Cold Comfort

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Aug 8, 2007,

By Sally K. Ride, Ph.D., former NASA astronaut and the first American woman in space.

Today's government agencies face an expanding array of threats that make effective risk management fundamental to their success.

From directing homeland security and managing national transportation systems to running weapons labs and research centers, government agencies oversee some of the nation's most critical activities. Maintaining these operations in the face of natural and man-made hazards is vital to the country's well-being.

Government agencies also house some of its citizenry's most sensitive information - Social Security numbers, health records, financial information and other personal data must be protected. That job grows harder each day as computer hackers become more sophisticated and mobile workers carry vast amounts of information in easily misplaced laptops and handheld computers.

In this environment, all public agencies must strengthen their ability to spot, evaluate and eliminate potential safety and security risks.

Focus on safety and risk management starts at the top and must permeate every layer of an organization. Government leaders must understand the importance of managing risk - and they must communicate that importance to all employees and empower them to make the right decisions despite budget pressure, deadlines and other factors.

My experience with risk management stems from my involvement in the U.S. space program. As a mission specialist aboard space shuttle flights in 1983 and 1984, I was extremely confident in NASA's safety procedures.

I also had the unfortunate duty of serving on accident investigation boards for the 1986 Challenger explosion and the 2003 Columbia disaster. Despite NASA's reputation for technical and operational excellence, our investigations revealed an agency with serious risk-management problems.

Our findings are instructive for public-sector leaders and managers because they highlight a particularly insidious risk-management shortcoming: the tendency to develop a false sense of security when everything is working fine. It's human nature to interpret the lack of problems as a lack of risk. When this happens, people and organizations can become complacent.

This phenomenon was a key factor in the space shuttle disasters. Although the Challenger and Columbia were destroyed by completely different technical malfunctions, the underlying cause of both accidents was rooted in risk-management failures. NASA managers, blessed by the good fortune of many successful shuttle launches, began to downplay the importance of significant technical challenges with tragic results.

If this type of risk-management failure can occur at NASA - an organization engaged in one of the riskiest endeavors known to mankind - it can happen anywhere. The space agency's experience shows that effective risk management demands leadership, communication and constant vigilance - particularly when everything seems to be OK.

What Went Wrong?
Through years of space exploration, NASA finely honed procedures for spotting and mitigating potential dangers. But cultural changes triggered by cost and schedule pressures of the space shuttle program in the '80s prompted NASA to lose focus and discount the seriousness of known design flaws. The longer operations continued without mishap, the more "acceptable" these flaws became.

Then on an unusually chilly morning in January 1986, Challenger thundered away from its Florida launch pad, commencing NASA's 25th shuttle mission. Seventy-three seconds later, the orbiter was destroyed in a massive fireball. Our accident investigation determined that failure of a rubber O-ring in one of the shuttle's massive solid rocket boosters triggered events that literally tore the craft apart.

At the time of Challenger's launch, NASA managers and engineers were well aware of problems with the O-rings, which sealed seams between sections of the rocket boosters. They'd seen evidence in earlier flights where hot exhaust gases from the rocket motors had nearly burned through the O-ring seals - particularly during cold-weather launches - endangering the shuttle and

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Comments

By Anonymous on Aug 29, 2007

Thank you for such a great, succinctly written article. It is clear, direct and profound. It makes me think about the complacency in my life, let alone in regards to the space shuttle. I recognized immediately that if I am complacent about the "this and that - similar to a mechanic" then it is just a matter of the 25th time or the 100th time that I would want to live with. I am not willing to see a 25th time in my life. This has been a tremendously valuable wake up call for me. Thanks to all of you - author, publishers and teams who brought this to the forefront of my attention. With gratitude! B : )

By Anonymous on Aug 23, 2007

As each shuttle mission goes by, we read of individual tiles being torn off. From a non-engineer's standpoint, it would appear that caulking or a solid foam construction would be in order. Until such point as safety can be assured, we will continue to horrify children as we watch entire crews being blown to bits. I hope that the data being gained is worth having children being launched into adulthood prematurely.

By Anonymous on Aug 22, 2007

St. Petersburg Times has this quote today 22 Aug 2007 - "I think we will continue to lose foam. ... I think we'll still expect to see some things come off, and we'll have to analyze them," said NASA associate administrator Bill Gerstenmaier. Said Griffin: "On every flight we seem to have some interesting question that has to be resolved, or certainly it's a rare flight where we don't. And I expect that to continue." Hmmm... maybe they need to read this article. My second thought was that when I heard all the astronauts that rode the last ride say that they didn't give the tile another thought after NASA said it didn't need repair. Maybe they should rethink that too.

By Anonymous on Aug 22, 2007

I read with great interest Ms. Ride's article and agree with her completely. "When the time has come to perform, the time to prepare has passed." These fundamental changes in our approach towards Risk Management must begin at the rudimentary level. As a Captain in a progressive fire department that is situated in a fast-growing jurisdiction, we have embodied the "empowerment" of each firefighter/EMT. The key, as Ms. Ride stated, is having the managerial environment ripe for feedback. This feedback needs to free from source bias and/or retribution. We find this level of managerial complacency or societal fear of being an outcast among our peers commonplace. No one wants to be the "One who cries wolf or chicken little," only to have the issue not materialize. However, Gordon Graham (Noted Risk manager) gives us a new twist on hindsight. "How could you not see it coming?????" Those of you that are familiar with Mr. Graham will know that it is the "train" that I am referring to. It is sad when we are caught off guard as a situation happens the first time, because we ignored the signs. But, it is an absolute travesty when it happens repeatedly because we ignored the signs AND history. This is a lesson that the fire service struggles with everytime a firefighter dies or has a close call. To quote Mr. Graham: "Is it a high risk, low frequency event? Uhhh Huh..... Then your risk management radar had better be in high gear." Or, as we have said for years, "Complacency Kills." Thank you again, Ms. Ride, for your article and calling additional attention to what should be a "common sense" subject, that isn't.

By Anonymous on Aug 22, 2007

This reminds of my brother who is an auto mechanic. My father used to say,"Good mechanics usually have terrible cars." Maybe you have noticed the same thing I have of mechanics on a budget. They usually have a personal vehicles at one time that a non-mechanic would be afraid to drive, but the mechanic owner would say, "nah, that's just this-and-that that's make that noise, no problem." As a programmer analyst, I can correlate to this story, in my own experience, as coding could get horrendous in trying to do a simple task of processing a payment, with more than half of the code dealing with all the wrong things that could avoid a bad payment. I can see why NASA requires a different level of leadership, but the mentality unfortunately as revealed by this article is so much the same. And unfortunately, unlike the mechanic driving his own, self-maintained vehicle, the shuttle doesn't have a floor jack and spare parts in the back of its trunk so it can pull over, crawl under its belly and try to fix "this-and-that" that's making that noise. Complacency has its place just to get through the day, although it could be misplaced, with great tragedy.

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