Root causes, lessons learned and pizza
2018-08-02
Safety and Mission Assurance (SMA) hosts a co-op and intern (co-tern) movie night
On July 31, nearly a hundred NASA Johnson Space Center team members, co-terns, SMA facilitators and other guests gathered over pizza to watch and discuss documentaries about the Challenger and Columbia space shuttle disasters. Most of the attendees included this summer semester’s class of co-terns. While many came to the session with background knowledge about the two most well-known mishaps in NASA history, everyone committed their evening to delving more into the root causes, lessons learned and key takeaways from the two tragic events.
Acting Associate Center Director Mike Hess opened the event with an introduction of James Reason’s “Swiss cheese” model of accident causation.
“Being from Wisconsin, this model really appeals to me,” Hess joked.
All kidding aside, the model depicts four hazards as holes in Swiss cheese: management deficiencies, inadequate controls, physical failures and unsafe acts. An accident happens when all of the holes in the cheese align just right.
Nigel Packham, associate director of SMA, facilitated the rest of the event by introducing both documentaries and leading group discussions on each.
The Challenger disaster was caused when a pressure seal—called the O-ring—failed due to cold weather, and burning gas from the solid rocket booster ignited the external fuel tank. Although multiple engineers, such as Arnold Thompson, Bob Lund and Roger Boisjoly, warned against launching when temperatures were under 53 degrees Fahrenheit, management proceeded with the launch in 22-degree weather.
“Roger Boisjoly is the one that is almost always quoted,” Packham said. “But there were four other engineers who had the same opinion. It’s exactly the same way today. You might find one person who is willing to come forward today with a problem, but there will be 10 to 15 people who share the same opinion, [but are] unwilling to voice it.”
The co-terns audibly gasped when Packham described two- to three-foot-long icicles hanging off the launch pad on the morning of Jan. 28, 1986.
“Those five dissenting engineers were given a nickname—they were called ‘the lepers,’” Packham said. “What a name to give a bunch of engineers who really believed that it was wrong to launch.”
The Columbia disaster occurred almost exactly 17 years later on Feb. 1, 2003, when a piece of insulating foam broke off the external tank and struck the wing of the orbiter during launch. The resulting hole in the wing proved fatal for the crew during re-entry.
“These people were all my friends,” Packham said. “It was a much more personal loss.”
There was a possibility for either rescue or repair, but management decided against investigating the foam loss when it was noticed during launch. Foam loss had been present during other shuttle launches, and so it was considered “in-family.”
“Anyone who works for me, who uses the term ‘in-family,’ won’t be working for me for very long,” Packham said. “When people say it’s ‘in-family,’ I ask, ‘How big is your family?’ For 99.5 percent accurate results, how many samples do you need? A million plus?”
After the documentary viewing, the audience broke up into smaller groups facilitated by SMA professionals and special guest Julie Kramer-White, deputy director of Engineering, to discuss ways to prevent future accidents. A common observation was the amazing similarities between the hazards that led to both Challenger and Columbia.
“We are almost as far now from Columbia as they were from Challenger,” said Amy Quartaro, an Engineering co-tern for ES5. “We are coming up on the same timeframe. It’s important to think about these key takeaways, especially now.”
Many other co-terns stressed the importance of welcoming new information, encouraging dissenting opinions and educating the community about the dangers of “normalizing deviance.”
“Not all engineers are aware of the psychological tendencies like groupthink or bias,” said Antonio Diaz, a co-tern from EC3. “Maybe if they were more aware, it would help prevent future accidents.”
To close the session, Packham walked through various safeguards that have been implemented since the two disasters, such as: the Independent Technical Authority, the NASA Safety Reporting System and the Dissenting Opinion process.
He also recommended that anyone who has not yet read the Columbia Accident Investigation Board Report, which is available here, and shared the information contained in the Significant Incidents and Close Calls in Human Spaceflight.
Although the material was sobering, all of the audience members walked away with a determination to do their part to prevent future mishaps. Many co-terns expressed the value of hosting more movie nights and group discussions to keep the lessons fresh.
Dillyn Mumme, a co-tern from CO, also announced the recent creation of the Co-tern Safety Initiative lecture series, which will be hosting their first event this week.
A panorama view of the co-terns enjoying a lively movie night discussion about root causes and lessons learned. Image courtesy of Cody Bryant.
Thalia Patrinos
NASA Johnson Space Center
On July 31, nearly a hundred NASA Johnson Space Center team members, co-terns, SMA facilitators and other guests gathered over pizza to watch and discuss documentaries about the Challenger and Columbia space shuttle disasters. Most of the attendees included this summer semester’s class of co-terns. While many came to the session with background knowledge about the two most well-known mishaps in NASA history, everyone committed their evening to delving more into the root causes, lessons learned and key takeaways from the two tragic events.
Acting Associate Center Director Mike Hess opened the event with an introduction of James Reason’s “Swiss cheese” model of accident causation.
“Being from Wisconsin, this model really appeals to me,” Hess joked.
All kidding aside, the model depicts four hazards as holes in Swiss cheese: management deficiencies, inadequate controls, physical failures and unsafe acts. An accident happens when all of the holes in the cheese align just right.
Nigel Packham, associate director of SMA, facilitated the rest of the event by introducing both documentaries and leading group discussions on each.
The Challenger disaster was caused when a pressure seal—called the O-ring—failed due to cold weather, and burning gas from the solid rocket booster ignited the external fuel tank. Although multiple engineers, such as Arnold Thompson, Bob Lund and Roger Boisjoly, warned against launching when temperatures were under 53 degrees Fahrenheit, management proceeded with the launch in 22-degree weather.
“Roger Boisjoly is the one that is almost always quoted,” Packham said. “But there were four other engineers who had the same opinion. It’s exactly the same way today. You might find one person who is willing to come forward today with a problem, but there will be 10 to 15 people who share the same opinion, [but are] unwilling to voice it.”
The co-terns audibly gasped when Packham described two- to three-foot-long icicles hanging off the launch pad on the morning of Jan. 28, 1986.
“Those five dissenting engineers were given a nickname—they were called ‘the lepers,’” Packham said. “What a name to give a bunch of engineers who really believed that it was wrong to launch.”
The Columbia disaster occurred almost exactly 17 years later on Feb. 1, 2003, when a piece of insulating foam broke off the external tank and struck the wing of the orbiter during launch. The resulting hole in the wing proved fatal for the crew during re-entry.
“These people were all my friends,” Packham said. “It was a much more personal loss.”
There was a possibility for either rescue or repair, but management decided against investigating the foam loss when it was noticed during launch. Foam loss had been present during other shuttle launches, and so it was considered “in-family.”
“Anyone who works for me, who uses the term ‘in-family,’ won’t be working for me for very long,” Packham said. “When people say it’s ‘in-family,’ I ask, ‘How big is your family?’ For 99.5 percent accurate results, how many samples do you need? A million plus?”
After the documentary viewing, the audience broke up into smaller groups facilitated by SMA professionals and special guest Julie Kramer-White, deputy director of Engineering, to discuss ways to prevent future accidents. A common observation was the amazing similarities between the hazards that led to both Challenger and Columbia.
“We are almost as far now from Columbia as they were from Challenger,” said Amy Quartaro, an Engineering co-tern for ES5. “We are coming up on the same timeframe. It’s important to think about these key takeaways, especially now.”
Many other co-terns stressed the importance of welcoming new information, encouraging dissenting opinions and educating the community about the dangers of “normalizing deviance.”
“Not all engineers are aware of the psychological tendencies like groupthink or bias,” said Antonio Diaz, a co-tern from EC3. “Maybe if they were more aware, it would help prevent future accidents.”
To close the session, Packham walked through various safeguards that have been implemented since the two disasters, such as: the Independent Technical Authority, the NASA Safety Reporting System and the Dissenting Opinion process.
He also recommended that anyone who has not yet read the Columbia Accident Investigation Board Report, which is available here, and shared the information contained in the Significant Incidents and Close Calls in Human Spaceflight.
Although the material was sobering, all of the audience members walked away with a determination to do their part to prevent future mishaps. Many co-terns expressed the value of hosting more movie nights and group discussions to keep the lessons fresh.
Dillyn Mumme, a co-tern from CO, also announced the recent creation of the Co-tern Safety Initiative lecture series, which will be hosting their first event this week.
A panorama view of the co-terns enjoying a lively movie night discussion about root causes and lessons learned. Image courtesy of Cody Bryant.
Thalia Patrinos
NASA Johnson Space Center
Safety and Mission Assurance organized the movie night, which focused on learning from the Challenger and Columbia accidents. Image courtesy of Thalia Patrinos.
Roundtable discussion focused on how attendees could do their part to prevent future mishaps and safeguard crews. Image courtesy of Thalia Patrinos.