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Phil LaDuke joins our panel of renown and highly respected safety writers including, Dr Rob Long, Bill Sims Jr and George Robotham. Everyone has enjoyed his previous articles (HERE). This is Phil’s latest article and provided exclusively to us. It is a much more sombre and less provocative than his previous work but one that sends a very powerful message about the importance of open communication.
I highly recommend his blog: http://philladuke.wordpress.com/
Jargon Killed the Astronauts
By Phil La Duke
I’m working with a large, faith-based healthcare system with an extremely strong culture. One of the practices this organization uses to continually reinforce its culture is to begin each meeting with a reflection. A reflection is a short, thought-provoking story that is meant to transition those gathered to a place mentally that would help center and focus the participants around a particular theme. What follows is a reflection I recently wrote on the importance of open and honest communication AND on accountability.
—Phil
The Cassandra Effect
FYI: The Cassandra effect is when one believes they know a catastrophic event is going to happen, having already seen it in some way, or even experienced it first hand. However the person knows there is probably nothing that can be done to stop the event from happening, and that nobody will believe them if they try to tell others.
Years ago I hired a man to teach Failure Modes Effects Analysis (FMEA) to engineers and program managers at the tier-one automotive supplier where I was employed as the Director of Training and Development. FMEA was an area about which I knew little and less so I hired a retired engineer who had worked on the space shuttle as a supplier to NASA and was a part of the Challenger program. In short, Gene was a rocket scientist. Despite his impressive credentials Gene was a soft-spoken, unassuming, man not given to hyperbole or braggadocio. He had indeed been on the Challenger team, (in fact, he was on the team when it exploded killing all aboard) but seldom if ever talked of it. It wasn’t a subject he eschewed; he just didn’t bring it up. I was acutely interested—how often does one get the opportunity to have a conversation to someone who was not only a first-person witness to history but a participant in a significant historical moment.
The purpose of an FMEA is to identify all the things that could go wrong (either with a design or manufacturing process) and identify both the preventive measure and the contingencies for when prevention fails. Perhaps because I lack social skills or maybe just because curiosity got the best of me, I asked Gene a question, “why did the FMEA for the Challenger fail to protect the astronauts?” Gene mood darkened. He explained to me that there was an FMEA that correctly predicted the disaster. “We knew the O-rings would fail in cold weather” he told me sadly. Visibly shaken after so many years, he related how the engineers warned NASA leaders that cold weather launches could cause catastrophic system breakdowns. “We had all the facts, all the data, and ultimately we were right. But none of that mattered,” he explained. “It doesn’t matter how much data you have or what you know, none of that means anything unless you are able to persuade the decision makers.”
“Unless you can put together a persuasive argument that compels the decision makers to take action with confidence, all your efforts are wasted”. I haven’t given Gene’s story much thought until lately. Last week, Challenger engineer, Roger Boisjoly, died at the age of 73. As I listened to the radio eulogy, I thought of Gene and the lessons he related to me. Roger Boisjoly lived out his life haunted by his failure to persuade.
Safety professionals tend to make the some mistakes (despite not being rocket scientists). Many hard working and deeply devoted safety professionals who work hard to research the causes of workplace injuries, are like Gene and Roger, frustrated by their inability to convince Operations to act. I’ve heard these safety professionals complain about a lack of leadership commitment to safety. Gene never blamed NASA leadership, instead he focused on his and his peers in ability to communicate. He talked to me about how the engineer spoke one language but the program managers spoke another.
Jargon Killed the Astronauts
Jargon is a language that evolves in a profession chiefly to exclude outsiders. It’s a natural phenomenon—as neophytes enter the field they want to adopt the vernacularly to demonstrate their belonging. It is an important part of the profession’s identity. Jargon in itself is neither bad nor dangerous but there is neither bad nor dangerous, but there is a time and place for it. Obviously speaking the same language is essential to communicate but it isn’t always obviously when we aren’t speaking the same language.
The difference between data and information
Gene told me that his conversations with the program managers were not information exchanges. Engineers kept presenting data—they talked in probabilities, risks, and failure modes—but it wasn’t framed in ways that the program managers understood or could use. As the engineers made more and more dire predictions none of them spelled out in no uncertain terms that if they launched the shuttle would explode no one were afraid to guarantee that if the launch took place disaster was certain. The end result was the engineers came of as timid worriers with guesses as to what might possibly go wrong. Program leaders were understandably reluctant to scrap a mission and waste millions of dollars based on analysis of data that they neither understood, trusted, nor respected.
{ 7 comments… read them below or add one }
Well certainly jargon alone didn’t kill the astronaut, but it did contribute a great deal. Jargon turns outsiders off and they stop listening Any of you out there who want to continue to use Jargon (and buzzwords, and every acronym in the book) God bless you, keep doing it. But when people stop listening to you, marginalizing your suggestions, and generally ignore your opinions don’t come crying to me
Good read and interesting conclusion. However, jargon was only one small part of the issue.
How leaders and managers deal with uncertain threats in a highly ridged organization is the real culprit. Here the feedback cycle, lack of channels to “voice,” and a psychological unsafe environment were the cause. Unfortunately NASA is the poster child for organizations that do not learn from their mistakes. Case in point: the flight director for the ill-fated Columbia mission was promoted.
I experienced the Cassandra Effect first hand. It’s a weird feeling. One that is hard to describe and it makes even you question your reasons at the time. It’s like a mental probability analysis and the failure requires certain conditions to happen or as some people refer it to a “perfect storm”. Safety is not only policies and procedures it’s leading by example. Unless an organization has a top down safety approach the program will fail.Safety needs to be part of the fabric of a worker. When they come to work it’s like another layer of clothing they need to put on, and I don’t mean personal protective equipment.
Please contact me if you would like to discuss or need a safety consultant.
Allen:
I can only relate what I was told by a first hand witness to the events. I can assure you that the people to whom I have spoken blamed themselves for not having made a more compelling argument against the launch. I do agree however, that the bulk of the blame lies with the team who ultimately made the decision—and also with a system where concerns were allowed to be ignored.
I think you are missing the primary point I was making, however. Unless one is unable to make one’s point credibly, coherently, and compelling enough to engage another to act one’s point is moot. After a tragedy “I told you so’s” offer little comfort. After all, it’s always better to be the worst part of a success than the best part of a failure.
Phil La Duke
http://www.philladuke.wordpress.com
http://www.rockfordgreeneinternational.wordpress.com
I was at Morton Thiokol working in the hazard analysis department at the time of the Challenger incident. I must respectfully disagree with much of the ultimate conclusions of the article. Management insisted that engineers virtually guarantee 100% that the shuttle boosters would explode if lauched. I cannot think of any but the absolute rarest of cases where a knowledgable system safety practicioner would state with 100% certainty that an incident was going to occur the very next time an operation, task, or process were to occur. There were many additional management pressure both internal and from NASA at the time that I won’t go into (including ignoring of range safety rules at NASA regarding launching in cold conditions. In addition, there were technical flaws in the assumptions NASA imposed as to what consituted a catastrophic vs critical hazard in the FMEA process. Some engineers who came out of the crucial meetings were shaken and clearly stated to coworkers they believed a disaster was very likely to occur. To this day I get a bit angry whenever I see blame diverted away from those who were responsible for the decision. I liken this to blaming the operator for engineering and management shortcoming. Rather, in this case, management blaming engineers for being ignored by management.
Interesting idea, and of course jargon is always important, but it’s just one part of communications and poor communications is always a concern. Nothing new here! However, in this case I think to place the blame on jargon is totally bogus and ill thought out. The managers understood the data and still made the decision regardless. Using “jargon” as the cause to remove the blame from management, or excuse management, does no one any good. What is needed is a better managment establishment that takes safety “seriously” and is willing to take the heat to stop unsafe acts even when it’s not ploitically correct to do so. I have worked on many different programs in my career and it’s my feeling that managment typically take safety seriously only up the point of their minmal pain/career threshold.
Great informative useful article, thanks for sharing.