This month contains NASA’s Day of Remembrance as it does each year. Each year the events that need to be remembered draw more deeply into the past.
This year is extraordinary because it marks the twentieth since we lost Columbia and her brave crew.
There are many who have come into the human spaceflight community following that accident. Some are too young to remember the events at all. Soon, joining the ranks of those who propose to send frail humans into the cosmos, will be ones who were not even born then.
These fresh faces, building the future, must understand not only what happened but why it happened and how to prevent such ruinous tragedy from happening again.
Ten years ago, at the encouragement of an old friend, Lisa Martignetti (who had her own role to play), I wrote a series of essays encompassing my memories, observations, and thoughts about the tragedy; what came before, how it transpired, and the way ahead.
It is my proposal to start reposting those remembrances, one a day, starting tomorrow January 15 and continuing to the conclusion on February 1. This pace should allow for some thoughtful reflection each day.
I hope these essays will lead the readers to find a better understanding of the complex nature of failure and – much more importantly – how to avoid making the same mistakes.
I hasten to add that I have not modified these essays from their original content. My memory grows less precise and I do not want to alter what I had written lest I introduce more error. There are certainly areas where other eye witnesses remember differently, that is the fact of human experience: we all see the same events from different vantage points and perspectives. I do not intent to defend or amend what I have written as it is the best my memory can produce.
Shortly after the CAIB report published when we were trying to learn better ways, I invited a series of speakers to interact with the Shuttle leadership team. First was Dr. Charles Perrow, a Yale sociologist, who had written a well-respected book entitled “Normal Accidents: Living with High-Risk Technologies”. His basic thesis states that complex, tightly coupled technical systems will always fail – that is ‘normal’. We who had just lived through tragedy were looking for ways to prevent failures in the future. Dr. Perrow was relentless; he gave us no hope. He stared us right in the face and said we were attempting the impossible. We should inevitably expect such a failure to happen again and nothing we could do would prevent it. Human error would creep in and defeat any protective system we might devise.
We could not accept that. It was the most disheartening talk ever. We could not wait to get him to leave so we could make plans to prove him wrong.
To some extent we succeeded; the remaining shuttle flights were all safe and successful.
So, is that the end of the discussion?
Lately I have begun to wonder if he was right. We are building and flying large complex, tightly coupled space systems with younger and less experienced workers. How can they learn the lesson? The only lesson I know to keep the wolf at bay, even for a short while, is extreme vigilance from everybody involved.
Please read and reflect on the essays to follow in the hope you can prove Dr. Perrow wrong.
Thank you Wayne.
I broadly agree with your points, and have certainly shared your blog at work in the past, but I think you perhaps are selling the current operators of spacecraft short by suggesting that youth and inexperience is increasing the risk.
A couple of factors that, I think, point us in the direction of reliability. I have worked directly in the space industry for 4 1/2 years. I haven’t checked the count lately, but the number of launches I’ve been part of is around the total number of flights in the Space Shuttle program. Rapid launch cadence builds experience rapidly, and when human spaceflight is, 5-10% of launches, there is a higher probability that a risk is revealed somewhere else.
The other thing is having a team with mixed experience levels means that the more experienced folks (who generally set up the systems) are being challenged by people who don’t have the experience, and this can offer opportunities to rethink problems and reduce the chances of getting into a fixed mindset.
I say this as a cause for optimism. It obviously purely represent my personal views. Spaceflight is inherently risky and every launch still makes me nervous, and nobody is immune to that risk. There are hazards that are tough to mitigate, such as the MMOD risk that was just realized on Soyuz. The important thing is running those risks down, understanding them, and mitigating them as well as possible.
Well said and worth sharing.
Thank you for doing this. Everyone needs to be reminded of these Shuttle “accidents”
both of which were totally preventable. I will never forget those two days and where I was and what I was doing when the tragedies occurred. I have read both the official Space Shuttle reports; the Roger’s Commission and the CAIB. Both should be required reading by every person employed by NASA and contractors each January so as to “refresh” their memories about mistakes made in the past that cost the lives of 14 Shuttle astronauts and destruction of two, one of a kind and irreplaceable $2 Billion spacecraft. Lastly, to remember the three Apollo astronauts lost in the Apollo One fire. These people were the best of the best and so were their spacecrafts.
Thanks for this Wayne. While I have long admired NASA and its goal, I remember remarks by Jon Clarke at the rededication of the Space Mirror Astronaut Memorial on October 28, 2003:
“We have to decide if we will be a space-faring or a space-fearing nation. For these will not be the last names added to the this monument.”
To your point, it remains critically important that we stay vigilant and continue to mitigate the risks.
Everyone entering this field should be required to review the past tragedies and study what it took to return to flight. The danger to avoid is hubris.
Perrow was right. We should do things as safely as reasonable, but it is unreasonable to imagine that we will open the harshest frontier in the history of humanity without losing people, and attempting to do so will result in its remaining closed.
Wayne thank-you for your plan to republish your essays. I look forward to them and I promise to do my part to get them out to the the next generation. Many whom I have had the pleasure to mentor now working on Artemis, or at Blue Origin or SpaceEx. I have taken the opportunity, every chance I get,to get the story out to the younger folks regarding the real events behind Challenger. I was “on console” at KSC for both of these launches and involved in post flight assessments, as I was for every shuttle launch. I look forward to spreading your message to a wider audience ASAP.
Can’t wait to start reading more! Was there with SRB, 1~135.
Seems like the normalization of deviance is the problem. A condition is defined as abnormal but it is perceived as not troublesome. It’s a failure of feedback between design and operation
I was frankly astonished at the success of the last few shuttle flights. Everyone involved knew that he or she was working to the end of a career, yet there was no evidence of FIGMO syndrome – if anything, there was a heightened sense of dedication to making it all work.
I only saw one shuttle launch in person, the last flight of Discovery. Prior to that I had been at the Cape for Apollo 14, 17, Skylab Crew 1, and ASTP – plus the launch of at least one of every unmanned vehicle we had. I avoided shuttle because I didn’t want to see a disaster, and knew that the complexity of the system was such that we would have one.
That launch was heavily attended, and was like old home week for me. One of the people I ran into was Alan Lovelace. I had brought Alan on board as a consultant to my company, KST, many years before. I remembered him describing how he finally got STS-1 off the ground. It was by going to every responsible engineer and asking if the shuttle was ready to fly. In every case, he got a non-committal response having to do with what could still be done to improve it. He cut those responses off, and demanded a reply to the question: “Is it ready now?” After receiving reluctant affirmatives from everyone, he proceeded to get it off the ground.
Not having seen him in years, I remarked “So this must be one of many shuttle flights you’ve seen.” He replied, it seemed rather sadly, that this would be the first since STS-1. He had retired from the shuttle program after that one, and didn’t want to see another until now. He figured it would go okay. STS-1 had been pretty sporty…
I have read the reports and your original assessments, and they were very well stated. I also spent 32 years at JSC, and was part of the investigation after Apollo capsule fire, Skylab solar shield failure during launch and Challenger. The one I was most personally involved was Challenger, when I was responsible for integrating the mission payloads safely with the Shuttle vehicle. When Columbia failed, was retired and working as a consultant to Boeing for ISS design of station hardware to assure the interfaces with the to the launch and operations systems.
The one lesson I carried away from all of those tragedies, is that all were preceded by some failure or issue that could have forecast the likelihood of a pending issue. All I mean by that is understanding all off nominal data or hardware problems is important, because it could be something that a small procedure change or further testing may provide better insight to probabilities of major failure. This might be factored into the procedures or hardware and reduce potential of tragedy.
Thanks for doing this Wayne. Looking forward to reading the reposts of the time around Columbia. A good book I recommend is The Devil Never Sleeps by Juliette Kayyem. It’s about lessons from past major disaster and how to “fail safer”.
My grandfather was Clifford Charlesworth. I was wondering if you worked with him. If so, do you have any stories or memories of him?
Of course I worked with Cliff. He was a mentor to all of us young Flight Directors
I look forward to your blog posts. They are always thoughtful and thought provoking to me. You mention reposting previous reflections daily starting on Jan 15. I’m not seeing them. Did something happen, or am I just not looking in the right place?
I have seen them on LinkedIn.