In 1987, NASA developed the NASA Safety Reporting System (NSRS)- anonymity where employees can report concerns to escalate hazards in case other channels fail. The timing mattered. A year before, Challenger had demonstrated how one silent protest could cost more than a million dollars in contemporary history.
A 31-year-old Morton Thiokol engineer, Brian Russell, was sitting in Utah on the eve of that launch as Florida continued counting down. He and other engineers in the room had a feeling against flying in the cold. It was known that the rubber O-rings that sealed the shuttle rocket solid boosters worked improperly in low temperatures, and the prediction at the Kennedy Space Center was much lower than what the information they collected was indicating. By managers changing their mind at the last moment and sanctioning liftoff despite all urgings, Russell ended up faxing a piece of advice that contradicted the beliefs of his own team.
The story of the Challenger is usually recounted as a failure of hardware- a failure of an O-ring to perform its duty in cold weather. However, the greater injury was cultural: the experts crying foul, the managers re-inventing the process, and in making unsafe become unsafe. Russell said his greatest regret was failing to say that the engineers were not alluding unanimously. That lack of opposition assisted the judgment in climbing up into sight purer than it was.
The teacher, Christa McAuliffe, who is the first private citizen to enter space among 11,000 candidates, never heard that argument. The mission was being sold publicly as evidence that the shuttle had become something almost routine. Privately it had already been flaunted by the spacecraft itself: a prior unsuccessful launch; an engine shutdown alarm; recurrent indications that the booster joints were a “Criticality 1” failure-point; one of those locations where redundancy might be more legend than fact. Even her own person, as a small-town icon, had some more incisive intentions, discussing inequity, teacher compensation, and civic engagement whenever questioned. Usually, no one did.
The results of the Presidential Commission would subsequently outline a decision-making process that was constructed on incomplete and even false information-some of the main objections that never made it to where NASA management could make decisions. The commission determined that, had decision-makers known “all of the facts,” the approval of the launch was not likely at all. That is, the system was not just having a slip.
It is that framework that makes the term “normalization of deviance” coined by sociologist Diane Vaughan resonate. Risk starts to become a normal thing as repeated “work” arounds seem to be working. Issues are relegated to the background. The organization continues to run, certain that it is being reasonable, until it runs out of luck.
NASA made attempts to develop antibodies after Challenger. Voluntary and anonymous and conducted through an independent contractor, the NSRS was created to provide an alternative avenue of communication with top safety executive when contractors and civil servants feel vulnerable or ineffective when speaking up. It was a confession of the institution that the most precarious time is not ignition. The one it is the encounter the night before when the room ceases to hear.
Such a lesson has been forced to be rewritten. The Columbia investigation of 2003 resonated with the previous ideologies of communication and culture, and continues to affirm that safety reforms are something that can rot away in neglect once they are seen as a one-shot solution to an issue and not an everyday routine. What anyone observing crewed missions today is that it is not unsafe spaceflight, but rather the pressure to seem safe that can occasionally be unsafe in itself.
The later move by Russell, who decided to go to NASA centers and recount the Challenger story to them face-to-face was not about honoring a tragedy but ensuring that future crews are not subjected to a common trend: the moment in which doubt exists but nobody demands to name the issue.
