**5. General unknown risk versus specific and foreknown risk**

There is a confusion that is frequently made between general and unknown risk that is operative in the universe and any specific risk that is known in advance to exist. For example, whenever one gets out of one's bed in the morning, one may trip, fall, crack one's skull and have a concussion. This is the general and unknown risk that is operative in the universe. We should not construe risk in these terms as this kind of risk exists, for the most part, outside of human control and intervention.

Risks that are foreknown in advance to the principals involved in the risk-taking are the only kind of risks that our discussion should consider. A classic case in point of the contrast that exists between general, unknown risk and specifically foreknown risk is the case of the faulty and dangerous O-rings that were known in advance to exist (by managers and engineers though not by the principal risk takers) prior to the fatal flight of the space shuttle *Challenger.* The classic case of the *Challenger* disaster can be used to illustrate the fallacies of the concept of 'risk management' and the need to replace this concept with the more accurate, new concepts of 'risk taking' or 'risky decision making'. While other cases could also be chosen, the availability of overwhelming, documented evidence in the case of the

*Challenger* disaster makes it an ideal case study for the purposes of examining the concept of risk management.

On the Very Idea of Risk Management: Lessons from the Space Shuttle *Challenger* 139

thereby had given their informed consent, or, (ii) that their knowledge and thereby consent

All of the above clearly points to the fact that the objection that one always takes a general, unknown existential risk in life and is aware of this fact is irrelevant whenever there is a specifically foreknown risk that carries with it great and unfortunate consequence. These points make a further argument to support the case that the very notion of risk management needs to be replaced with the idea of risk taking when a known risk carries with it a high probability of life and death danger and there is nothing crucial to be gained by taking such a risk, such a risk is never "managed", such a risk is never *taken*. In such a case, any possibility of risk is *eliminated* by not being taken in the first place. *Risk management becomes* 

In the classic case of the space shuttle *Challenger* example, two years after the horrific event, when the official, U. S. government committee on Shuttle Criticality, Review and Hazard Analysis examined the risk that had been taken in launching the *Challenger*, the Chairman of that committee wrote in the very first paragraph of chapter four of their report, entitled

*Almost lost in the strong public reaction to the Challenger failure was the inescapable fact that major advances in mankind's capability to explore and operate in space – indeed, even in routine,* 

And, later, in the body of that same report, the Committee wrote: 'The risks of space flight

It is rather easy to spot the fallacy that is being made in this case. It is the fallacy of equating a general unknown risk (space flight in general) with a specifically foreknown fatal risk (the flawed design of the O-rings about which the senior engineer Roger Boisjoly had issued red flagged warnings).13 If the committee were pressed on this matter and replied that they were aware that there was some risk in the use of the technology employed at the time (the hazardous O-rings), in the case of the *Challenger* disaster, what the Committee on Shuttle Criticality, Review and Hazard Analysis would then seem to be saying is that it was justifiable to employ the 'risky technology' that was employed at the time because of the understanding that in order to make progress in space exploration that one was required to take chances with very risky technology. Is this actually the case? Was it necessary to take cavalier chances with risky technology in order to make progress in the arena of space exploration? The implication is that the risk would have to be taken and the "management" of the risk would seem to amount to something on the order of crossing one's fingers, and

12 Preface by Alton Slay, Chairman, Committee on Shuttle Criticality, Review and Hazard Analysis, *Post-Challenger Evaluation of Space Shuttle Risk Assessment and Management*, Washington, D.C.: National Academy Press, 1988, p. v; p.

13 Robert Elliott Allinson, *Saving Human Lives, Lessons in Management Ethics*, Dordrecht: Springer, 2005, p. 138.

*risky management.* We can now turn to the examination of risky management.

**6. Risky technology versus risky management** 

*atmospheric flight – will only be accomplished in the face of risk.* 

must be accepted by those who are asked to participate in each flight …12

'Risk Assessment and Risk Management':

hoping that nothing would happen.

33.

to take such a risk, was completely irrelevant.

One can argue, fallaciously, that whenever an astronaut goes into space, that astronaut is subject to that general, unknown, universal-style risk of space travel. This, however, is not comparable to an astronaut going into space equipped with the full knowledge of the existence of a real, specific and pre-existing mechanical fault that could be potentially fatal to her or his space craft. It is only with the latter kind of known risk, known fully to those taking the risk, that a discussion on risk management should focus. Such was not the case with the astronauts and civilian passengers of the U.S. space shuttle, *Challenger*.

In the case of the *Challenger* launch, the overwhelming evidence has revealed that the astronauts were completely unaware of the specific dangers that the O-rings posed. According the Malcolm McConnell, the science reporter, no one in the astronaut corps had been informed of any problem with the SRB field joints.8 According to Charles Harris, Michael Pritchard and Michael Rabins, authors of *Engineering Risks, Concepts and Cases*, '… no one presented them [the astronauts] with the information about the O-ring behavior at low temperatures. Therefore, they did not give their consent to launch despite the O-ring risk, since they were unaware of the risk.'

Claus Jensen writes in *No Downlink, A Dramatic Narrative about the Challenger Accident and Our Time*, that when the Rogers commission summoned a group of space shuttle astronauts, 'During this session, the astronauts reiterated that they had never been told about the problems with the solid rocket booster.' And, in a private correspondence with the present author and Roger Boisjoly, the late senior scientist and the engineer who knew the most about the O-rings, Boisjoly wrote, 'I KNOW for a FACT that the astronauts on Challenger did NOT KNOW about the problem with the O-rings at temperatures below 50 degrees F.' (emphasis his)9 According to Richard Lewis' book, *Challenger, The Final Voyage*, 'Along with the general public, the astronauts who were flying the shuttle were unaware of the escalating danger of joint seal failure. So were the congressional committees charged with overseeing the shuttle program. NASA never told them that the shuttle had a problem.' Later, in the same work, Lewis pointedly quotes from the Presidential Commission report:

*Chairman Rogers raised the question of whether any astronaut office representative was aware [of the O-ring problem]' Weitz, [an astronaut's representative] answered: "We were not aware of any concern with the O-rings, let alone the effect of weather on the O-rings.10*

Despite the very clear declarations above, nowhere in the 575 pages of Diane Vaughan's book, *The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA*, is it ever mentioned that the astronauts and the civilians were not informed of the O-ring dangers.11 By not ever mentioning this crucial point of information, her book leaves one with the impression either" (i) that the astronauts knew about the risk they were taking and

<sup>8</sup> Robert Elliott Allinson, *Saving Human Lives, Lessons in Management Ethics*, Dordrecht: Springer, 2005, p. 156.

<sup>9</sup> *Ibid*., p. 184.

<sup>10</sup>*Ibid*., pp. 184-5, 187.

<sup>11</sup>*Ibid*., p. 187.

thereby had given their informed consent, or, (ii) that their knowledge and thereby consent to take such a risk, was completely irrelevant.

All of the above clearly points to the fact that the objection that one always takes a general, unknown existential risk in life and is aware of this fact is irrelevant whenever there is a specifically foreknown risk that carries with it great and unfortunate consequence. These points make a further argument to support the case that the very notion of risk management needs to be replaced with the idea of risk taking when a known risk carries with it a high probability of life and death danger and there is nothing crucial to be gained by taking such a risk, such a risk is never "managed", such a risk is never *taken*. In such a case, any possibility of risk is *eliminated* by not being taken in the first place. *Risk management becomes risky management.* We can now turn to the examination of risky management.
