Safety: Culture, Risk and Death
Columbia @ 19: “the glories of an earlier time”
February 2022 is the 19th anniversary of the destruction of Space Shuttle Columbia. The entire crew of seven perished as she broke up over Texas and Louisiana during reentry.
On liftoff, a thin piece of insulating foam peeled away from the main fuel tank and the leading edge of the orbiter’s left wing struck it at a relative velocity of around 570 MPH creating a breach in the reinforced carbon.
The orbiter was doomed though the crew remained unaware.
During reentry, hot gases seeped into the wing structure and were funneled to the left wheel well, melting critical aluminum components.
Mission Control continued to track Columbia not knowing what had occurred, they found out when an engineer received a cell phone call from outside saying they had just seen the orbiter break up on live TV.
The tragedy was followed by an exhaustive investigation to determine the root cause as well as the entire chain of causes which led to the event.
The Columbia Accident Investigation Report zeroed in on NASA’s organizational culture:
“the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force.”
They further stated the culture was rooted in the Cold War era and that the successes of the Apollo Program had created a “can do” culture where NASA was the “perfect place” to work:
“NASA personnel maintained a vision of their agency that was rooted in the glories of an earlier time, even as the world, and thus the context within which the space agency operated, changed around them.”
NASA sounds like much of the fire service or vice versa.
NASA’s shuttle program was chock full of near misses which were “normalized” and accepted as part of doing business, just as many firefighters routinely accept dubious risks without a second, or even a first, thought.
100% of shuttle launches included shedding foam from the main fuel tank and thermal tiles were routinely damaged, sometimes hundreds of them from this debris.
Three months before the accident, NASA engineers wrote, “The Orbiter has not yet experienced “Safety of Flight” damage from loss of foam in 112 flights (including 3 known flights with bipod ramp foam loss)”
The odds caught up to them on the very next flight.
The investigation also revealed, in addition to the known risks, unknown ones, as well, proving that we often don’t know what we don’t know is an accurate statement.
As an example, 65 lb. bolts holding the solid rocket boosters to the main fuel tank were separated with an explosive charge with “bolt catchers” installed on the tank to catch and hold the free end. It was discovered that these devices were subpar, untested and could have allowed ricocheting debris to damage the orbiter.
Interior firefighting is a very dynamic environment where both known and unknown risks must be considered in a complex setting.
Like the shedding foam, near misses bordering on culpable negligence are examples of excess and even reckless risk acceptance. Chief fire officers who tolerate and even abet such activity should be held fully accountable for such a culture during their watch.
As General Powell once said, “You break it, you bought it.”
Each succeeding safe entry and exit under such circumstances reinforces tactical decision making which is not based in either logic or reality.
They do, however, buttress and reinforce “can do” values that are unsupported by either risk management or sound judgement.
No better example is the open competition between fire companies to have the first line on the fire even to ignoring operating procedures or the threat to other firefighting teams.
Many chief officers see such competition as an example of esprit de corps when it is the opposite: a complete lack of discipline and maturity on the part of so-called leaders.
And our “thermal tiles”, i.e. personal protective equipment, is constantly damaged with many members taking a perverse satisfaction in wearing and using items where degraded performance is a given.
Why?
The culture and symbols of glory.
Properly executed, risk-based interior firefighting is dangerous enough without the added risk of emotion substituting for stone cold professionalism.
“With each successful landing, it appears that NASA engineers and managers increasingly regarded the foam-shedding as inevitable, and as either unlikely to jeopardize safety or simply an acceptable risk.”
Acceptable risk should be oft debated and under constant scrutiny by any healthy fire/rescue organization.
