Netflix has a new four-part documentary out called Challenger: The Final Flight on the January 1986 space shuttle disaster. As other reviewers have written, the documentary does an excellent job telling the stories of the ordinary people, engineers, NASA employees, journalists, astronauts, and families affected by the explosion. The use of archival video footage is excellent and the historical re-enactments are tasteful. Even folks highly knowledgeable about the episode will learn something new. I consider myself moderately informed about it, and I for one learned that Peter Billingsley (Ralphie from A Christmas Story) was at the launch as part of the Young Astronauts program.
The documentary does a good job explaining the proximate cause of the Challenger explosion as well. In brief, cold weather the day of the launch caused rubber O-rings on one of the shuttle’s solid rocket boosters (SRBs) to fail, which caused exhaust gasses from the to leak out from the side of the rocket:
This exhaust plume led the main fuel tank to explode and the orbiter to break apart. Most tragically of all, the astronauts were still alive and probably conscious after the initial explosion. It is most probable that the astronauts died when the crew cabin hit the water at over 200 miles per hour several minutes after the explosion.
Beyond the proximate cause, the documentary follows the explanation of the distal causes of the accident endorsed by the Rogers Commission. Their hearings received extensive media coverage at the time, including Richard Feynman’s famous demonstration placing rubber O-rings in ice water, and their findings correspond largely to the public narrative that crystalized in the aftermath. The Rogers Commission blamed organizational malfeasance and faulted NASA middle-management for launching in unsafe conditions, a culture focused on “producing” shuttle launches at the expense of safety in the shuttle program, and ignoring warnings regarding the effects of cold temperatures on the SRB O-rings.
This narrative became widely accepted in the aftermath of the disaster. On the whole, the documentary portrays NASA managers as the villains in this story for gambling with astronauts’ lives. The sociologist Diane Vaughan calls this common explanation of managerial wrongdoing in representations of organizational failure the “amoral calculator hypothesis”: driven by organizational goals, competitive pressure, or just naked self-interest, rational managers will break the law or compromise safety if they believe the expected benefits outweigh the expected costs.
As Vaughan has shown in her comprehensive study of NASA’s organizational and safety culture leading up to the Challenger disaster, however, a story of middle-management gambling with astronauts lives misconstrues the relationship between safety and risk-taking in the shuttle program. Vaughan shows that rather than political considerations and “production pressure” directly overriding safety concerns, even during discussions the night before the launch over whether to delay in view of the cold temperatures, a combination of factors had caused the safety culture to redefine unexpectedly poor performance by the O-rings as acceptable risks. Vaughan called this phenomenon the “normalization of deviance.”
One provocative implication Vaughan draws from her work is that NASA’s decision to launch was justifiable within accepted safety norms at the time in the organization. Rather than a story of self-interested managers overriding concerned engineers, Vaughan argues that the problem lay with how engineers and managers working on the shuttle program had come to understand “acceptable risk.” The result was that concerns regarding the low temperatures the night before launch, which engineers had raised concerns about the effect of cold temperatures on the O-rings and recommended a delay in the launch, were rationally regarded as “excessively” risk-averse. There is a fascinating moment in the third episode of the documentary when one of the NASA managers at the meeting claims, “the data did not support the conclusions [the engineers] were making. The data was [sic] totally inconclusive.” Rather than explore this claim, however, the documentary simply sails on without any further reflection on the nature of the disagreement and the existing safety norms.
My point here is not to exculpate NASA management or claim that the decision to launch on January 28th was unproblematic. Rather, what Challenger: The Final Flight gets wrong is that it misses the really hard problem with risk and safety. In a sense, the “amoral calculator” explanation endorsed by the Rogers Commission makes the problem of safety too easy. What we need to do, on this view, is to promote safety culture and protect it from bad actors. What Vaughan points out, however, is that our safety cultures themselves can be deformed from the inside, but it is not easy to deforming influences from the normal process of learning and adjustment especially in novel, experimental systems like the shuttle. More safety, paradoxically, is not always safer. Engineers are well aware of how procedures facially intended to increase safety can reduce them by increasing system complexity. Moreover, choices around safety and risk invariably embody value choices. How much risk should we expect astronauts and their families to accept? These are the really hard questions that cases like the Challenger explosion raise and which, unfortunately, Netflix’s new documentary sidesteps.