When I was a youngster, I would hear comments from the grown ups, they could all remember where they were when President Kennedy was shot. This struck me as most odd, I’d watched a police drama or two and I knew for a fact that you only needed an alibi if the police thought that you’d “done it”. Why would people in our village need an alibi for a crime committed in America?
As we grow, we get to understand more. I know now of course that those grown ups had been mortified by the news of Kennedy’s assassination, and they would forever remember where they were when they first heard the news of his death. We receive bad news most days, the world is full of some calamity or other, but we are affected very negatively when the “Kennedy Moments” occur; Lockerbie, the death of a princess, the attack on the Twin Towers or the Challenger Disaster.
On January 28th 1986 I was driving along Broad Street in Birmingham, heading home when I heard that seven astronauts aboard the Space Shuttle Challenger had died after it exploded 73 seconds into their flight. That was wrong! Space flight was supposed to be at the routine end of risky, there were so many checks, double checks, back up systems and fail safes. What could possibly have gone wrong?
The Shuttle fleet was grounded for three years whilst a very exhaustive investigation was pursued. In a very litigious society, the question of “Who’s to blame?” was uttered in unison with “What went wrong?”
It became apparent that O-Rings used to seal the joints on sections of the solid rocket boosters had failed. Hot gases streamed out of the joint in a visible blowtorch-like plume that burned into the external hydrogen / oxygen tank which subsequently exploded. The fact that the O-Ring design was not fit for purpose was documented at least 12 months prior to the Challenger incident, so why wasn’t it resolved?
Morton Thioko Inc was the NASA contractor engaged to supply the solid rocket boosters. At least two of their Engineers, Bob Ebeling and Roger Boisjoly detailed in writing why the O-Rings required more work. They were ignored by their managers. As the Challenger launch date approached, they became more vocal. Overnight temperatures were forecast to be sub zero which they calculated would reduce the O-Ring material integrity still further.
Senior managers at Morton Thioko finally agreed that the issue was serious enough to recommend delaying the flight. NASA protocols required all shuttle sub-contractors must sign-off on any flight. During the go/no-go telephone conference with NASA managers Morton-Thiokol officially notified NASA of their recommendation to postpone the flight. NASA officials strongly questioned the recommendations and pressured Morton-Thiokol to reverse their decision.
The Morton-Thiokol managers asked for a few minutes off the phone to discuss their final position again. The management team held a meeting from which the engineering team, including Roger Boisjoly and Bob Ebeling, were deliberately excluded. The Morton Thiokol managers decided to advise NASA that their data was inconclusive. NASA asked if there were objections. Hearing none, NASA decided to launch with tragic consequences.
A Presidential Commission concluded that “The caucus called by Morton Thiokol managers, which resulted in a recommendation to launch, constituted an unethical decision-making forum resulting from intense customer intimidation.”
Seven people died and countless lives were devastated, not least their proud families who witnessed the horrific spectacle from the launch site. All because there was a need to “save face”. NASA was unprepared to reschedule a shuttle launch so close to the planned date. Arrogant pride was more significant that human life. Those seven astronauts were probably giddy with anticipation at traveling into space, but would they have been so excited if they had been told their launch boosters would most likely fail?
Components were redesigned, and a new policy on management decision-making for future launches was implemented. Too late, seven people were already dead. Criminal charges were never brought against any individual or institution. Lawyers were kept busy however as all the various organisations sued and countersued each other. Recovering money was more important than ensuring those responsible be made to account for their actions.
32 years after this event, we MUST ensure such irresponsible attitudes cannot prevail in the workplace where we have an input.
Assess all the risks associated with what your business is doing
Manage out those risks as much as possible by applying controls
Ensure your staff are fully aware of any residual risks
Train your staff
Think about the “stupid” way to complete a task and ensure it can’t occur
Review your systems to ensure bad practices are not creeping into your business
Refuse to be intimidated by a poor-quality client who wants you to cut corners. Do you really need business like that?
Understand what you’re being asked to do
Follow safety instructions
Never put yourself or anybody else in harm’s way
Never cut corners
Never undertake a task when you know safety issues are being ignored
Be prepared to “step up” where dangerous practices are witnessed – stop the activity if you can, if not, report the dangerous practice to an employer / Health & Safety Executive / Local Authority
Never expect a supplier to undertake a job “on the cheap” If a charge is applied to ensure staff safety, it is applied for a very good reason.
Be suspicious of potential suppliers / contractors who submit a wholly unrealistic quotation for work you’ve offered for tender.
Ensuring that your staff go home safely is not a big ask. Is it? Stop for a moment, how can you influence safety management in your workplace? If someone you love didn’t arrive home tonight because of an incident at work how devastated would you be? Yes, a whole lot. Of course, you would be.
If something goes wrong, and injuries or fatalities occur, there will be a host of Enforcement Officials looking at you and your business to comprehend your personal culpability. (Irrespective of whether you are the contractor or the client). Unlike the grown-ups of my childhood, your alibi is very unlikely to pass muster.
So then, take a moment, work out how you can act today, to ensure that your staff go home safely every day. It’s not “rocket science!”