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Preventing Space Shuttle Disasters Means Getting to the Root Causes
By Robert Latino
The
Space Shuttle Columbia disaster was barely an hour old and already pundits
were speculating about the "cause." In the days after the tragic
event, a litany of speculators paraded in front of the media talking about
falling foam, missing tiles, the left wing leading edge, and anything
else that could make them look like they knew the "cause of the accident."
This clamoring by the media and pundits about the cause of the Columbia
disaster will undoubtedly result in only one true answer, and they will
not know the true root cause of the disaster. Sure, they will come up
with one of the causes, but preventing failures from reoccurring means
discovering all the root causes, not just the first cause you can identify.
I thought the whole reason for the mammoth investigation currently being undertaken involving the Columbia tragedy was to determine the causes and to take steps to prevent it from happening again. Surely no one would admit to wanting to find a quick fix if it only means we'll lose another seven astronauts down the road. If no one would want it, then why is the media putting so much pressure on the investigators to give us an answer? That type of media pressure can only have one result: giving a quick, easy-to-find cause to make the hounds go away.
The problem with this result is that no disaster like the Columbia ever comes about because of one or even two easy-to-identify causes, such as the often-mentioned insulation falling and damaged left wing tiles. The root causes always go much deeper. For example, what decisions were made to have the insulation designed and installed the way it was, and why were they made? I read with interest a news story that noted the insulation was redesigned to be more environmentally friendly. Does that mean decisions were made that could've contributed to the disaster purely for environmental reasons? Those types of questions and subsequent investigations will lead to the true root causes of this accident.
You want to draw conclusions as quickly as you can based on the information, but you shouldn't. We have been in this business long enough to know that if you go down that merry path, you will be fooled. You need to go through the process, gather the data. You need to correlate all the data, the time frames, the evidence, the photos, and the way the system behaved. And you need to do it under the scrutiny of a microscope to get the right answer.
Businesses and industry have applied this methodology for years to prevent recurring equipment and process failures in an effort to make organizations more productive and cost effective. Dramatic returns on investment have resulted from root cause analysis for numerous industries, from oil and paper to manufacturing and service. We need to get that same return for our space program, and the media needs to demand that NASA and Congress accept nothing less.
That will be hard for the media and Congress, because it means they will
have to back off and allow the investigators to do their jobs without
the pressure of reporters and politicians demanding answers quickly. The
role of investigators in this tragedy is no different than that of a police
detective, and they must collect the evidence and draw conclusions based
on it. Hearsay doesn't carry weight in a court of law and shouldn't carry
weight in the media. Let the facts guide the investigation, not public
opinion.
The bottom line: it will take a lot of time and investigating without outside pressure to determine the true root causes of the Shuttle disaster. If we don't give NASA that opportunity to do it, then we are setting ourselves up for another disaster in the future.
As with the Challenger investigation, the Columbia investigation will
not only focus on the physical causes that lead to the disaster, but also
the latent root causes or system failures. These are the decision-making
systems that led to the physical root causes. We expect to hear, as we
did
with Challenger, questions such as: 1) If there was a prior history of
losing foam insulation or tiles, what was done to eliminate the risk of
recurrence? 2) Were safety decisions compromised based on the availability
of proper funding? 3) Were risk analyses conducted on potential events
such as this, and were they acted upon?
Put the pressure on the investigators to find the facts, and don't pressure them to come up with an answer to satisfy media or public demand!
Robert Latino is senior vice president of development for Reliability Center, Inc., a Hopewell, Virginia firm specializing in global root cause analysis for businesses, and the author of the book Root Cause Analysis, Improving Performance for Bottom Line Results. He can be reached at blatino@reliability.com.
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Progressive
Engineer
Editor: Tom Gibson
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