A challenge to you
by
The National Aeronautics and Space Administration is one of the most emulated organizations in the world. And for good reason. NASA means quality and innovation. Its employees have "the right stuff." Its best practices and training programs are the standard for corporations in any industry.
That said, it's no surprise that retired astronaut Mike Mullane recently told a crowd of 500 Society of Maintenance & Reliability Professionals members to learn from NASA. However, his keynote address at SMRP's conference in Denver stressed learning from the unhealthy actions and behaviors present in NASA in the early 1980s, which culminated in the destruction of the Space Shuttle Challenger on Jan. 28, 1986.
"Challenger wasn't an accident," says Mullane, who flew on three shuttle missions in the late 1980s. "An accident is an unforeseen act."
History links the catastrophe to failed O-rings in the right-hand solid rocket booster. Mullane prefers to go deeper, tying it to a breakdown in teamwork.
"What kind of team do you have, and what kind do you want?" says Mullane. "When my life is on the line, I want a team that's trained. I want a team that communicates. I want a team that practices ownership and responsibility, and understands the accountability that comes with responsibility.
"I want a team with great trust among its members. I want a team that understands no matter how great things were in the past -- record profits, safety, maintainability and reliability -- none of that makes you bullet-proof to the risks of the future. And, I want a team filled with courageous leaders (supervisors and non-supervisors) who aren't afraid to say, 'Hold it. This isn't right, or safe, or the best way.'"
Mullane says the legendary NASA team lacked these critical elements in the years prior to the Challenger flight. He says "normalization of deviance" and lack of communication deafened NASA to warnings of defects.
"In 14 of the 24 flights before Challenger, inspections found these O-rings, which were not to be touched by fire, were being touched by fire," he says. "The rocket's manufacturer sent memos two years before the explosion saying, 'Your design is flawed, it's going to fail, and people are going to die.'"
Warnings went unheeded. NASA, bowing to budget and schedule pressures, rolled the dice. The O-rings, which received an "intoleration to deviance" label during the design process, now were expected to show some damage. NASA believed it was bullet-proof to failure.
Some NASA employees also knew of problems, but a lack of an open-door policy ("the ideas of team members weren't sought") and fear (a person standing up "would have been crucified") suppressed such thoughts.
"When a major problem occurs in such a project, it's natural to scream, 'This can't be happening! We've invested too much time and treasure in this,'" he says. "You look for the easy way out."
NASA changed the rocket assembly process rather than the O-ring design. The end result was the explosion that killed seven crew members.
"You can't turn back the clock," says Mullane. "Therefore, look close (at yourself, your company). Are you walking the Challenger path?"
This article appeared in the December 1999/January 2000 issue of MRO Today magazine. Copyright, 2000.
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