cruz (yes, that Ted Cruz) became chairman of the Subcommittee on Space, Science, and Competitiveness which oversees NASA.


For three decades, Boisjoly traveling to engineering schools around the world discussing ethical decision-making. "What I'm afraid of is that some young engineers will see what happened to me and think it isn't worth it to speak out, to take a stand." 


After his death in 2012, his family remembered him, "He always stood by his work. He lived an honorable and ethical life and he was at peace when he died."


Bob Ebeling, now 89, was interviewed by NPR earlier this month. For 30 years, he has had difficulty with extreme guilt and serious depression. "I think that was one of the mistakes that God made. He shouldn't have picked me for the job. But next time I talk to him, I'm gonna ask him, 'Why me. You picked a loser.' "


The interviewer reminded Ebeling about his fellow engineer. Boisioly was devastated by the disaster but believed they had done everything they could do. "We were talking to the people who had the power to stop that launch." "We did our level best" 


Ebeling, tearful and upset considered. "Maybe Roger's right."

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