A Major Malfunction

Risky Technology, Culture, and Deviance at NASA
By Diane Vaughan
University of Chicago Press, 575 pp.

Even in the deadpan lexicon of NASA, what happened to the space shuttle Challenger on Jan. 28, 1986, goes by the designation WOW. The acronym stands for “worst-on-worst” circumstances: failure upon failure leading to disaster.

What happened was that sealants in a joint of the right solid rocket booster – the now-famous O-rings – had been made brittle by unusually cold weather at Cape Canaveral. After repeated delays, when the engines finally powered up hot motor gases burned through the rubber rings. The vehicle might have detonated on the launch pad except that the charred remains of the O-rings paradoxically sealed the joint. Everything might still have gone well if not for unprecedented wind shear that morning. The bumpy ride skyward shook the O-ring debris loose, allowing a jet of hot gas to punch its way out of the booster. The vehicle stayed intact for 73 seconds.

I suspect one has to be an American to appreciate how deeply the United States felt the Challenger tragedy. Canadians grieved too, as any good friend and neighbour would, but in the United States the moment was seared into the national consciousness.

This was the flight that carried Christa McAuliffe, the first teacher in space. School kids across America gathered in one giant assembly to follow her progress. For their parents, who have fond memories of regular classes being interrupted for NASA launches, it was supposed to be a thrill from the past bequeathed to their children. Instead, a generation raised on the triumph of “one small step” sat their kids in front of the TV and let them watch what turned out to be death, which was described as “obviously, a major malfunction.”

Right from the start, the question was not how did this happen, but how could this have been allowed to happen?

There were two official external inquiries, one by a committee of the House of Representatives, the other – much more high-profile – by a blue-ribbon presidential commission. Journalists swarmed over both. What emerged from their blow-by-blow coverage has now installed itself as the standard account.

In a nutshell, it goes like this: NASA knew it had a faulty booster design on its hands. Nevertheless, budget constraints and production demands – the need to shore up support in Washington – dictated that the damn thing fly. NASA management therefore sent shuttles up repeatedly, overriding safety concerns and betting that the booster problem would be solved before catastrophe occurred.

The press seized upon two facts in particular. First, NASA was well aware of O-ring erosion in flights prior to the Challenger. Second, on the eve of liftoff NASA disregarded the advice of Morton Thiokol engineers – the people who built the boosters – who argued that they couldn’t guarantee the safety of the launch.

The beauty of this explanation is that it is readily understandable and narratologically satisfying, because it allows culprits to be identified and blame to be apportioned. Unfortunately, it is simplistic, wrong and makes scapegoats of the innocent.

Diane Vaughan, a sociologist at Boston College, has pored over the documentary evidence – the presidential commission alone ran to five volumes and generated hundreds of thousands of pages of data – as well as conducting her own extensive interviews. Her version of events leading to the launch, utterly convincing, amounts to a wholesale revision of the standard explanation.

The received version, she points out, makes “amoral calculators” of NASA middle managers. It is as though they were unscrupulous automobile executives who placed on the roads a car they knew to be unsafe, simply because it was cheaper to look the other way. But if you think about it twice, this explanation makes no sense whatsoever. If NASA was under pressure to launch for what amounted to public relations reasons, and if the agency knew the orbiter was unsafe, how would the cause of public relations be served if – as it did – the vehicle erupted into a fireball live on CNN? For the standard explanation to be correct, NASA managers would have to be not only amoral but thick as planks.

Vaughan’s account of how the launch decision was made rests on a meticulous reconstruction of the internal organization of the space agency and the political and economic contexts in which it was working. Painstaking and exhaustive, the book is simultaneously a detective story and an illuminating sociology of, in the phrase of Mary Douglas, how institutions think. What Vaughan shows is that the decision was a mistake, not the result of misconduct. Beyond that, it didn’t happen because rules were being violated. On the contrary, it happened because the engineers and managers steadfastly conformed to the very rules that were supposed to prevent disaster.

Yes, NASA and Morton Thiokol knew they had a problem with the O-rings and were trying various techniques to fix it. But nothing in their experience led them to think the problem would result in catastrophic failure. They genuinely believed that even if one O-ring burned through, its backup would seal the joint.

And yes, some Morton Thiokol engineers, worried about the effect of the cold, argued against launching during a Flight Readiness Review teleconference on the eve of liftoff. But these reviews are conducted according to a strict protocol. One must argue for one’s position; one must have evidence at hand. You can’t scrub a launch on the basis of a hunch. And at the time, the Thiokol people simply didn’t have – or didn’t know they had – the data to support their concerns.

This is a most impressive work of scholarship that corrects the welter of misconception that has surrounded the Challenger disaster. What remains worrisome is where those misconceptions came from in the first place. Journalists, whose job is to enlighten the public, apparently did the exact opposite. They fabricated a myth. They obscured the complexity of the truth. “Perhaps the most obvious lesson,” Vaughan concludes, “is about the manufacture of news and the social construction of history in an age when most people are distanced from events.”eg

  • Globe and Mail March 16, 1996