Friday, March 9, 2007

One question: Richard C. Cook

I heard Rick Cook, author of the new book, Challenger Revealed (Thunder's Mouth Press), speak at the Williamsburg Library last Friday. I've read and even written a little about the 1986 Challenger disaster and knew that it was caused by a failure of management as much as a failure of o-rings. But Rick lived it and lived with it for the past 20 years. Now, he has also written the definitive book, which PW called a "gripping true-life thriller" no less, on the tragedy.

Rick was NASA's lead resource analyst for the shuttle's solid rocket boosters and six months before the launch, wrote the first memo warning NASA's top management of the dangers inherent in the huge o-rings that helped seal the joints between the booster sections. In the aftermath of the disaster, he re-reported this information to NASA and the Rogers Commission. When it appeared that a cover-up was in progress, Rick took his files to the New York Times. His action paved the way for Morton Thiokol's engineers to step forward with the story of the managerial pressure to approve the ill-fated launch they experienced.

In his talk at the library (Rick grew up in Williamsburg and his mom was in the audience), Rick argued that the Challenger disaster was not an accident. He says the risks were known and preventable, that the decision to launch made by NASA's management was driven by political considerations and flew in the face of known facts. That led me to ask him: Given that internal and external 'political' pressures apply to every important organizational decision, what can executives in corporations and other organizations do to avoid making the same type of error that resulted in the deaths of the Challenger's seven crew members?"

Here is his very generous and insightful response:

This is a very good question, so I have put together the following "Sixteen Lessons from the Challenger Disaster." These would seem to apply to many organizational situations, as well as to events in the news today.

Lesson One: ASSURE ADEQUATE RESOURCES. The space shuttle was chronically underfunded, both while it was being developed and later, after it began to fly, when hardware glitches should have been repaired.

Lesson Two: DESIGN IT RIGHT IN THE FIRST PLACE. NASA knew of design flaws in the solid rocket booster joints which doomed Challenger years before the shuttle ever flew. Once a flawed design is engineered into a product, it is much more difficult to change than if it is caught early-on.

Lesson Three: DON'T OVERREACH. The shuttle was supposed to fly like a scheduled airline to serve every conceivable launch need, including scientific, military, and commercial. This resulted in design compromises and excessive launch schedule pressures.

Lesson Four: TEST, TEST, TEST. The shuttle testing program was "hardware starved." The solid rocket boosters were never tested under the full range of anticipated operating conditions.

Lesson Five: INVOLVE THE USERS. NASA concealed the severity of the problems with the O-rings in the joint seals, and the degree of concern the experts had that they could fail, from the astronauts whose lives were at stake.

Lesson Six: LISTEN TO THE EXPERTS. At various stages, engineers who warned of possible disaster were ignored, told not to put it in writing, passed by for promotion, denied adequate resource support, or overruled.

Lesson Seven: STOP AND FIX IT. NASA knew years earlier that the O-ring joint wasn't working properly, and they knew for over a year that the joint was susceptible to failure in cold weather. They had designed a repair, but planned to "fly as is" for two more years while the change was being implemented.

Lesson Eight: DON'T CUT CORNERS: Largely due to cost considerations, the shuttle never had a crew escape mechanism. The Challenger crew cabin emerged from the fireball intact, and the crew might have survived if a parachute/flotation system had been in place.

Lesson Nine: BE AWARE OF WHAT CAN GO WRONG: There are many ways a complex system can fail. Conscientious management seeks out potential problems rather than assuming, hoping, or praying that everything will work as it is supposed to. NASA had cut back on its safety system even before the shuttle was declared operational.

Lesson Ten: HAVE SOME HUMILITY. It would seem to make sense that if the leading experts say not to do something and you go ahead and do it anyway, bad things could happen. What makes you think that the laws of nature don't apply to you?

Lesson Eleven: THE REWARD SYSTEM SHOULD PROMOTE, NOT DETRACT, FROM QUALITY. NASA's authoritarian culture and a reward system that emphasized "flexibility" tended to promote those who went along with the party line, rather than the ones who raised issues and insisted on substantive answers.

Lesson Twelve: TELL THE TRUTH. Deceit about the dangers of the space shuttle ran like a thread through the history of the program and the investigations which followed the disaster. The disaster was blamed on flawed "communications," when it was often a matter of simple honesty.

Lesson Thirteen: BE ABLE TO SAY "NO." The Thiokol engineers had the courage to recommend against the launch of Challenger because the O-ring joints could fail in cold temperatures. Their managers overruled them and approved of the launch following pressure from NASA officials who themselves had been pressured. Too many people caved in.

Lesson Fourteen: VALUE HUMAN LIFE. Negligence involving human life and safety is a crime. One of the astronauts' widows said that NASA showed "shockingly sparse concerns for human life."

Lesson Fifteen: TELL THE POLITICIANS TO BACK OFF. From members of Congress who wanted to ride on the shuttle, to an acting administrator eager to please, to White House figures who wanted the shuttle in orbit in time for the president's state of the union speech, the space shuttle program was suffocated by politicians who wanted attention.

Lesson Sixteen: SAY YOU'RE SORRY. After the Challenger disaster, a multi-layered cover-up was kindled to protect the management brass and the politicians. Due to the whistleblowers, some of the details became known, but it would have been much better if those in charge had simply admitted they were wrong.

If executives, managers, and employees observe these sixteen lessons, they will have a much better chance of dealing with political pressures when crunch time comes. [Copyright 2007 by Richard C. Cook]

Richard C. Cook is the author of Challenger Revealed: An Insider's Account of How the Reagan Administration Caused the Greatest Tragedy of the Space Age, called by Publisher's Weekly, "easily the most informative and important book on the disaster." He worked in the Carter White House and NASA before spending 21 years as an analyst with the US Treasury Department. He is now a writer and consultant on public policy issues and is working on a book on economic and monetary reform. Visit his website at:

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