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I'm literally guest lecturing at a Harvard class tomorrow on systemic failures in decision making, using the Columbia and Challenger disasters as case studies,

• actimod 6mo ago
  It is bound to happen again and again considering humans are so oblivious to safety.
  • danesparza 6mo ago
    Then explain the Apollo program, and the actual printed literature that came out of the program that summarized how they were successful.
    • mathgeek 6mo ago
      If you're looking for programs where mistakes were not made, Apollo is not the program to choose. I highly recommend visiting Kennedy Space Center some time where they go in-depth on how close it came to never happening after Apollo I. https://en.wikipedia.org/wiki/Apollo_1 https://en.wikipedia.org/wiki/Apollo_1 That being said, I'm a big proponent of "you can't make ICBM's carrying humans 100% safe", but you sure can try your best.
    • mikkupikku 6mo ago
      Apollo killed three astronauts. NASA learned some lessons from that and the rest of the program was safer, although still extremely risky.
  • hluska 6mo ago
    I wouldn’t say humans are oblivious to safety. The Apollo program was very successful as long as you’re not related to Gus Grissom, Ed White or Roger Chaffee. But those three (preventable) deaths aside, Apollo was quite successful and figured out some huge problems. If you’re interested in a heck of a good read, the Columbia Accident Investigation Report is a good place to start: https://ehss.energy.gov/deprep/archive/documents/0308_caib_report_volume1.pdf https://ehss.energy.gov/deprep/archive/documents/0308_caib_r... It looks at the safety culture in NASA and at how that safety culture ran into budget issues, time pressure and a culture that ‘it’s always been okay’. But people were aware of the problems. There’s a really frustrating example from Columbia where engineers on the ground badly wanted to inspect the shuttle’s left wing from the ground using ground based telescopes or even observations from telescopes or any other assets. There’s footage available was an email circulated where an engineer all but begged anyone to take a look with anything. That request was not approved - they never looked. Realistically there’s a point to be made that NASA wasn’t capable of saving those astronauts at that point. But they had a shuttle almost ready to to, they could have jettisoned its science load and possibly had a rescue of some sort available. They never looked though but alarm bells were ringing. It’s more accurate to say people are highly aware of safety but when you get a bunch of us together, add in cognitive biases and promotion bands we can get stuck in unsafe ruts.
    • sfn42 6mo ago
      I'd say it's more accurate to say the people who are actually smart work as engineers. Leadership is generally engineers who were better at office politics than engineering, or just business majors etc. So you have a group of really talented people using their talents to do awesome things, and then you have some useless idiots who are good at kissing the right asses, running the show and taking most of the credit. And that's how you end up killing astronauts, because the useless assholes in charge aren't even competent enough to recognize when they should listen to the brains of their operation. All they care about is looking good to their superiors and hitting some arbitrary deadline they've decided to set for no damn reason etc.
  • CWuestefeld 6mo ago
    humans are so oblivious to safety It seems that in modern times, humans focus on safety almost to the exclusion of everything else. As much as the more traditional salutations "godspeed" or "have a nice day", we're even more likely to hear "drive safe" or "have a safe trip" or "be safe". We're very nearly paralyzed by insisting that everything must be maximally safe. Surely you've heard the mantra "...if it saves just one life...". The optimal amount of tragedy is not zero. It's correct that we should accept some risk. We just need to be up-front and recognize what the safety margins really are.
    • MeetingsBrowser 6mo ago
      > We're very nearly paralyzed by insisting that everything must be maximally safe. Are we? People saying "have a safe trip" is pretty weak evidence. The counter evidence is just about everything else going on, at least in the US. Relaxed worker safety standards, weakened environmental protections, and generally moving as fast as possible.
      • adamsb6 6mo ago
        My kids are going to be legally mandated to be in car seats until they’re about 12 years old.
        • MeetingsBrowser 6mo ago
          Your implied frustration at a relatively easy change backed by experts and mountains of data is another point in favor of > humans are so oblivious to safety
          • enoch_r 6mo ago
            We have 4 kids. Before we had our 3rd, we needed to buy a new vehicle solely because we couldn't fit 3 car seats into the back of our old car. And when traveling with kids, carrying 4 gigantic car seats plus your other luggage is not exactly as easy as you might think! It essentially rules out solo parent travel with all 4 kids. Transferring car seats between two cars, or installing car seats in a taxi, is a serious pain. Furthermore, the evidence that car seats actually benefit safety is significantly less robust than you might think. The "mountains of evidence" that do exist for things like 70% reductions in fatalities, bizarrely enough, generally compare the rate of fatalities for car seats vs completely unrestrained kids. When you compare the rate of fatalities in car seats to kids wearing adult seat belts, the bulk of the evidence suggests essentially no difference. Fatalities happen when the forces involved are catastrophic and sadly a car seat doesn't help much for kids over 2. Even a back of the envelope comparison makes this extremely plausible: car crash fatalities for kids 9-12 have declined by 72% from 1978-2017. If car seats and car seat laws save significant numbers of lives, you'd expect that the fatality rate for kids 0-8, who are generally in car seats, to have decreased much more. But it hasn't, it declined by 73% over the same period. Now, car seats and boosters do seem to moderately reduce non-fatal injuries - huge spread of estimates here, most clustering around 10-25%. It's reasonable for most people to use car seats or boosters most of the time based on this alone, IMO, especially for young kids. But do they justify a mandate? IMO: no. Absolutely not. Worth mentioning that mandates probably do succeed in one thing: they reduce the number of children born at all by at least 57x more than they prevent child fatalities. Roughly 8,000 kids per year, 145,000 kids since 1980. That's with the (unlikely, as discussed above) assumption that car seats do in fact save significant numbers of lives. But it's also entirely possible that they've prevented hundreds of thousands of kids from being born, somewhat reduced the nonfatal injury rate, and saved essentially no lives. Citations below: Fatality reduction with car seats or boosters: - https://pricetheory.uchicago.edu/levitt/Papers/seatbelts.pdf https://pricetheory.uchicago.edu/levitt/Papers/seatbelts.pdf (found that seat belts as effective as car seats for children 2-6) - https://onlinelibrary.wiley.com/doi/10.1002/jae.2449 https://onlinelibrary.wiley.com/doi/10.1002/jae.2449 (independent replication of above with different data set) - https://pubmed.ncbi.nlm.nih.gov/19959729/ https://pubmed.ncbi.nlm.nih.gov/19959729/ (no statistically significant difference between booster seats and seat belt alone for fatalities) - https://pubmed.ncbi.nlm.nih.gov/16754824/ https://pubmed.ncbi.nlm.nih.gov/16754824/ (the main counter-estimate to the above, with the 28% fatality reduction) Non-fatal injury reductions: - https://ideas.repec.org/a/bla/ecinqu/v48y2010i3p521-536.html https://ideas.repec.org/a/bla/ecinqu/v48y2010i3p521-536.html (no difference in serious injuries, ~25% reduction in least serious injury category) - https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/811338 https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/... (14% reduction in likelihood of injury for boosters) - https://pubmed.ncbi.nlm.nih.gov/19841126/ https://pubmed.ncbi.nlm.nih.gov/19841126/ (45% estimate) - https://pubmed.ncbi.nlm.nih.gov/12783914/ https://pubmed.ncbi.nlm.nih.gov/12783914/ (59% estimate) Reduction in birth rate from car seat mandates: - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3665046 https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3665046 (car seat mandates "led to a permanent reduction of approximately 8,000 births in the same year, and 145,000 fewer births since 1980, with 90% of this decline being since 2000") Note that both the 45% and 59% estimate for injury reduction and the 28% estimate for fatality reduction all come from one research group using a proprietary data set. Everything that's independently reproducible points towards small or zero effect on fatalities and modest effects on injuries.
  • irchans 6mo ago
    Us humans do have difficulty with safety. Sometimes we are able to overcome that problem to an extent. Here are some the few examples where humans have done well with safety: FAA commercial airlines, Soyuz, ISS, Shinkansen trains, US Nuclear power post 3 mile island, Vaccines, and the Falcon 9.
  • nritchie 6mo ago
    Maybe not so much "oblivious to safety" as "oblivious to probable risk." We worry to much about low risk events (like airline flights) and don't worry enough about higher risk events (like trips-and-falls, driving a car, poor diet...)
• hluska 6mo ago
  The most frustrating part of the whole thing is that when you read Charles Camarda’s thoughts after his meeting with NASA in January, it could have been written in 1986 or in 2003. https://docs.google.com/document/u/1/d/1ddi792xdfNXcBwF8qpDUxmZzIksrs0jy/mobilebasic https://docs.google.com/document/u/1/d/1ddi792xdfNXcBwF8qpDU... It’s pretty clear at this point that the shuttle was already broken at design. But seeing the same powder keg of safety/budget/immovable time constraints applied to a totally different platform decades in the future feels like sitting through a bad movie for the third time.
  • randomNumber7 6mo ago
    [flagged]
    • knappe 6mo ago
      This is so distasteful. We're talking about the potential death of astronauts here. Maybe be a little less glib and uncaring.
• inaros 6mo ago
  [flagged]
  • iwontberude 6mo ago
    Those astronauts don’t have anyone that loves them at home because no way in hell would any of my loved ones let me be a sacrificial turkey in a fully automated oven.
    • inaros 6mo ago
      They do, but they are not in a position to judge. Same way as the Challenger crew despite NASA and astronauts saying, "we would not fly we would not believe to be safe enough".
  • tomjen3 6mo ago
    Didn't they have a crash dummy in it the last time? The data from buster should be able to tell us if the parachute worked or not.
  • tchebb 6mo ago
    What you have written here is pretty much exactly the contents of the article we are all commenting on.
• thesuitonym 6mo ago
  ``It is difficult to get a man to understand something, when his salary depends on his not understanding it.''
  • randomNumber7 6mo ago
    Isn't NASA run by the government? Why not pay people to do their job correctly?
    • jabl 6mo ago
      Because the grifters are running the show. The point is not to fly to orbit/moon/mars/whatever, but shovel taxpayer money to politically well connected large aerospace contractors.
    • gojomo 6mo ago
      The word "government" doesn't magically erase all the same individual & institutional incentives, ambitions, biases, & flaws that exist elsewhere. And sometimes, the extant magical belief that "government" is different & immune lets those same human factors be ignored until they feed bigger, slower disasters that everyone is afraid to admit, because (ostensibly) "we all did this together".
    • nostrademons 6mo ago
      Just because you pay people doesn't mean they do their job correctly. It just gives you the option of not paying them if they don't do their job correctly.
    • bell-cot 6mo ago
      Is "Why not pay people to do their jobs correctly?" a way of voicing frustration with massive gov't incompetence? Or a way of saying that organizational incompetence is top-down?
      • randomNumber7 6mo ago
        Both, but its also a genuine question. If you look at the Boeing 737 max for example they did it clearly with the idea of profit. I can understand the reasoning (it is still criminal and people should have gone to jail imo). Why you would pay something like that with tax money is beyond my understanding.
• jessewmc 6mo ago
  As an aside, do you have any suggestions for "state of the art" reading on safety culture?
  • FrustratedMonky 6mo ago
    I just had a conversation about engineers not understanding the need for grounding. I'm wondering if every generation has to relearn the basics for themselves through experience. Each generation has to make the same mistakes. Because book learning doesn't seem to do it for some things.
    • cindyllm 6mo ago
      [dead]
    • randomNumber7 6mo ago
      Most people are just resistant to learning (without pain).
    • trey-jones 6mo ago
      Sure. Even a history of safety success contributes to this. We haven't had an accident in 3000 days, what was dangerous about this job again? Also what's this stupid policy for anyway, I've never seen anybody even come close to (non-dangerous-sounding fate) while working here. But probably the policy is in place because it used to happen before the policy was in place. It's just not obvious to people who have never seen the consequences before.
      • HeyLaughingBoy 6mo ago
        Complacency kills! It's why it's usually the old farmers that die in stupid ways. I'm also reminded of the Yale machine shop safety supervisor who died by getting herself wound around a lathe spindle. Working alone, late at night on powerful rotating machinery wearing loose clothing.
        • 6mo ago
• AndrewKemendo 6mo ago
  It’s fundamentally a human coordination problem that cannot be solved The more populated and complex an organization gets it becomes impossible to maintain a singular value vector (get these people around the moon safely) Everyone finds meta vectors (keep my job, reduce my own accountability) that maintain their own individual stability, such that if the whole thing fails they won’t feel liable
  • njovin 6mo ago
    It can't be solved 100%, but it can be _mostly_ solved with systemic buy-in to the safety culture. Commercial aviation is a great example IMO. We've spent the last several decades making sure that every single person trained to participate in commercial aviation (maintenance, pilots, attendants, ATC, ground crew) knows their role in the safety culture, and that each of them not only has the power but the _responsibility_ to act to prevent possible accidents. The Swiss Cheese Model [1] does a great job of illustrating this principle and imparting the importance of each person's role in safety culture. A big missing piece with manned space flight IMO is the lack of decision-making authority granted to lower staff. A junior pilot acting as first officer on their very first commercial flight with real passengers has the authority to call a go-around even if a seasoned Captain is flying the plane. AFAIK no such 'anyone can call a no-go' exists within NASA. [1] https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model
    • AndrewKemendo 6mo ago
      No, CRM is a disaster you clearly are not in aviation. The reliability in aviation came from incredibly strict regulation and engineering improvements, NOT from structural alignment of parties. They were forced to get safer by the government if you can believe there was a time where the government did anything useful at all. I could go off for literally hours on this topic but suffice to say I’ve done an unbelievable amount of CRM as an officer in the United States Air Force who flew on and executed 100s of combat missions in Iraq My friends from Shell 77 are all dead because of CRM failures Sounds like you need to watch the Rehearsal
• MisterTea 6mo ago
  > This broken safety culture has been around since the beginning of the Shuttle program. It's broken everywhere. I have worked in some dysfunctional shops and the problem I see time and time again is the people who make it into management are often egoists who don't care about anything other than the financial compensation and clout the job titles bestows upon them. That or they think management is the same as being a shotgun toting sheriff overseeing a chain gang working in the summer heat in the deep south. I've worked with managers who would argue with you even if they knew they were wrong because they were incapable of accepting humiliation. I worked with managers who were wall flowers so afraid of confrontation or negative emotions that they covered up every issue they could in order to avoid any potential negative interaction with their superiors. That manager was also bullied by other managers and even some employees. A lot of it is ego along with a heavy dose of machismo depending. I've seen managers let safety go right down the tubes because "don't be a such a pussy." It's a bad culture that has to go away.
  • mmooss 6mo ago
    > people who make it into management are often egoists > they were incapable of accepting humiliation I agree mostly but here is a different take on it: I think these are normal human feelings and behaviors - not the best of us, but not unusual either. If we want to get good things done, we need to work with and through human nature. Power corrupts everyone and shame is generally the most painful thing for humans. Putting people in a position where they need to treat their power with absolute humility or accept humiliation (and a major blow to their careers) in order to do the right thing is going to fail 99% of the time. (I'm not saying people can't do those things and that we shouldn't work hard and aspire to them, but it's not going to happen reliably with any but a few people.) That expectation itself is a culture, organizational and managerial failure. If you see a system in which so many fail, then the problem is the system. And when I say 'managerial' failure, I include leadership by everyone and also 'managing up'. We're all responsible for and agents of the team's results, and whatever our role we need to prevent those situations. One important tactic is to anticipate that problem and get ahead of it, putting the team in a position where the risk is proactively addressed and/or they have the flexibility to change course without 'humiliation'. We're all responsible for the team's culture. I think many blaming others underestimate their own human nature, the effect of power on them and their willingness to endure things like humiliation. Rather than criticising others, I keep my attention on the one in the mirror and on strategies to avoid situations equally dangerous to my own character; otherwise I'll end up doing the same very human things. EDIT: While I still agree with everything I wrote above, there is an exceptional cultural problem here, one which you'll recognize and which is common to many SV leaders, the Trump administration, and others you're familiar with (and which needs a name ...). From the document referenced in the OP by "heat shield expert and Shuttle astronaut Charles Camarda, the former Director of Engineering at Johnson Space Center." "Instead, the meeting started with his [Jared Isaacman, the new NASA Administrator's] declaration that the decision was final. We would launch Artemis II with a crew, even though the uncrewed Artemis I mission around the Moon returned with a seriously damaged heat shield, a failure in my opinion. I was not going to be allowed to present my position on why the decision was flawed. Instead, the public would hear, through the two reporters allowed to attend, the Artemis Program narrative, only one side of the story. They would be bombarded with technical information which they would have very little time to understand ... Jared could claim transparency because the only thermal protection expert and public dissenter, me, was present. ... I was allowed only one-day to review some of the technical documents which were not open to the public and which were classified Controlled Unclassified Information/International Traffic and Arms Regulations (CUI/ITAR) prior to the Jan.8th meeting. ..." https://docs.google.com/document/d/1ddi792xdfNXcBwF8qpDUxmZzIksrs0jy/edit https://docs.google.com/document/d/1ddi792xdfNXcBwF8qpDUxmZz...
• light_hue_1 6mo ago
  What strikes is not the systemic failures. But the intense culture of secrecy. Reports are heavily redacted. They aren't shared. Failures aren't acknowledged. Engineering models aren't released. That secrecy eventually causes what we see today.
• torginus 6mo ago
  But in the 80s I guess there was the pressure to one-up the Soviets, so everything had to be done yesterday, but Artemis has existed most of my adult life at various levels of maturity (Orion and its predecessors certainly did), and considering its been more time spent between that famous Kennedy speech and the actual Moon landing (where there was apparently no issue with safety culture). Considering how much humanity has allegedly advanced since then, I don't understand what are we gaining thats caused us to have to abandon safety.
  • youngNed 6mo ago
    > where there was apparently no issue with safety culture Narrators voice: there was, in fact, issues with safety culture at nasa between Kennedy's speech and the moon landing https://en.wikipedia.org/wiki/Apollo_1 https://en.wikipedia.org/wiki/Apollo_1
• pragma_x 6mo ago
  May as well link the full report too. IMO, this is a bit easier to read. https://ehss.energy.gov/deprep/archive/documents/0308_caib_report_volume1.pdf https://ehss.energy.gov/deprep/archive/documents/0308_caib_r...
• aaron695 6mo ago
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