Richard Feynman, the late Nobel laureate and CalTech physicist, saw that “bulletized” thinking contributed to the Challenger disaster, where 7 crew members died and a multi-billion dollar craft destroyed due to an O-ring failure. The big problem was that NASA management wasn’t really listening to the engineers – and breaking issues up into bullets helped them do that.
We looked at the summary of the report. Everything was behind little bullets, as usual. The top line says:
- The lack of a good secondary seal in the field joint is most critical and ways to reduce joint rotation should be incorporated as soon as possible to reduce criticality.
And then, near the bottom, it says:
- Analysis of existing data indicates that it is safe to continue flying existing design as long as all joints are leak checked* with a 200 psig stabilization . . .
I was struck by the contradiction: “If it’s ‘most critical,’ how could it be ‘safe to continue flying’? What’s the logic of this?”