Critical Root-Cause Analysis (Part One)

Words: Zach Everett, Brazos Masonry Corporate Safety Director
Photos: metamorworks

It was January 28, 1986 as I sat in my elementary school. There was an excited buzz, especially from teachers, about the launch of the space shuttle. This particular excitement came from a special guest on board the space shuttle that was not an astronaut by trade. She, Christa McAuliffe, was a schoolteacher, therefore a reason to celebrate. She was 1 out of 11,000 applicants trying to get into the NASA Teacher in Space Project. She made it. The first teacher to travel to outer space. She was planning to teach two lessons from the Challenger. Her husband Steven, along with their two children Scott and Caroline, cheered her on as she boarded the shuttle and awaited the count-down.

As the countdown reached zero and billows of white smoke erupted around the base of the space shuttle, smiles and tears seemed to help lift the shuttle slowly from the ground. 73 seconds into the launch, those smiles and tears turned to confusion and utter disbelief. There was an explosion and before everyone’s eyes the shuttle broke up and fell, almost in slow motion, down to the Atlantic Ocean. There were no survivors.

Alan McDonald, the Director of the space shuttle solid rocket project, one of the engineers for the launch, refused to sign the launch recommendation for the Challenger prior to launch. He cited safety concerns that the rubber O-rings designed to seal fuel within the rockets could be compromised in freezing temperatures. He said the rubber could become stiff and result in leaking rocket fuel. His fears were realized. In an intense critical root cause analysis of the tragedy, it was found that the rubber O-rings chosen to seat between the metal components due to their pliability, failed. When compressed they sealed the rocket fuel in the tanks. In freezing temperatures however, they lost their pliability. Under those conditions, it was more like using hard plastic or wood as a gasket, rather than a soft compressible O-ring.

How could such a simple thing cause such death. Seven people lost their lives that day. The families of those seven were looking on and impacted permanently. Why? A few degrees in temperature. A stiff O-ring. Some would say it was more the stubborn push to continue and avoid another launch delay. Asking the questions “why” and “how” tragedies happened is in order to make the necessary changes to prevent that type of tragedy from occurring again. From an industrial safety and health perspective, it is not to figure out who is to blame, rather what is to blame, so the problem can be avoided next time. If we can determine what leads to the problems, and ultimate failure, we can work to avoid that problem next time and prevent the tragedy.

Industry has figured this out. Business owners spend billions of dollars in critical root-cause analysis to answer those “how” and “why” questions. “How did this incident happen and why,” but most importantly, “what can we do to prevent it from happening again?” They spend this money answering questions and digging deep into incident investigation because it’s well worth it. By a long shot. The cost of a tragic incident is staggering. The loss of life is immeasurable. There is no dollar amount that can quantify the toll on a family whose mom, dad, spouse, is not coming home ever again. There are medical bills, legal fees and settlements, law suits, OSHA fines, insurance costs, equipment replacement, investigation costs, loss of production, reputation, loss of future business, and this is the short list. The old adage that “an ounce of prevention is worth a pound of cure” is still true. Whether it’s the shuttle disaster, the Deepwater Horizon or BP Oil Spill, the Texas City Refinery explosion, the Piper Alpha platform explosion, or the mason that cut his hand, finding out how and why it happened is of paramount importance, because we want to prevent it from happening again. We can take a cue from these larger industry leaders concerning the value of problem prevention.

The Challenger disaster cost seven lives and 3.2 billion dollars conservatively. The Deepwater Horizon, or BP Oil Spill, cost 11 people their lives and 65 billion dollars. The Texas City Refinery explosion cost 15 lives and 1.5 billion dollars and the Piper Alpha platform explosion cost 167 people their lives and 3.4 billion dollars. I don’t list these numbers as merely facts on a spreadsheet. Not the loss of lives. There are no words to accurately describe or measure the pain, emotional trauma, children being raised without their mom or dad.