Thursday, June 21, 2018

Theranos and O-rings: A Note on Disaster Avoidance

On a cold Florida morning in late January 1986, the space shuttle Challenger lifted off from Cape Canaveral.  Just over a minute into the flight the vehicle blew apart and disintegrated, killing all 7 astronauts.  The immediate cause of the failure was a breach in a joint of the solid rocket booster resulting from O-rings that had stiffened and shrunk in the cold.  The maker of the O-rings was Morton Thiokol.

The evening before, knowing that temperatures at launch time could be as low as 30F, NASA and Thiokol representatives conducted a lengthy conference call.  NASA had an ambitious flight schedule and wanted to launch.  Thiokol engineers knew that the O-rings might fail in the cold and came armed with data.  There was shouting, maybe some table pounding.  NASA pressed.  The Thiokol engineers dug in.  Management backed its engineers.  "We all knew if the seals failed the shuttle would blow up," one engineer remembered.

And then something happened.  Thiokol management caved, overruling its engineers.  The launch was approved.

I sometimes think of this reversal as a “Morton Thiokol Moment”—when you absolutely, positively know the right thing to do but let yourself get talked out of it anyway.  Maybe it's pressure.  Maybe exhaustion.  Maybe the other side is so adamant that it creates a bit of doubt.
The next day, the inevitable happened.  "When we were one minute into the launch,” a Thiokol engineer recalled, “a friend turned to me and said, 'Oh God. We made it. We made it!'  Then, a few seconds later, the shuttle blew up. And we all knew exactly what happened."