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| The Challenger Shuttle Disaster 1986 |
When
I was growing up my friend lived an old fashioned cottage, the entrance to his
cottage was particularly low and in my opinion ergonomically poorly designed. Every
time, without exception, when leaving his cottage I would bang my head on the
oak beam above the door. My pal would always laugh and ask me “will you ever
remember the door frame?” – “obviously not” would be my predicable sarcastic
retort.
Sometimes
we have painful lessons, which enable us to draw the necessary knowledge to
move forward and develop, personally or professionally. Occasionally though we are met with such a
painful lesson that the learning is etched into the minds of those present.
NASA felt this pain with the Challenger disaster in 1986 and the Oil & Gas
industry with Piper Alpha in 1988, painful lessons that could not be forgotten
easily – but they were forgotten though? When the Columbia Shuttle broke up 16
minutes before landing in February 2003 the ensuing report was highly critical
that NASA did not learn from the Rogers Commission, set up in the aftermath of
the Challenger disaster. NASA’s disregard for the safety of its Astronauts
brought particular criticism, especially once the Commission discovered that
NASA had known about the fatal flaw in the rubber O ring seal for the Solid
Rocket Boosters (SRB) since 1977. Many mistakes were made and many promises
were undertaken to ensure space exploration was as safe as viably possible. In the aftermath of Challenger, the Rogers
Commission made specific recommendations to NASA surrounding the governance and
management of the space program. In 1996 only 10 years after Challenger NASA
returned to old practices to save money much to the dismay of the head of Space
Shuttle Program at NASA, Brian O’Connor, who argued at the time:
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| Columbia Crew 2003 |
“Its
is a safety issue, we’ve ran it this way (with the program management at HQ, as
recommended by the Rogers Commission) for 10 years without a mishap and I don’t
see any reason why we should go back to the way we operated in the
pre-Challenger days.”
O’Connor’s
concerns fell onto deaf ears and NASA chose to ignore his outspoken opinion, he
felt this left him no other choice than to resign from NASA. Although both
accidents are unique from a physical perspective, they are eerily close in
managerial errors; this did not go unnoticed by the Columbia Accident
Commission which was highly critical of the middle management hubris of NASA. In
both examples a fatal flaw to both Shuttles, which was known by NASA, became
watered down and a culture of acceptance of risk overtook the desired culture
of safety first – without compromise.
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| Challenger Crew 1986 |
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| Deep Water Horizon 2010 |
It
seems that this short term memory is not uniquely preserved for NASA, the Oil
& Gas industry have a similar example with Piper Alpha in 1988, and the
Deep Water Horizon (Macondo blow out) in 2010. Once again although the physical
elements of the disaster have their uniqueness, the human factors bear similar
resemblances – specifically with regards to the acceptance of risk in the presence of profit, although NASA's problems lay in the opposite end of the spectrum - maintaining the output with less financial resources. It is this desensitisation of this
risk acceptance, which runs through all 4 examples, in all cases the associated
issues that contributed to the final event, became acceptable.
Can
an organisation fully commit to a safety first culture while management
decisions clearly reflect a profit first mind-set?
What
signal, be at the conscious level, or unconscious level, is sent by organisations to the work force?
My
honest belief is no to the first question and the wrong one to the second, and
so is Lord Cullen’s who led the enquiry into the Piper Alpha disaster.
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| Piper Alpha 1988 |
The
similarities between these 4 catastrophes are striking from a Human Factors
perspective. Effective decision making in the aftermath of both Challenger and
Piper Alpha were criticised by the respective enquiries, however, it only took
17 years for NASA and 22 years for the Oil & Gas Industry to forget some of
the vital lessons learned.
Once
again the lessons taken from Columbia and Macondo are raw to those working
within these risk related industries. In the immediate aftermath of such events
motivation is at it’s most intense to ‘turn the corner and improve safety’. The
pain of loss can be viewed as a metaphor for ‘the stick’ in motivation; this
represents an organisational ‘away from’ motivational preference. It represents
a motivational system which is at it’s most intense after the event - however
there is another way to approach safety?
The
‘carrot’ which represents a ‘towards’ motivational preference encompasses an organisation
continually moving towards a complete safety culture. Each day, week after
week, the organisation works towards a common vision communicated throughout the
workforce and embodied by the management.
This avoids the spike in activity, which inevitably follows a
significant accident, more over acts as bow wave of activity continually
evolving with relentless energy and without pause.
My
stick typed lesson when banging my head on my friends door frame eventually
became embedded, there was only so many times I seemed prepared to endure the
pain associated with my clumsiness. My hope in the future is NASA and other
risk related industries do not require persistent 20-year ‘bumps’ on the head.
