Last night I watched the Netflix mini-series on the Challenger accident. It had some nice personal moments from family members of the crew and even two of the decision makers who insisted on the launch despite the warnings. I enjoyed it and it’s worth watching but ultimately it didn’t break new ground. After all, we’ve known for decades why seven people unnecessarily died in 1986.
I’m not referring to the failure of the O-rings or Morton Thiokol’s flawed joint design on the SRBs. I’m referring to the human failures which culminated in the explosion.
I attended the presentation by an engineering firm into the findings of the causes of the Bonfire disaster at Texas A&M 20 years ago. The physical cause wasn’t nearly as pertinent as the organizational issues. Complex systems can have catastrophic failures. This necessitates multiple barriers to failure. Ideally, in a system with multiple barriers, having a small number of failures won’t lead to an undesired outcome as the other barriers will catch the error.
So why do we see disasters like Challenger or what happened at Texas A&M? Human elements overwhelmed the system. Groupthink and hubris combined with outside pressures focused on outcomes rather than safety bypass enough of those barriers to failure as to result in tragedy.
In NASA’s case, the public had been sold the idea that the shuttle system was safe, little different than flying on a plane. The public assumed this was a freak accident, impossible to foresee. That wasn’t the case. Engineers had been warning for years about the design problems with the boosters and the potential of the O-rings to fail in cold weather. In fact, there was a recommendation to overhaul the entire SRB design. NASA shot down this recommendation. Why? It would have grounded the fleet for two years. The day of Challenger’s launch, engineers who knew the SRB best said the shuttle should not be launched. Morton Thiokol initially took the stance of their engineers but pressure from NASA caused them to change their advice – they said it would be safe to launch.
Engineers and scientists, the foremost experts in the world in their areas of expertise, were overridden when they were flat out saying “If you ignore us, people will die.” The pressure from the government to have more launches was too strong. The pressure to act as if the shuttle fleet didn’t face catastrophic problems on a normal basis was too strong. The science and the data were ignored because groupthink decided the actions taken if the science were followed were undesirable and therefore it didn’t matter what the science said.
This entire process got repeated when Columbia was lost to a different design elemental but the same behavioral failures.
And we are in the middle of watching this same process unfold right now. Only now instead of 7 dead, it’s over 200,000 dead. Trump is a huge part of the process, but he isn’t the only contributor.
This chart is of the positivity rate in my state of Texas. (You can view the data yourself here. Read the yellow line.) I’ve added two lines. Towards the end of May, Texas relaxed restrictions and bars began to re-open. As you can see, the positivity rate skyrocketed. In July, Governor Greg Abbott finally acquiesced and advocated masks in public in most Texas counties. The positivity rate began a steady movement downward.
The scientists were correct. And those in charge chose to ignore the science for no other reason than they didn’t like the outcome if the science were followed. Our barriers have again failed.
Covid-19 is Challenger. It’s Texas A&M’s Bonfire collapse. It’s Columbia. We are repeating all the same mistakes over again. Except now the death toll is tens of thousands of times worse.
So is all hope lost? Of course not!
Firstly we’re likely looking at a change in national leadership in January. National messaging, coordination, supply chain management, etc… will all improve. But secondly, most people ARE behaving as they need to in order to slow the spread of the virus. Yes, we have individuals and systems contributing to the spread, but a larger number are isolating as much as possible and wearing masks.
Keep wearing your mask. Keep limiting your contact with others. And vote.