A recent project required the need for a case study to reinforce the message that complacency and calamity are the Ant & Dec of the HSE world, inseparable and unyielding. Regrettably our oldest friend human nature has given us many examples to pick from over the years.
The case chosen was that of STS-51-L. The final mission of the Space Shuttle Challenger.
I had seen a documentary on the telly as a teenager and had read the Wikipedia page once or twice before so I was all clued up on what happened and confident that I could wrap this one up in a half hour. Cold weather, ice on the launch pad, O-rings turning into ‘oh no’ rings, case study done. Yes? No. As one might suspect when trying to shoot people into space in metal tubes filled with rocket fuel, the truth is much more complicated.
The external pressure on Challenger was quite literally astronomical. This was to be the first time that a real person, Christa McAuliffe, a school teacher, you or me, not Action Man or Wonder Woman was to be sent into space. The whole world was watching and with each passing delay losing faith.
Temperatures the night before launch were low. So low, in fact, that they fell beneath several NASA ‘red lines’, thresholds indicating the point at which components used to seal the highly volatile fuel on board may fail. These concerns were brought to the attention of launch management by shuttle engineers but it was determined that any increased risk was manageable and a decision was made to proceed, after all, they had never failed before in over a dozen missions so they would be ok this time, wouldn’t they?
70 seconds after the launch the crew received instruction to ‘throttle up’. 73 seconds after the launch the shuttle exploded killing all 7 crew members.
The Rogers Commission Report into the disaster found the main cause to be the failure in the O-rings sealing a joint on the right solid rocket booster. This failure allowed pressurised hot gases and eventually flame to compromise the O-ring and contact the adjacent external fuel tank, causing structural failure.
GO FEVER? GO FIGURE.
You’re working on a big deal… For a big client… and you’re late. Deadlines have been pushed back and back and your entire team is getting it in the neck from all angles. From on high your superiors are cracking the whip unaware of and uninterested by the complexities of the task at hand. Your colleagues are arguing amongst themselves about the best course of action. Each deadline missed creates an even greater sense of urgency and a stronger desire for swift completion. These outside pressures quickly start eating away at your initial strategy and you begin to cut corners. You start rushing, entertaining ideas of ‘ach it’ll be ok without that’ and ‘if we leave this, we can save time, money, stress’. The product is rolled out and your fingers are crossed, they call it Go Fever.
Also known as groupthink, go fever is defined as the practice of thinking or making decisions as a group, resulting in typically unchallenged, poor quality decision making. I bet you can already think of some immediate examples from your own personal and professional life. Dipping Hula Hoops in banana yoghurt under coercion from a screaming toddler in a busy shopping centre, pretending you love that mauve and tangerine colour scheme your Mrs is dead set on for the wedding invites or keeping shtum when the big boss has a ‘brilliant idea called New Coke’. Why do we do these things? To just get things done, to avoid conflict, because you’re the new guy and you don’t want to rock the boat? All pragmatic, reasonable, path of least resistance based decisions, understandable, after all, everyone is just trying to get on with their lives. In the case of Challenger however, the emotional pressures of time and frustration resulted in an adoption of risk that was as unsafe as it was unnecessary. The goading of this risk, in turn, lead to very real and tangible pressure on a vital component part that was past it’s breaking point.
Commenting on the Space Shuttle Columbia disaster which occurred in 2003 former engineer, USAF officer and NASA Astronaut Mike Mullane - 'That was the true tragedy of Challenger. Nothing was learnt. Only janitors and cafeteria workers at NASA were blameless in the deaths of the Challenger seven. Columbia was a repeat of Challenger, where people had a known design problem and launched anyway'.
A recent BBC article highlighted a study done by the Rotterdam School of Management. The study concluded that ‘projects led by junior managers were more likely to be successful than those that had a senior boss in charge, because other employees felt far more able to voice their opinions and give critical feedback’. It is a feeling that everyone experiences at some point, especially when inexperienced in a role and you feel outranked. After all, with the enthusiastic big cheese looking over your shoulder it isn’t exactly a good look if you start poking holes in what you are all trying to achieve. The greatest challenge in health and safety culture is finding a way to negate that feeling. Health and safety isn’t and should never be emotional. Best practices, rules, standards, guidelines, limits, tolerances, ‘red lines’, and so on and so forth come under the HSE umbrella for a reason, they exist to keep you healthy and to keep you safe. It isn’t rocket science.
Feedback and criticism shouldn’t be scoffed at or tutted towards. They are both (in)valuable tools which should be wielded to construct the best possible version of what you are trying to create. Asking questions and voicing concerns must cease to be seen as negativity and instead be cultivated to covet innovation and above all else, keep people safe.
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