Other Voices

On Challenger anniversary, we need to remember lessons of tragic failures

Challenger astronauts from front left: Pilot Michael J. Smith, Commander Francis R. (Dick) Scobee and mission specialist Ronald E. McNair. From rear left: mission specialist Ellison Onizuka, teacher Christa McAuliffe, payload specialist Gregory Jarvis, and mission specialist Judith Resnik.
Challenger astronauts from front left: Pilot Michael J. Smith, Commander Francis R. (Dick) Scobee and mission specialist Ronald E. McNair. From rear left: mission specialist Ellison Onizuka, teacher Christa McAuliffe, payload specialist Gregory Jarvis, and mission specialist Judith Resnik. AP

Wonder turned into horror on Jan. 28, 1986, when flaming debris rained from the skies above Cape Canaveral into the Atlantic Ocean.

The space shuttle Challenger had exploded soon after liftoff, claiming the lives of seven brave Americans.

On Feb. 1, 2003, Mission Control in Houston lost contact with space shuttle Columbia, and debris fell from the skies above Texas. Columbia disintegrated during re-entry, taking the lives of all seven crew members.

The investigations of both accidents found not only that they were preventable, but they were preventable for similar reasons.

As a researcher who studies why organizations keep making the same big mistakes, I can say it is not uncommon. But there are steps we can take to learn from failures.

A presidential commission attributed the Challenger accident to flawed communication and decision-making processes.

Although some individuals had concerns about a faulty component (O-rings), the decision to launch the shuttle did not take their views into account.

NASA did take steps to correct flawed organizational processes, increasing both the number and status of safety personnel, and it strengthened safety operating procedures.

But learning waned as meeting deadlines and the desire to avoid launch delays became increasingly important.

This gradual forgetting was at the root of the Columbia disintegration. Management started viewing potential problems as acceptable and shifted attention to launch schedules and cost-cutting measures.

NASA is not alone in forgetting what it has learned from failures.

You probably remember the Deepwater Horizon drilling rig explosion in the Gulf of Mexico in 2010, an accident that killed 11 workers, injured 16 and caused an oil spill of epic proportions.

BP, the company at the center of this accident, had another major failure a few years earlier — the Texas City Refinery explosion in 2005, which claimed 15 lives and injured 170 people.

Despite the recommendation of the Chemical Safety and Hazard Investigation Board for BP to focus on safety, court rulings related to the second explosion pointed to cost-cutting despite safety risks.

Why organizations forget what they learn, even when stakes are high, is a complex problem involving many factors.

External pressures to correct the situation that led to an accident and maintain safety as a priority lessen over time.

Changes add up, and the organization gradually forgets what it has learned at great expense.

Learning from failures starts with how we react to them.

Aware of organizations’ tendencies to forget, managers should remain especially vigilant in the promotion of a culture of safety. Communication channels should be open for employees to express safety concerns and help shape decision making.

Francisco Polidoro Jr. is an associate professor of management at the McCombs School of Business at The University of Texas at Austin.

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