Born From Hubris - Learning The Lessons of NASA

When the inevitable dust of disaster settles only the sour taste of humility remains with some burning questions, who or what was to blame? Often the urge to proportion blame eclipses the real elephant in the corner, procedures are examined and training is prescribed, however, does this prevent further disasters? Albert Einstein once postulated that to repeat the same action over and over whilst expecting a different result is a sign of insanity. Procedures do not make mistakes; the humans interacting with them do. If this is true is it not then unusual this human error by reviewing, amending and adding new layers of complexity to the procedures?  

Human Factors is the relationship that connects man, machines and the surrounding environment, the balance of livewire and hardware, or more accurately the breakdown of this delicate partnership. There is no such entity more brilliant and contrived than mankind, capable of brilliance one day and complete incompetence the following. We as a race, conquer any challenge accepted - or is this my own hubris talking? 

Human Factors is much debated, discussed and indeed taught in the Aviation Industry. The product of NASA’s space programs, it has been adopted by both the Civil and Military Aviation Authorities (CAA & MAA) before spreading into other industries such as NHS, Financial Sector and Oil & Gas. It has been claimed through much credible research, over 80% of all accidents can be attributed to the human interaction with technology. History it seems gives us lessons, which, through our foggy hubris we seem unwilling to learn?

“Hubris means extreme pride or arrogance. Hubris often indicates a loss of contact with reality and an overestimation of one's own competence, accomplishments or capabilities, especially when the person exhibiting it is in a position of power.”

The most poignant sentence here is the last one, ‘especially when the person exhibiting it is in a position of power.’ There are many examples to examine this hypothesis, SS Titanic and the battlefields of the Somme from the early part of the century, Piper Alpha within the Oil & Gas Industry or maybe the National Coal Board’s (NCB) questionable leadership and management before, and after, the Aberfan landslide of 1966? Perhaps, tragic as they are, all of these disasters would suffice and hubristic leadership and attitudes were certainly present alongside systematic safety violations that had become common practice. It seems appropriate, somehow, to use an example from NASA itself.

If NASA can be described as the father of Human Factors, then Human Factors was born in the womb of hubris!

On the 28 January 1986 Space Shuttle Challenger exploded 74 seconds after launching from Kennedy Space Centre. The disaster resulted in a 32-month hiatus in the shuttle program and the formation of the Rogers Commission, a special commission appointed by the then President Ronald Reagan. The launch was beset with problems from the outset, extreme low temperatures, a punishing launch schedule, media scrutiny, which was intensified by the first ‘teacher in space’ astronaut, Christa McAuiliffe. All of the ingredients of a flawed decision making strategy were present. Ironically one of the contributing factors to the reluctance further delay the launch was that Mrs McAuiliffe was due to teach students across America from space. Had it been delayed another day there would have been no children to teach as the mission would of fallen over the weekend, astonishing with hindsight!

So where does hubris fit into this?

NASA managers had known since 1977 that there was a potential fault with the rubber O-rings which seal the Solid Rocket Boosters (SRB’s), in fact they had launched dozens of times knowing this potentially catastrophic flaw. Added to this it was also known that in colder temperatures performance of these O-rings was further reduced. The coldest recorded launch was 12 C, with a predicted temperature for the Challenger launch at -1C, even at 12C there had been extensive damage on both the primary and secondary O-ring. Should both O-rings fail there was no back up device making this a Criticality 1 Component (it is forbidden by NASA to rely on a backup system of a C1C). These SRB’s were designed and manufactured by a contractor called Morton-Thiokol, who, the night before the launch after much discussion concluded that it was absolutely not possible to launch in the predicted temperatures. However, Thiokol managers under extreme pressure from NASA overturned this decision (Morton-Thiokol were in contract negotiations to renew the SRB contract, worth an estimated $10 Billion), going against the advice from their own vastly experienced engineers. The engineers accurately predicted that extreme low temperatures would result in the SRB fragmenting gas, known as blow-by, resulting in the O-rings being unable to seal the gasses within the SRB’s and certain death for all on board with no hope of escape for the astronauts.

The engineers could not prove this prediction outright without known data, as they had never launched below 12C, thus had no data to support their claims. It was decided, by the Thiokol management (under pressure from NASA) that because previous launches had been a success, albeit with varying damage to the O-ring seal in the aft SRB’s, they should continue with no further delays.

Institutional hubris, with catastrophic consequences.

The Rogers Commission was damming in its findings, citing multiple failings from both the Management of NASA and Morton-Thiokol. President Kennedy gave NASA 30 days to act on the nine recommendations from the Rogers Commission. Unfortunately though only 17 years after Challenger the same managerial failings resulted in the Shuttle Columbia disaster, much to the dismay of those involved in the original Rogers Commission. Somehow the same level of mismanagement and blind arrogance had permutated back through the upper management of NASA. The question still remains, does hubristic attitudes and decisions take place in your work place. Evidence would suggest that usually, when disaster strikes, the person in the position of power, has to some extent, become the victim of their own hubris.

NASA may be the father of Human Factors but stills bears the petulant child of hubris firmly on the bosom of its glory (and disasters).