Astronaut Mike Mullane addressed the fire service about self-leadership and safety in hazardous environments on Friday at Fire-Rescue International.
“When your life is on the line, what type of a team do you want behind you? A great one,” Mullane said.
Mullane easily related his experience from NASA, which he described as one of the most accomplished teams in history – which had safely put people on the moon and returned them home six times – but then went on to write the tragic scripts of the Challenger and Columbia disasters.
“Why do bad things happen to teams with stellar histories?” he asked.
Mullane detailed how those disasters were brought about, and how fire service leaders can fall into the same trap of rationalizing why they can’t perform a job to the level of best practices.
Avoiding normalization of deviance
It’s natural for teams to look for shortcuts, especially when under pressure, he said. Then, when there are no immediate consequences, the shortcut becomes accepted and ingrained.
“The deviance becomes the norm and leads to ‘predictable surprises,’ which can be injurious and can be deadly,” Mullane said. “Challenger was no accident – it was a predictable surprise.”
Mullane explained that the Challenger explosion was due to the failure of a rocket o-ring because it was touched by fire, which it was never intended to do - a problem that had been seen on 14 of 24 missions before Challenger, but never with such consequences.
Engineers had labeled the o-ring issue as “urgent” two years before the Challenger mission, and previous best practices dictated that NASA’s fleet should have been grounded, Mullane said, but the team looked for a shortcut. They tested a pristine o-ring under worse conditions than any had been exposed to before, and concluded that it had a sufficient level of tolerance. They set aside the fact that fire should not be reaching the o-ring and that the process by which this was occurring was not fully understood.
Mullane offered steps to avoid such a trap of rationalization:
- Realize your vulnerability. “If it can happen to NASA, a great team, it can happen to anyone,” he said.
- Plan the work and work the plan.
- Do periodic re-sets to best practice standards.
- Communicate. “Everybody should have the wisdom of everybody else,” Mullane said.
No fire department should have to make the same mistake as another simply because they didn’t know it had already been done, Mullane said, just as NASA shouldn’t have taken a similar shortcut 17 years after Challenger with Columbia, which exploded due to a known risk regarding foam. He encourages departments to document their lessons learned so that experience isn’t lost with team turnover.
Empower the team
Mullane also pushed the concept that “We’re all in this together,” and that teams should be empowered to speak up when they have ideas or see problems.
Mullane illustrated with a story from his days in the Air Force, when he was flying “goose” to a pilot more experienced with that plane, and didn’t say a word when the pilot decided to pass their “go home” fuel point in order to complete their data gathering mission.
“My rationalization was that he knows what he’s doing,” Mullane said. “I ceased to become a team member and was a passenger.” As a result, they ran out of gas, had to eject and the plane crashed. “Would you want anyone on your team being a passenger?” he asked.
Mullane also illustrated the value of getting input from all team members. He shared the story of how, after Challenger, NASA tried to devise a way for astronauts to evacuate their pod in the event of a survivable explosion and parachute to the ground, which would have saved the Challenger crew.
He said the engineers could only come up with one very “flaky” and dangerous solution, involving blasting each astronaut out the hatch so that they could clear the wing of the shuttle before parachuting down. It was the flight surgeon, who was not constrained by his experience in this field, who came up with a much safer suggestion – that the astronauts simply slide down a pole to clear the wing.