Countdown to disaster

When a lack of psychological safety leads to death

It was January 28th 1986.

A severe cold snap had swept across Florida, and icicles covered the launch tower at Cape Canaveral. The night before, engineers had begged NASA’s management to cancel the scheduled space flight due to concerns about a tiny gasket known as an ‘o-ring’ becoming more brittle the colder it got.

We all knew if the seals failed, the shuttle would blow up,” said engineer Roger Boisjoly.

My God,” came the response from NASA manager Lawrence Mulloy, “When do you want me to launch? Next April?

That morning, engineer Bob Ebeling drove his daughter to the engineering complex. ‘He said “The Challenger’s going to blow up. Everyone’s going to die.” He was beating his fist on the dashboard. He was frantic.

We all remember what happened next. 73 seconds after lift-off, and with millions, watching around the world, the slow, silent blooming of debris against the clear blue sky was met with horrified shock from the spectators on the ground, including the parents of Christa McAuliffe, a notable member of the crew who’d been selected from thousands of applicants to Reagan’s ‘Teacher In Space’ project.

A Rotten Culture Revealed

The aftermath was brutal. The Rogers Commission released its report which heavily criticized NASA’s organizational culture and its decision-making processes that had led to a division between its engineers and management. The differing perspectives over the decade-long concern over the o-rings were significant; to management, why stall now when nothing had happened? But it meant the very opposite to the engineers, who knew the odds were shortening. A rotten culture, lacking in active risk management and psychological safety had doomed the flight from the start, but it took seven people to die publicly to prove the point.  

The Nightmare Workplace

At the time, NASA had a bullish, goal-driven culture where groupthink triumphed over individual expertize, or objective evidence. Engineers lived in dread at what would be sent up into the skies, and management targets were more important than the lives of their astronauts. The more launches they authorized, the better; the less they were distracted by the worried nit-picking of the engineers, the better.

And what are those indicative of? A lack of psychological safety, a critical concept that ensures everyone in a team feels it’s safe to speak up. Without it, people subscribe to the prevailing priority of those in charge, and feel reluctant to voice concerns, ask questions, or display their own vulnerabilities. Another example is a surgeon amputating the wrong limb because nobody else in the team feels it’s safe to point out the mistake.

Making psychological safety a priority

Hopefully the risks in your business aren’t as stark, but there’s not an organization alive today that wouldn’t benefit from making psychological safety in the workplace a priority. So how do you do that?

  • You’re only as good as you’re inclusive, so emphasize the importance of the individual contribution for the good of the team; encourage and support people to provide feedback and ideas and be flexible in how they might feel most comfortable doing that. Teams in which only a small number of people speak up can feel laboured and hostile.
  • Create shared priorities that everyone can buy into. While, for example, NASA’s management prioritized outcomes over the engineers’ focus on safety and process, had they both been united behind a safe launch, Challenger wouldn’t have made the headlines. Think about your cross-department connections. Do any work in silo? Does one’s objectives hinder those of another? Are they difficult to unite?
  • Encourage your team to understand dissent and diversity drive innovation, problem-solving, and performance. When someone raises a contrary viewpoint, take a deeper look; it’s possible that you might uncover a gem of truth that you’d have otherwise missed. And by doing so, you’re showing them their opinion matters.
  • Make them feel safe in other ways, e.g ensuring that you have an active risk management system in place, that as a leader you expose your vulnerabilities

Of course, the Challenger disaster lies at the furthest, darkest end of risk management failures; most of us will never operate at those extremes.

But the need to be able to work successfully and safely is only possible if you do what NASA didn’t: create a culture of genuine psychological safety in the workplace, which permits everybody not just a seat at the table, but the courage to speak up. In doing so, you become better at many other things, too.

Change is less frightening when you’re all onboard and there’s a genuine sense of ‘us.’ People are more likely to be flexible if they believe that they’re safe to be so. Innovation will flourish as people understand that there are no bad ideas. Yes, it takes confidence, skill and trust to create psychological safety in the workplace, but it is one of the very best things you can do for your organization, and the assets which matter most – your people.

https://www.nasa.gov/feature/35-years-ago-remembering-challenger-and-her-crew

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