ARCHIVAL (NASA, MISSION CONTROL 1-28-86):T-minus, ten, nine, eight, seven, six We have main engine start four, three


ARCHIVAL (NASA, MISSION CONTROL, 1-28-86):And we have liftoff! Liftoff of the 25th space shuttle mission and it has cleared the tower!

ARCHIVAL (J. AULT FOOTAGE, 1-28-86):SPECTATORS: Ahhhh! Wow! How beautiful!

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):Start your roll, Challenger.Good roll program confirmed Challenger now heading downrange.

ARCHIVAL (J. AULT FOOTAGE, 1-28-86):SPECTATORS: Oh my gosh. Ahhh. Oh, wow

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):Engines beginning throttling down now at 94%. Velocity, 2250 feet per second. Altitude, 4.3 nautical miles, downrange distance three nautical miles.Challenger, go with throttle up.Roger go with throttle up.


ARCHIVAL (J. AULT FOOTAGE, 1-28-86):SPECTATORS: Multi-lingual chattering and shock.

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):Flight controllers here looking very carefully at the situation obviously a major malfunction.

ARCHIVAL (J. AULT FOOTAGE, 1-28-86):SPECTATORS: A major malfunction?

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):We have no downlink. Reports from the flight dynamics officer indicate that the vehicle, um, apparently exploded.

ARCHIVAL (J. AULT FOOTAGE, 1-28-86):SPECTATORS: What?The vehicle has exploded!What?

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):We are looking into checking with recovery forces to see what can be done at this point.

ARCHIVAL (J. AULT FOOTAGE 1-28-86):SPECTATORS: The vehicle has exploded Oh, please dont say that.Escopiando? Escopiando?

LARRY MULLOY (FORMER NASA PROJECT MANAGER): Up until the Challenger Accident, NASA was a very untypical government agency. We were inventing as we went along, so we had a lot of freedom.

DIANE VAUGHAN (AUTHOR, THE CHALLENGER LAUNCH DECISION): It was viewed internationally as a fantastic place. The Apollo missions gave it an aura of invincibility.

ARCHIVAL (CBS, 4-12-81):ANCHOR: Four minutes and 27 seconds to go before the start of this historic mission.

NARRATION: The year was 1981 and NASA was about to amaze the world with Columbia, a new spacecraft that pushed the limits of imagination.

ARCHIVAL (CBS, 4-12-81):ANCHOR: They never before have sent a spacecraft into orbit that is going to come down as a plane.

NARRATION: Instead of using a single rocket, like Apollo, the shuttle was attached to an external fuel tank and two solid-rocket boosters. Each of the boosters was constructed of joined metal tubes, and the field joints were sealed with two rubber gaskets, called O-rings.

ARCHIVAL (CBS, 4-12-81):ANCHOR: Look at those huge engines getting ready to catapult this strange assemblage off the Earth.

NARRATION: But all this technology wasnt cheap, and NASA had to come up with a new funding model. So Congress and NASA decided the shuttle program could pay its way by carrying payloads into orbit.

DIANE VAUGHAN: The Department of Defense, private contractors that wanted experiments done in space, would pay them to take them up on the shuttle.

NARRATION: And unlike Apollo, the shuttle system was going to be almost entirely reusable.

ALLAN MCDONALD (FORMER MORTON THIOKOL EXECUTIVE): They had to return this hardware back into space as rapidly as they could. It wasnt long into the program they realized that that process was far more difficult than they ever anticipated.

DIANE VAUGHAN: They were under constant pressure to launch.

ARCHIVAL (CBS, 4-12-81):COLUMBIA MISSION CONTROL: T-minus ten, nine, eightCOMMENTATOR: Im getting a few butterflies myself, right now.ANCHOR: Sure.COLUMBIA MISSION CONTROL: Weve gone for main engine start we have main engine start.COMMENTATOR: Cmon baby! Cmon baby!COLUMBIA MISSION CONTROL: And weve launched Americas first space shuttle!COMMENTATOR: Go, baby, go! Fly like an eagle!

NARRATION: Columbia was a fantastic success, but NASA had to figure out how to make these technological feats routine.

DIANE VAUGHAN: They predicted in the beginning that they would be able to launch 60 shuttles a year. That NASA would in fact become self-paying, or self-funded.

LARRY MULLOY: We had two pads up and running, so you had two vehicles out on the pad. And they were going to launch like three days apart.

DIANE VAUGHAN: But that really never happened. It was an experimental technology, and they just couldnt manage that many, so they continually fell behind.

NARRATION: The shuttle program never had more than nine launches in a single year.

ARCHIVAL: (NASA, MISSION CONTROL 8-30-84):We have a beautiful picture now.

NARRATION: And to help meet their ambitious schedules, NASA worked with private contractors to build many of the shuttles systems, while NASA engineers analyzed data to see how well everything performed.

ALLAN MCDONALD: NASA kept very good records of anomalies the problem is that they ran into a lot of these.

NARRATION: One thing engineers saw was the O-rings that sealed the booster joints werent behaving according to design. On several flights, especially those at cold temperatures, rocket propellant had blown by the primary O-ring.

DIANE VAUGHAN: The first time it happened, they accepted it. They tested it. They thought they knew what had happened. And then the next launch, everything worked. And then a few more launches and it happened again.

NARRATION: But each time the secondary O-ring prevented gasses from escaping the side of the booster. So rather than stalling the program to redesign the joint, NASA waived the requirements governing O-rings, which effectively made it acceptable to fly with minimal erosion.

DIANE VAUGHAN: Even with the worst O-ring erosion theyd ever had, it hadnt failed, so, they started to work on it, but they really werent rushing. It didnt seem so terrible. But they continually expanded the bounds of acceptable risk.

NARRATION: And then came the tenth Challenger launch and a mission unlike any NASA had attempted before.

ALLAN MCDONALD: They decided to make that the first flight that a ordinary citizen could fly and that drew a tremendous interest from the public, plus the school systems were going to show this live on television.

ARCHIVAL (NASA CHALLENGER PRELAUNCH PRESS CONFERENCE):NASA ASTRONAUT: At this time Id like to introduce you to perhaps the person you came to see, and thats Christa McCaulliffe, our payload specialist, Teacher in Space.

ALLAN MCDONALD: My job at the time of the Challenger was the director of the space shuttle solid rocket motor project for my company, Morton Thiokol.

NARRATION: Morton Thiokol was an engineering firm out of Brigham City, Utah and had the NASA contract to build the shuttle boosters.

ARCHIVAL (NASA CHALLENGER PRELAUNCH PRESS CONFERENCE):CHRISTA MCCAULLIFFE: Well, I am so excited to be here, and I just hope everybody tunes in on day four now to watch the teacher teaching from space.

DIANE VAUGHAN: On the day before Challenger, there was an overnight low that was record-breaking.

ALLAN MCDONALD: I got a telephone call from one of the program managers back in Utah that worked for me. And he says, Al, we just heard that it might get down to as low as 18 degrees by tomorrow morning. Good grief, I said, Im really worried about these O-ring seals being able to operate properly at those kinds of temperatures.

NARRATION: The mission had already been rescheduled after routine delays. So now, Morton Thiokol and NASA scheduled an emergency teleconference the night before the launch.

DIANE VAUGHAN: The engineers at Thiokol were very concerned. So they began scrambling to put together an analysis of temperature data.

NARRATION: Larry Mulloy was NASAs project manager for the solid rocket boosters.

LARRY MULLOY: We went out to the teleconference, and uh, Roger Boisjoly who was kind of the O-ring czar at Morton Thiokol did most of the talking. The recommendation was that we wait until it is 54 degrees before we launch. So I said something like, 54 degrees where?

DIANE VAUGHAN: They had never drawn a temperature line before. And it meant a tremendous change to the shuttles schedule.

ALLAN MCDONALD: It isnt what they wanted to hear. In fact, Larry made a comment, Thiokol, when the hell do you want me to launch, next April?

NARRATION: Thiokols engineers in Utah were caught off guard by NASAs strong reaction to their recommendation, so they asked if they could have some time off the teleconference to review the data in private.

LARRY MULLOY: After they went offline Al McDonald was visibly upset. And he said, I wouldnt want to be the guy that had to appear at a board of inquiry if this thing blows. And I said, I understand that, Al, and you wont have to. Thatll be me.

DIANE VAUGHAN: At Thiokol the vice president was asking those engineers to stand up for what they said. Roger Boisjoly took the lead in the objections. He said, I cant prove it to you. All I know is that its away from goodness in our experience base. But the engineers at Thiokol didnt have the data. So the vice president took the decision-making away from the engineers and asked the managers to decide.

NARRATION: And they did. More than 30 minutes after the engineers had gone offline, Thiokol managers voted to reverse the recommendation and to launch the Challenger as planned. The teleconference became a focal point for the White House appointed Rogers Commission that investigated NASA after the disaster.

ARCHIVAL (ROGERS COMMISSION):ROGER BOISJOLY: There was not one positive statement for launch ever made in that room.

ARCHIVAL (ROGERS COMMISSION):DONALD KUTNYA: What was driving you here? What was going to be achieved that caused you to go?

ALLAN MCDONALD: NASA pressured the folks at Thiokol to change their mind. And it was clear to me that we finally came back and gave them what they wanted to hear.

LARRY MULLOY: You know, wed been rationalizing this erosion since the second flight.

DIANE VAUGHAN: None of the information the NASA managers were getting was new. This was not individuals getting used to something. This was organizationally supported.

LARRY MULLOY: Thats where the accident was inevitable.

NARRATION: Once Thiokol reversed their initial recommendation, someone needed to sign off on the launch rationale.

ALLAN MCDONALD: I did the smartest thing I ever did in my lifetime. I refused to sign it. I just felt it was too much risk to take.

NARRATION: So just before midnight, McDonalds boss, Joe Kilminster, signed off instead. After the disaster, the commission concluded cold and joint design were major factors in Challengers O-ring failure. It also squarely pointed a finger at NASA managers like Mulloy.

DIANE VAUGHAN: The Commission did recognize that there was pressure to launch. But they saw it as enacted by amorally calculating managers who were in positions of responsibility. I found something completely different.

NARRATION: So Vaughan began her own investigation.

DIANE VAUGHAN:No one wanted this to happen. But intuition, you know, I dont feel good about this, should have been OK. And they applied all the usual rules in a situation where the usual rules didnt apply.

ARCHIVAL (NASA, MISSION CONTROL 1-28-86):Four, three, two, one.

LARRY MULLOY: We made a grievous error.

DIANE VAUGHAN: So the real crux of the matter is, how do you get people to recognize when you need to do something different than what youd been trained to do?

NARRATION: After Challenger, the Rogers Commission prompted many changes at NASA, including an increase in the programs budget, adding a third O-ring to the booster joints and moving some managers, including Mulloy, out of the shuttle program.

DIANE VAUGHAN: But there was nothing really about how to change the organization that came out of the commission report.

NARRATION: And then in 2003, after NASA had completed 15 years of successful missions, came the 28th launch of the space shuttle Columbia.

RODNEY ROCHA (NASA ENGINEER): It seemed like any other launch. But on the second day someone called me on the phone and said, Youve heard about the large piece of debris, or foam, that came off the tank and hit the left wing? Caused a cloud a poof. I said, No, I didnt.

NARRATION: Columbia made it into orbit safely, but the concern was that if debris had caused damage to the left wing, it could be vulnerable on re-entry. So just days after the launch, NASA formed a special team to asses the damage.

RODNEY ROCHA: The decision to ask for more data, the need for it, was unanimous.

NARRATION: But management was worried about unnecessarily diverting Columbia from its mission, since foam damage had been generally considered to be non-threatening. NASA manager, Linda Ham, denied three requests to get pictures of the shuttles underside from a nearby satellite.

DIANE VAUGHAN: And they were all put down for different reasons. The similarity between Challenger and Columbia was the falling back on routine under uncertain circumstances.

NARRATION: In the end, NASA sent just one communication to the astronauts about the debris strike. And on February 1, 2003, the crew began their return to Earth.

ARCHIVAL (NASA, MISSION CONTROL, 2-1-03):COLUMBIA ASTRONAUT: K.C., can you look at the camera for a second? Look at me. There. (laughs)

RODNEY ROCHA: Part of our engineering culture is that you should work through your chain of command. I will regret, always, why I didnt break the door down by myself.

ARCHIVAL (NASA, MISSION CONTROL, 2-1-03):And were ready, Willy. No Deltas.Everything look good to you?I dont see anything out of the ordinary.

ARCHIVAL (NASA, MISSION CONTROL, 2-1-03):This is amazing. Its really gettingits really bright out there.

RODNEY ROCHA: They had just started the de-orbit burn, theyre coming down, and, um, we started seeing temperatures change higher on the left side versus the right.

ARCHIVAL (NASA, MISSION CONTROL, 2-1-03):FYI, Ive just lost four separate temperature transducers on the left side of the vehicle.

RODNEY ROCHA: The anomalous data confirmed my worst fear.

ARCHIVAL (NASA, MISSION CONTROL, 2-1-03):Columbia Houston, UHF com check. Columbia Houston, UHF com check.

RODNEY ROCHA: I looked up and I saw one of our chief engineers in tears. We cant get the crew, she said. Theyve been incommunicado. It happened. It happened.

NARRATION: Columbia was destroyed on re-entry.

After the disaster, Vaughan worked closely with the Columbia Accident Investigation Board, which concluded that NASA had inefective leadership and a flawed safety culture.

ARCHIVAL (8-26-14):HAROLD GEHMAN: We are quite convinced that these organizational matters are just as important as the foam.

NARRATION: Ham soon left the shuttle program, and NASA restructured its management team.

DIANE VAUGAN: This happens in many different kinds of organizations. I dont think that the general public got the position of either Larry Mulloy or Linda Ham, and that their behavior was to a great deal determined by working in a very rule-oriented organization.

NARRATION: Using her insights from NASA, Vaughan developed a theory that went beyond the space agency, calling it normalization of deviance. She says it explains how, over time, organizations come to accept risky practices as normal.

DIANE VAUGHAN: Its widespread. With Katrina, where the engineers were saying these structures are not going to hold, we need to do something more here. With British Petroleum early warning signs ignored.

ARCHIVAL (CBS, 10-29-10):ANCHOR: The cement used in the Gulf oil rig was flawed.

DIANE VAUGHAN: The 2008 financial failure.

ARCHIVAL (CBS, 1-26-11):ANCHOR: The federal commission concluded it could have been avoided.

DIANE VAUGHAN: You had a lot of heavy technology, derivatives and formulas and there was a fine line between what is devious and whats a good business decision.

NARRATION: And in 2017

ARCHIVAL (PBS, 1-17-18):ANCHOR: Two deadly accidents involving U.S. Navy ships.

NARRATION: the U.S. Navy cited Vaughans theories to help explain accidents that killed 17 sailors.

ARCHIVAL (C-SPAN):ADMIRAL WILLIAM MORAN (VICE CHIEF OF NAVAL OPERATIONS, U.S. NAVY): We accepted this, what was termed normalization of deviance. In other words, we allowed our standards to drop, thinking we were still ok.

DIANE VAUGAN: We can never resolve the problem of complexity, but you have to be sensitive to your organization and how it works. While a lot of us work in complex organizations, we dont really realize the way that the organizations we inhabit, completely inhabit us.