**9. Subjective judgment versus performance data**

The Nobel laureate physicist, Richard Feynman was shocked to learn that NASA management had claimed that the risk factor of a launch crash was 1 in 100,000 which they had arrived at through a subjective engineering judgment without relying upon any actual past performance data. If one calculated risk based upon actual past performance data, the risk was, according to Professor Feynman, 1 in 100.29 While management, in defending its decision to launch, pointed to the risk involved as being 1 in 100,000, there was no examination of how these figures were generated. If one took the actual performance data of rocket engines in the past, as the Nobel laureate physicist Roger Feynman did, the risk was far greater. When one does this, one can more clearly consider the case of the possibility of incidence versus the actuality of consequence. Does one wish to risk the lives of the astronauts and the civilians when the chance of their death is 1 in 100?

144 Risk Management – Current Issues and Challenges

accurate.

House later denied it.

wrote: 

<sup>26</sup> *Op. cit*.., p. 156.

*of the Space Age*, New York: Avalon, 2006, pp. 177-8.

In the case of the red-flagged warnings, regarding the launching of the *Challenger*, the consequences were not the consequences marked out by the Committee on Shuttle Criticality, Review and Hazard Analysis. The consequences marked by that Committee were outlined in terms of the risk that was to be accepted in terms of general space exploration. The implication is that those who accepted such a risk were space explorers and that they were fully aware of the risk that they were taking. Neither of these implications is

The first straw man was to examine the case as if all aboard were astronauts. This assertion was contrary to fact. Not every person aboard the shuttle was an astronaut. In addition to the five astronauts, one of whom was a female, Judith Resnik, there were two passengers: one, a junior and high school teacher, a 37 year old mother of two, Christa McAuliffe and the other, Greg Jarvis, an engineer from Hughes Aircraft (not a member of the Astronaut Corp) who had been given a ride in a space flight as a prize for winning a company competition. Mrs. McAuliffe was scheduled to deliver a nationwide "lesson from space" called the "Ultimate Field Trip" to the nation's school children. She was also supposed to

Part of the consequences, then, was the risk of the death of two civilians, who were there, not to operate the space craft, but one to act as a Teacher in Space and the other to claim his contest prize. Both civilians were given the deceptive, camouflage designation of "payload specialists" that implied some kind of crew responsibilities that did not exist. For a cover, Mr. Jarvis was given the task of conducting a fluid dynamics experiment and Mrs. McAuliffe was to videotape six science demonstrations of the effects of weightlessness on gravity, etc.25 The Teacher-in-Space mission portion was to be featured in President Reagan's State of the Union address the evening of Tuesday, January 28, though the White

The second straw man argument is to assume that knowing the risk of space flight in general was equivalent to knowing the risk of a launch under weather conditions that were known to be unsafe with the O-ring technology in use. Again, neither the astronauts nor the two civilians aboard were made aware of the risk that they were taking. They may have been aware of the existential, general unknown risk of space exploration, but they were not aware of the specific, needless risk they were actually committing to take by being launched into space with a known, faulty technology.26 Indeed, would not the inclusion of the schoolteacher Christa McAuliffe, who had been given the understanding that the launch was safe, create the vivid impression to all aboard, and to the public at large around the world that this was a very safe flight? The genuine risk being taken was perceived to be minimal around the world by the inclusion of non-necessary personnel on the shuttle.

Was Mrs. Christa McAuliffe made aware of the risk that she was taking? Grace Corrigan

25 Richard C. Cook, *Challenger Revealed, An Insider's Account of How the Reagan Administration Caused the Greatest Tragedy* 

receive a telephone call from President Reagan in mid-flight.

<sup>27</sup> Grace George Corrigan, *A Journal for Christa, Christa McAuliffe*, Teacher in Space, Lincoln and London: University of Nebraska Press, 1993, pp. 115, 118.

<sup>28</sup> *Op*. *cit*., p. 185.

<sup>29</sup> *Ibid*., p. 183.

From the above example, one can generate the conclusion that whenever possible, when calculating risk, one should not calculate risk in any other way than from the conclusions generated from actual, real-life, past performance data. The lesson to be learned is that in risk assessment, past performance data, when available, must always be consulted. One should avoid guess work. Unless the risk estimates are based on past performance data as a data base, according to Professor Feynman, 'it's all tomfoolery'.30 There is no reason why we should not learn from the lessons of the *Challenger* disaster to generalize sound conclusions concerning the method we should employ when engaging in risk assessment.

On the Very Idea of Risk Management: Lessons from the Space Shuttle *Challenger* 147

One must also be very careful when one considers safety back-ups. In engineering language, safety back-ups are referred to as redundancies. (It is important to take note of the difference in English language usage in the case of technical engineering terms and ordinary English language usage since, in the latter case, a redundancy is that which is unnecessary!) In the case of the *Challenger*, the back-up system was a secondary O-ring seal. The secondary seal was known also to be prone to failure. In effect, there was no secondary seal. Of course, if we are to consider the argument made above carefully, if the primary seal is unsafe, and the secondary seal is made from the same materials with the same design, how is it any safer? When examining any safety back-ups, one must be certain that the back-ups are not of the same faulty design as the technology that they are supposedly "backing-up". Since the Oring was considered to be at Criticality 1 (no back-up), it is thus not suprising that the

In addition, it must not be forgotten that initially all 14 engineers and managers unanimously voted against launching the *Challenger*. Such a vote of no confidence would be proof enough that all 14 engineers and managers had no confidence in the secondary seal. If, when Professor Feynman in his famous, improvised experiment during the televised hearings dropped a piece of the rubber O-ring into a glass of ice water obtained from a waiter, and demonstrated that it had no resiliency left to it at a freezing temperature and therefore could not expand to contain superhot inflammable gases, how would a second piece of the same rubber material be of any use? If one piece of rubber would not seal, why would another piece of the same rubber not also be stiff?32 There is no safety back-up if the materials of the back-up suffer from the same defect as the materials of the primary material

As a final point in the question of risk taking, we must consider what gives any person or group of people the right to make decisions which will have life and death consequences for those who partake in the actions that will take place as a result of that decision-making. It has been argued that astronauts already knew the risks of space travel when they undertake such an adventurous role. Again, this is to confuse the general unknown risk of space travel with the specifically foreknown risk of launching with an unsafe part. It is also to ignore the

What if we consider the question of decision making over life and death when the one involved is oneself? Suppose, for example, the astronauts and the civilians had been told of the dangers. It is entirely possible that the astronauts would still have chosen to launch. Even if the decision were placed in the hands of the Captain of the astronauts on that launch and he was fully informed of the dangers, should he have the right to decide if the launch should proceed? In a war, a general does decide if troops should engage in battle. There, of

secondary seal was not considered to be a back-up by this designation.

**12. The right to make decisions over others' life and death** 

fact that two civilians were aboard in addition to the five astronauts.

**11. Safety back-ups** 

they are supposedly backing-up.

<sup>32</sup> *Ibid*., p. 171.
