Mike Mullane has a warning: no matter the pressure you are under, always go back to best practice in whatever you do.
“Make sure best practice are incorporated in procedures and those procedures have been validated,” he says.
Mullane should know. As a three-time Space Shuttle mission specialist, he will provide insights into and lessons from one of the great space tragedies: the Challenger disaster of 1986 which killed all seven crew on board one of the US space programme’s four shuttles.
He was brought here by NZ Refining, the Business Owners Health and Safety Forum and IBM partner Certus this month to speak and record a video interview for an executive breakfast briefing series to be held in Wellington, Auckland, Melbourne and Sydney in June.
The Challenger disaster was a “schedule driven” tragedy, Mullane says. Over four years before the disaster, people were driven more and more frequently into shortcuts that ultimately contributed to the failure.
Workforces have to be trained at best practice level and both leadership and people at lower levels need to be empowered as part of a greater team. This should be done even to the point of allowing staff to call stop-works and to be free to bring forward their concerns.
Mullane will talk about “normalisation of deviance”, a term used by sociologist Diane Vaughan in her book The Challenger Launch Decision.
"Social normalisation of deviance means that people within the organization become so much accustomed to a deviant behavior that they don't consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety,” she wrote.
Pressure was the enemy in the case of Challenger in that it produced what Mullane calls a “predictable surprise”. These can seem obvious in retrospect, the trick is to recognise them as they are happening.
In the case of the O-rings that failed in the Challenger, decisions by really good engineers proved to be flawed.
Mullane, an engineer himself, says he would have come to the same decision, that the low frequency of damage on O-rings in previous flights indicated the issue wasn’t a design, but an assembly problem.
That proved not to be the case – it was a design flaw that post-Challenger caused huge expense and delay to fix. It also showed all the previous missions were at unrecognised risk.