Groupthink and the Challenger disaster

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Groupthink and the Challenger disaster. (8/19/05)

Groupthink: a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when the members' strivings for unanimity override their motivation to realistically appraise alternative courses of action.

A line in "Roving Mars" reminded me of something. Over the years a lot of folks have studied the Roger's Commission Report to understand why the Space Shuttle Challenger disaster happened. The commission, for those that don't know, was President Reagen's Commission on the Space Shuttle Challenger Accident. The decision making process on the day of the incident is commonly cited as an example of groupthink. There is even a film making the connection. Business students will encounter the example in at least one if not two or three of their classes.

The irony in all of this is that the use of the Challenger disaster as an example of groupthink is in itself an example of groupthink, in this case the group being business people attempting to understand and reach consensus on the disaster from their perspective as business people. I call this an example of groupthink for one very important reason: their conclusion is completely wrong.

Read the Roger's Commission Report. The direct cause of the accident was the failure of the O-Rings. They didn't fail because of groupthink, they failed because of the piss poor engineering specs they were designed to and the lack of concern for mission failure under which the specs were created, and the launch decision was made. That's poor leadership, not groupthink.

Groupthink only comes into play as a contributing cause of failure on the day of the launch, in the meeting of managers of one of the contractors. Their decision, to ignore their engineer's recommendations is talked about in the report, but they also talk about why there should have been other systems at work to question that decision, to ensure it was correct, to ensure it was safe. The absence of that checking process has nothing to do with groupthink either.

The focus on groupthink causes business folks attempting to learn from the Challenger disaster to miss the major lessons and focus on a less important one, allowing them to repeat the same mistakes.

"The unrelenting pressure to meet the demands of an accelerating flight schedule might have been adequately handled by NASA if it had insisted upon the exactingly thorough procedures that were its hallmark during the Apollo program. An extensive and redundant safety program comprising interdependent safety, reliability and quality assurance functions existed during and after the lunar program to discover any potential safety problems. Between that period and 1986, however, the program became ineffective. This loss of effectiveness seriously degraded the checks and balances essential for maintaining flight safety." - Report of the PRESIDENTIAL COMMISSION on the Space Shuttle Challenger Accident, Chapter 7

It is important to learn these lessons. NASA didn't and we lost another shuttle, Columbia, because of it:

The CAIB [Columbia Accident Investigation Board] report concludes that while NASA's present Space Shuttle is not inherently unsafe, a number of mechanical fixes are required to make the Shuttle safer in the short term. The report also concludes that NASA's management system is unsafe to manage the shuttle system beyond the short term and that the agency does not have a strong safety culture.

The Board determined that physical and organizational causes played an equal role in the Columbia accident - that the NASA organizational culture had as much to do with the accident as the foam that struck the Orbiter on ascent. The report also notes other significant factors and observations that may help prevent the next accident.

Systems Safety was built to handle these things. Read Nancy Leveson's white paper [PDF] as an introduction to it and never be afraid to err on the side of safety, at the very least in the planning stages of any substantial project. And if you are reading this as a business student being taught this disaster was due to groupthink, please pass this page on to your professor.