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73 seconds after launch, the Space Shuttle Challenger disintegrated over the Atlantic Ocean, off the coast of Florida. An O-ring in the right solid rocket booster (SRB) failed at liftoff allowing hot gas from within the booster to escape and subsequently damage the SRB attachment hardware and the external fuel tank. This led to the eventual detachment of the right-hand SRB and the structural failure of the external tank at which point, aerodynamic forces broke up the orbiter.

While the space shuttle itself was destroyed, the crew cabin remained intact. It is known that the astronauts would have still been alive however the elevated G forces at the time of break-up and possible air leaks in the cabin may have quickly left them all unconscious. After approximately 2 minutes and 45 seconds of free fall, the cabin hit the ocean at an estimated 207 mph (333 km/h), a deceleration of over 200 g. Anyone still alive would have been killed instantly.

At that particular moment, like many other people I was glued to my television set watching this historic launch. Like many other people I stared at the screen perplexed by the ball of smoke, vapour and fire wondering what happened then realising that the worst had happened. Over the years, I have thought many times about the crew with the hopes they were spared the agony of being cognisant of their fate as they fell back to Earth and to their death. How many pictures have I seen over the years of a plane crash caught in mid-air realising that at that particular moment, people are alive and screaming or gritting their teeth as they hang on with some shred of hope they are going to be spared from that inevitable meeting with destiny.

Aftermath
Beyond the tragedy, I have thought a great deal about everything surrounding the accident itself and how such a large organisation, supposedly well planned with the best project management in the world could make such a mistake. The Presidential Commission on the Space Shuttle Challenger Accident or the Rogers Commission, named after its chair, investigated the disaster and arrived at some damning criticisms of NASA and its partners.

While the commission explained the cause of the accident, the failure of the O-ring, it also uncovered questionable management practices. The flaw in the design of the O-rings had been known within engineering circles since 1977 but the flaw or the gravity of the flaw was never discussed outside of the normal reporting channels. As such, the flaw became an "acceptable flight risk" and in the end, the decision to launch the Challenger was based on incomplete and sometimes misleading information. I quote from the Wikipedia article:

One of the commission's most well-known members was theoretical physicist Richard Feynman. During a televised hearing, he famously demonstrated how the O-rings became less resilient and subject to seal failures at ice-cold temperatures by immersing a sample of the material in a glass of ice water. He was so critical of flaws in NASA's "safety culture" that he threatened to remove his name from the report unless it included his personal observations on the reliability of the shuttle, which appeared as Appendix F. In the appendix, he argued that the estimates of reliability offered by NASA management were wildly unrealistic, differing as much as a thousandfold from the estimates of working engineers. "For a successful technology," he concluded, "reality must take precedence over public relations, for nature cannot be fooled."

Management
This condemnation of NASA and the environment which put public relations ahead of safety is one of the most telling criticisms of people working together. Any organisation works with the problem of maintaining public confidence. Not only must the group deliver the goods, it must ensure it delivers goods which work and which are safe. Unfortunately, the public is fickle and is easily swayed by sound bites and tidbits of information which may offer incomplete and uncorroborated evidence. Nevertheless, the public can quickly react not to a real problem or threat, but to a perceived problem or threat. It comes down to the sad fact that the majority of us never bother to properly verify "the facts" before we make a decision.

However, as the shuttle disaster so clearly demonstrated, those who are at a distance from the epicentre of any problem may not fully appreciate the magnitude of the problem. In fact, their entire decision making process may be based on something which has absolutely nothing to do with safety. Years ago, I saw a PBS special on the Challenger disaster and it pointed out how continued funding for NASA had somehow be directly tied to the successful launches of the shuttles. There was the threat of funding being cut or there was the perception of funding being cut which could have inadvertently led to more pressure being put on the organisation to succeed no matter what. If a manager who is not an engineer is standing there weighing the options of funding being cut or an O-ring failing, there is an excellent chance he may not have a clue of what an O-ring is. However, I bet he's going to easily understand what funding being cut means.

I have half jokingly; half seriously painted the scenario of a boss somewhere looking at these two issues. "If I launch, I get funding but I risk having the O-ring fail. If I don't launch, I risk having my funding cut and I could be out of job. What the heck is an O-ring anyway? I want to keep my job." What happens? 73 seconds later he's standing in front of a television set like the rest of us thinking to himself, "Oh, that's what an O-ring is for!"

For me, what is so fascinating about my little scenario is that I have actually lived through this. Okay, the results haven't been as dramatic as a loss of life, certainly nothing as spectacular as being televised in front of the entire world, but the central idea of mismanagement is very much true. I am picturing this to be a much more common occurrence in companies than we would care to admit.

In my own experience, I have watched people in positions of authority make decisions which are completely based on what amounts to being absurd reasoning. How many times have I had a superior tell me that I don't understand funding as I try to impress upon them the importance of an O-ring? This falls on deaf ears. However, because nobody is killed, because it's not televised, most of the time these issues fall by the wayside and go unnoticed by the higher-ups. What the Rogers Commission found out, that public relations comes before safety, seems to be a cultural phenomenon which may be a natural characteristic of any group of people working together. The only difference between NASA and these other possible incidents in any one of a number of organisations is the number of people killed and the televised coverage.

Final Word
Today is the 25th anniversary of the Challenger Space Shuttle disaster. This was a tragedy. However, it is even more tragic when we realise that it was preventable. Yes, going into space is a complicated business fraught with danger. As a spokesman for NASA jokingly explained at a press conference, "Let's not forget, this is rocket science."

The old saying goes, "ignorance is bliss" but sticking your head in the sand like an ostrich is not going to solve your problems. Even if nothing goes wrong today, sooner or later, something is going to come back and bite you on the posterior.

According to Wikipedia:
The Challenger accident has frequently been used as a case study in the study of subjects such as engineering safety, the ethics of whistle-blowing, communications, group decision-making, and the dangers of groupthink. It is part of the required readings for engineers seeking a professional license in Canada and other countries.

Ah, "groupthink". What a term; what a concept. As defined in Wikipedia:
Groupthink is a type of thought within a deeply cohesive in-group whose members try to minimize conflict and reach consensus without critically testing, analyzing, and evaluating ideas.

I can't help thinking of this demotivational poster:



References

Wikipedia: Space Shuttle Challenger

Wikipedia: Space Shuttle Challenger disaster

2011-01-28

Site Map - William Quincy Belle

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A municipal project took place a few years ago to expand the subway system. During the 2 years of construction, I witnessed an interesting phenomenon which gave this article its title.

Expanding the subway system involved the digging of tunnels around a major intersection. During the tunnelling, traffic had to rerouted several times. This rerouting entailed the setting up of concrete barriers to divert traffic first to one side of the intersection then to the other depending on where the tunnelling was taking place. Standing at a window in a tall building beside the intersection, I could watch the flow of vehicles forced into lanes which lead the vehicles around the areas of construction.

During this time, I was out on a major highway when I ran into a traffic jam which brought everything to a dead halt. As I sat in my car, I turned to a local radio station in an attempt to find out if there was an accident up ahead causing the back-up and whether or not I would be better off to just get off the highway altogether. As I debated with myself what to do, I was looking at my limited options as the next exit, although in view, was still a bit of a ways up the highway. Getting to it would mean I would have to drive on the shoulder for quite a distance; something I figured was not kosher and was probably worth a ticket.

All of a sudden, beside me first one, then two then three cars go driving by me on the shoulder. Obviously, they had concluded that waiting for the traffic to clear was not the best bet and had decided to take matters into their own hands by using the shoulder to drive to the next exit to get off the highway. I looked around me. I could see no police so even if this action contravened the traffic laws, there weren't any policemen at the moment to enforce those laws so in essence, and anybody could do what they pleased without any fear of reprisals by the law.

Later on the same day, I was back in the tall building overlooking the intersection where the subway tunnelling was going on. I looked at the concrete barriers and how traffic was being diverted. The barriers were forcing traffic to go somewhere; anybody in a vehicle had no choice but to follow the lanes defined by the concrete barriers. I thought about the people driving on the shoulder up the highway to the next exit to get off the highway and avoid sitting in the traffic jam.

It occurred to me that we, society, have set up laws to define a certain behaviour we collectively find acceptable. You drive on the highway, not the shoulder. This behaviour is defined by law and if we do not ascribe to this behaviour, society enforces the law by handing out tickets, punishing the offender. However, as noted by the absence of police to enforce the desired behaviour, people will do what they want even if this behaviour is by definition, illegal.

As I looked at the concrete barriers, I realised that people were physically prevented from doing anything but what was defined. They couldn't drive on the shoulder because the concrete barrier prevented them from going anywhere but in the defined lane. Even if there were no police, the driver of a vehicle could only go in the prescribed route. There was no way somebody could contravene the law; it was physically impossible.

What a curiosity. On the highway, we have a situation where we hope people will obey the law: do not drive on the shoulder; always drive in the designated lanes. We know they do not always do so and consequently, we have to have police to enforce those laws. At the intersection, at the subway construction site, people are physically stopped by the concrete barrier and can only go where they are told to go. No police are necessary; no law enforcement is necessary. Physically, you cannot break the law.

Are there other areas of life where we can see such an idea? No policing is necessary; people are physically prevented from breaking the rules. That seems simple. If I want you to write with a blue pen, I only have to take all of your pens away and just give you a blue one. Now you can't write in any other colour because you don't have another colour pen.

Unfortunately, it seems, as I reflect on this, that probably for the most part our lives are governed by rules, not physical limitations. The rule is to drive at 100 km/h but I am not physically prevented from breaking the speed limit. Consequently, society has the police to enforce the rule. Hmmm, if we had cars that physically couldn't go any faster than 100 km/h...

2010-07-21

When I was studying Business Administration at university, I had the requirement to follow a class for a couple of semesters on management. This class covered the basics of dealing with people; something I found at the time a tad juvenile.

One of the training methods was to present various situations in which the student would have to figure out how to achieve the desired outcome. Students would be set up in pairs in order to role play or act out the situation. While one student would play the manager; the other student would play the employee. The scenarios were to provide people with an opportunity to understand the possible situations which could arrive between people and how to manage them.

One such scenario was to teach the adage, "Praise in public, criticize in private." I went through this exercise with my partner thinking to myself that this particular lesson seemed a bit dumb, a bit unnecessary. After all, who did not know such an idea? I'm chuckling about this right now as I write this but at the time I thought it was dumb, teaching a class such a rule. Who didn't possibly know that?

Guess what? After I started getting some real world experience under my belt, I started discovering that there were a lot of people who did not seem to know how to handle people, never mind managing them in a business context. Nasty? Mean? Unable to inspire people to work hard? Criticize in public, praise in private? You name it; I saw it. Ha! Obviously, there were people who had managed to work their way up the ladder into some sort of management role but were no more equipped to manage than I could... well, paint the Mona Lisa!

Now, in looking back on my university experience, I realize that being a manager, which can be taught to a certain extent, seems to be many times more a factor of some innate ability on the part of the individual. Some people have it; some people don't and there are many in between on the spectrum. I was certainly deriding the management class but have come to understand and appreciate that a good manager is worth his or her weight in gold. Being able to inspire people, to control a situation where the individual workers are allowed to shine is a very valuable commodity. Not everybody can do it.

If I can paraphrase the Peter Principal, "We rise to our level of incompetence."



True Story: Trial By Fire

A manager told me how he started his career in the financial world by working at a bank. His first task was to review some financial documentation and write a report. He completed this task and handed his report to his immediate supervisor. This supervisor proceeded to throw out all of his work and re-write the entire report. Apparently this scenario was repeated over and over again until finally, the manager arrived at a point where his reports were not thrown out but required less and less editing until finally they were accepted as is by his superior.

On the one hand, I was sure the manager was telling me his personal story of "trial by fire" but on the other hand did the manager realize and appreciate how dumb this was? He was given no real training in his job, no training about how to review financial statements and write a report and his immediate superior had taken, so it seemed, no time to discuss with the manager how to improve his performance. The manager pretty much guessed by doing his task over and over what was supposedly acceptable.

The real point in this story is that the manager in question ran his own shop in a similar manner. He learned by this "trial by fire" method and consequently, used this "trial by fire" method in managing his own department. Yes, over the years this manager had been to the usual managerial workshops but nevertheless retained a militaristic, no questions asked type of leadership style. I'm quite sure he would take offense at my assessment but just how blind are any of us at our faults?


True Story: Constructive Conflict

I worked at a company for 15 years. During that time, the president of the company has espoused "constructive conflict" as his management tool. There are many who deal with this topic much better than me and I'm sure there are cases where this can be a good thing, but here are my observations of what I have personally experienced.

I think of this as an example from the army. The general sets out the goal for a war game where company A and company B must fight each other to get to the top of the hill to retrieve a flag. In this scenario, both sides, companies A and B hone their fighting skills by working against each other. Fine, I go along with that.

In the scenario of my own company, I am sitting here watching the president supposedly playing one division against the other. Unfortunately, this company is so small, the divisions are divisions more in the sense of a management unit within the greater whole. Unlike the army's company A and company B which are distinct and separate and self-contained, the divisions of this company are interdependent and complimentary and must work together to achieve the overall goal. This is more akin to all of us being in a rowboat together. The president, as our leader, must get us to all pull at the same time in the same direction.

Instead, I have watched the divisions literally set up conflicting goals. It's as if the people on the port side of the rowboat decide to row north while the people on the starboard side decide to row south. Instead of the rowboat moving forward, we're actually turning around in circles; the work of one division cancelling out the work of the other division.


True Story: I don't know

It is difficult speaking in generalities. It is difficult to talk about any one particular incident when we weren't there or we weren't the one in the driver's seat. In the cold light of day, who hasn't said something akin to macho bravado in describing how they would have reacted when looking down the barrel of the gun? Yes, it's Mr. Monday Morning Quarterback, Mr. Armchair General.

Nevertheless, I have witnessed over and over again a style of leadership where the person in question never says, "I don't know". Somehow, uttering these words is tantamount to not being a leader. Nobody can know everything and yet, I have seen supposed leaders plough ahead with a course of action when the correct response would have been to ask questions and seek more knowledge. I have been flabbergasted to watch leaders make a decision when they think they must make a decision as opposed to seeking out the assistance of his underlings in gathering what may be necessary. At that precise moment, while all eyes are turned upon them, the very act of making a decision has become a question of personal ego, of wanting to show everybody else that we're in charge, that we're made of the right stuff, that we are truly a leader.

This has resulted in people thinking through problems in a bubble. Instead of seeking out assistance, asking for information, they remain sort of locked up by themselves while attempting to work out a right answer in their head. It's as if one can determine a priori what the correct course of action is. Personally, I can only think of René Descartes arriving at, "I think therefore I am" as a real example of a correct priori conclusion. It seems to me that everything else requires of collection of "other information"; that is, all other conclusions should and must be a posteriori.


2010-06-13