Wonder turned into horror on Jan. 28, 1986, when flaming debris rained from the skies above Cape Canaveral into the Atlantic Ocean. The space shuttle Challenger exploded soon after liftoff, claiming the lives of seven brave Americans.
On Feb. 1, 2003, Mission Control in Houston lost contact with space shuttle Columbia, and debris fell from the skies above Texas. The Columbia disintegrated during re-entry, taking the lives of all seven crew members. The investigations of both accidents found not only that they were preventable, but they were preventable for similar reasons.
How could an organization employing some of the nation’s brightest minds fail to learn? As a researcher who studies why organizations keep making the same big mistakes, I can say it is not uncommon. But there are steps companies can take to learn from failures.
The Rogers Commission Report created by a presidential commission charged with investigating the Challenger disaster attributed the accident to flawed communication and decision-making processes. Although some individuals had concerns about a faulty component (O-rings), the decision to launch the shuttle did not take their views into account.
After the Challenger accident, NASA did take steps to correct flawed organizational processes. For example, it increased both the number and status of safety personnel, and it strengthened safety operating procedures.
We would think that after the Challenger explosion, a similar failure at NASA would not be an option. But learning waned as meeting deadlines and the desire to avoid launch delays became increasingly important.
This gradual forgetting was at the root of the Columbia disintegration. Once again, management started viewing potential problems as acceptable and shifted attention to launch schedules and cost-cutting measures.
Challenger and Columbia loom large in our memories. But NASA is not the only organization to forget what it learns from failures.
You probably remember the Deepwater Horizon drilling rig explosion in the Gulf of Mexico in 2010, an accident that killed 11 workers, injured 16 and caused an oil spill of epic proportions. What you may not remember is that BP, the company at the center of this accident, had experienced another major failure a few years earlier — the Texas City Refinery explosion in 2005, which claimed 15 lives and injured 170 people.
Despite the recommendation of the Chemical Safety and Hazard Investigation Board for BP to focus on safety, court rulings related to the second explosion pointed to cost cutting despite safety risks.
Why organizations forget what they learn, even when stakes are high, is a complex problem involving many factors. External pressures to correct the situation that led to an accident and maintain safety as a priority lessen over time. The political agenda moves to other pressing issues. Regulators shift attention to another crisis. The media move to the next big news story.
Internally, avoiding new failures for a certain period creates a false sense of security in the organization. What used to be cause for concerns starts to be seen as normal. Attention shifts to other goals, such as launching new products or increasing sales. Cost-cutting measures resume. Employees leave the company, new executives take the helm.
These changes add up, and the organization gradually forgets what it has learned at great expense.
Learning from failures starts outside organizations; it starts with how we react to them. Tragic accidents should not result in a “Here we go again” attitude. Instead, they should instill a “Never again” resolve. Aware of organizations’ tendencies to forget, managers should remain especially vigilant in the promotion of a culture of safety. Communication channels should be open for employees to express safety concerns and help shape decision making.
NASA seems to have learned that a lull in high-visibility failures can cause its attention to shift to other pressing issues, such as costs or schedules. Leadership plays a critical role in keeping the entire organization alert to weak signals of danger. Learning such a lesson is a good way to pay tribute to the memory of the lives claimed by tragic accidents such as the seven Challenger heroes we lost 30 years ago. Let’s not disappoint them.
Francisco Polidoro Jr. is an associate professor of management at the McCombs School of Business at The University of Texas at Austin.
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