This week, I’d like to acknowledge the first anniversary of the passing of engineer Bob Ebeling.

Mr. Ebeling—who died last year on March 21st, at the age of 89—was one of the Morton-Thiokol engineers who tried to warn NASA that the O-rings he helped design for their space shuttles weren’t safe at cooler temperatures. As we all know, the shuttle Challenger exploded shortly after take off on a brisk January morning for this very reason, killing all 7 crew members.

I mention this today not just to pay my belated respects to a fellow engineer and scientist. For me, Mr. Ebeling’s story is also a powerful—and sober—reminder of just what can be at stake when we talk about management, management’s decisions, and the consequences for those affected by them.

 

“The Challenger is going to blow up.”

These are words Mr. Ebeling (pronounced EBB-ling) said to his daughter, Leslie, as they drove to the headquarters of his employer, the aerospace contractor Morton-Thiokol, to watch the Challenger’s launch.

He then added, “Everyone is going to die.”[1]

If anyone could have known this for certain, it would have been Ebeling. Having helped design the shuttle’s O-rings, he was well aware of their limitations – one of which was poor performance at low temperatures. To bring attention to the problem, Ebeling had gone so far as to circulate a memo within Morton-Thiokol with the subject heading “Help!”, but to no avail.[2] And the day before Challenger’s launch, Ebeling and his colleagues argued passionately for a postponement in conference calls with NASA managers at the Kennedy Space Center in Florida and the Marshall Space Flight Center in Huntsville, Ala. In the end, however, they were overruled – both by NASA, and their own managers.[3]

This decision of course had terrible consequences. Not only did seven astronauts lose their lives, millions of schoolchildren were traumatized as they witnessed the death of Christa McAuliffe—who would have the first schoolteacher in space—play out on live television.

But no one, it seems, took it harder than Mr. Ebeling.

According to a touching obituary written by William Grimes of The New York Times, Ebeling left the engineering profession entirely following the accident, and was thought to have never fully recovered. In 1987, he told the Houston Chronicle, “I have headaches. I cry. I have bad dreams. I go into a hypnotic trance almost daily.” And in an interview with Howard Berkes of NPR on the 30th anniversary of the disaster, Ebeling said:

I think this was one of the mistakes that God made. He shouldn’t have picked me for that job. I don’t know, but next time I talk to him, I’m going to ask him, ‘Why? You picked a loser.’

 

“A kind of Russian roulette…”

According to the Rogers Commission, the body created by then President Ronald Reagan to investigate the matter, the Challenger disaster was indeed the result of a failed O-ring on the shuttle’s solid rocket booster, just as Ebeling had warned.[4]

But management, they felt, was also responsible.

According to the commission’s findings, NASA and Morton-Thiokol had known of the O-ring problem—and the potentially catastrophic consequences of their failure—as far back 1977. Serious O-ring erosion had also been observed on the second shuttle mission—that of the Columbia—in 1981, but it still was not addressed.[5] In fact, after repeated launches with no major incident, it seems that NASA and Morton-Thiokol simply concluded that the issue had resolved itself. As the commission wrote in its report:

“The Space Shuttle’s Solid Rocket Booster problem began with the faulty design of its joint and increased as both NASA and contractor management first failed to recognize it as a problem, then failed to fix it and finally treated is as an acceptable flight risk.”[6]

Other poor decisions and practices by management were also cited by the commission:

“The Commission is troubled by what appears to be a propensity of management at Marshall [Space Flight Center] to contain potentially serious problems and to attempt to resolve them internally rather than communicate them forward.”[7]

They also singled out for criticism Morton-Thiokol’s decision to ignore the warnings of their own engineers:

“…Thiokol Management reversed its position and recommended the launch [of the Challenger], at the urging of Marshall contrary to the views of its engineers in order to accommodate a major customer.”[8]

But Richard Feynman, the Nobel Prize-winning physicist—and a member of the Rogers Commission—was a bit more blunt in his assessment. He characterized NASA management’s decision making with respect to shuttle launches as playing “a kind of Russian roulette.”[9]

 

Management matters

To be sure, there is no doubt that those at NASA, Morton-Thiokol, and anyone else affiliated with shuttle program wanted anything other than to keep those astronauts as safe as humanly possible. Having worked in the sciences myself for a time, it is my belief that those who enter such fields bring with them their best selves, and their best intentions.

Nor were the pressures that NASA and Morton-Thiokol were under that day likely to be unfamiliar to anyone who’s ever been in a position of management. Not only was the world watching owing to Ms. McAuliffe’s participation in the mission, Challenger’s lift-off had already been postponed repeatedly.[10] Management officials at these organizations might thus be forgiven for hoping to avoid further delays.

So if I have anything at all to add to any of this, it is perhaps simply to ask the following:

How is that a group of people, who without exception were undoubtedly well-intended individuals, collectively come to make such a terrible series of decisions?

Is there something about the way we, as human beings, currently organize that might contribute to this? Could there be something systemic, in other words, that creates an organizational condition that would account for why the correct decision (to heed Ebeling’s warnings) instead loses out to the worst possible option?

 

You have to have an end to everything.”

In the aftermath of the disaster, NASA would suspend shuttle flights for 32 months. The organization also initiated a total redesign of the solid rocket boosters, which was overseen by an independent governing body as stipulated by the Rogers commission. Nevertheless, another space shuttle disaster in 2003—that of the Colombia—and its subsequent investigation, revealed that NASA had failed to learn many of the lessons of Challenger disaster.[11],[12]

As for Mr. Ebeling, according to Mr. Grimes’ obituary, he spent much of his time and efforts on issues of conservation following the loss of the Challenger. After leaving Morton-Thiokol, he volunteered at the Bear River Migratory Bird refuge near his home in Brigham City, Utah. Later, he helped raise money for restoration efforts after it was damaged by flooding. His engineering background was also to prove useful in repairing dikes and other water control structures in the area. And in 1990, Ebeling received the Theodore Roosevelt Conservation Award for this work from President George Bush.[13]

His 2016 interview with Mr. Berkes on NPR was to touch thousands of listeners, and prompted an outpouring of sympathy and support. This included his former boss at Morton-Thiokol who called to tell him that he was not a “loser,” and that “a loser is someone who has a chance to act and doesn’t, and worse, doesn’t care.”[14]

All of which seems to helped. Less than a month before he passed away, Ebeling had this to say to his well-wishers in a follow-up interview with Mr. Berkes:

“You helped bring my worrisome mind to ease. You have to have an end to everything.”[15]

Robert Ebeling, 1926-2016. May he rest in peace.

 

 

Endnotes

[1] “Robert Ebeling, Challenger Engineer Who Warned of Disaster, Dies at 89” by William Grimes. The New York Times (online), March 25, 2016. https://www.nytimes.com/2016/03/26/science/robert-ebeling-challenger-engineer-who-warned-of-disaster-dies-at-89.html?_r=0. Retrieved March 23, 2017.

[2] https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster. Retrieved March 23, 2017.

[3] Grimes, op. cit.

[4] Space Shuttle Accident and the Rogers Commission Report. 1986. p. 40&73. https://history.nasa.gov/rogersrep/genindex.htm. Retrieved March 24, 2017.

[5] https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster. Retrieved March 23, 2017.

[6] Ibid., p. 121.

[7] Ibid., p. 105.

[8] Ibid., p. 105.

[9] Ibid., p. 149.

[10] https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster. Retrieved March 23, 2017.

[11] https://en.wikipedia.org/wiki/Space_Shuttle_Columbia_disaster. Retrieved March 23, 2017.

[12] Colombia Accident Investigation Board Report, 2003. https://spaceflight.nasa.gov/shuttle/archives/sts-107/investigation/CAIB_medres_full.pdf. Retrieved March 23, 2017.

[13] Grimes, op. cit.

[14] Grimes, op. cit.

[15] “Your Letters Helped Challenger Engineer She 30 Years of Guilt” by Howard Berkes. NPR. Aired February 25, 2017. http://www.npr.org/sections/thetwo-way/2016/02/25/466555217/your-letters-helped-challenger-shuttle-engineer-shed-30-years-of-guilt. Retrieved March 23, 2017.