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Denise Robitaille

Management

Feynman and the O-Ring

Root cause analysis takes commitment, and sometimes, courage

Published: Monday, August 8, 2016 - 11:19

The great physicist Richard Feynman is best known—at least among laypeople—as the person who solved the mystery of the Challenger space shuttle explosion more than two decades ago.

Many of us remember the image of an O-ring suspended in a glass of ice water sitting on a conference table surrounded by a blue panel of science experts representing multiple disciplines. The conclusion that ultimately ensued was that the horrific accident that took the life of several astronauts and the first teacher/astronaut was a frozen O-ring resulting in a broken seal that allowed fuel to leak and ignite.

Authorities would have been happy to close out the investigation with that conclusion. What most people don’t realize was that for Feynman and some of his colleagues, the conclusion was not the end of the investigation. Actually, for Feynman, it was the launching pad for further scrutiny. He continued the investigation, trying to understand how the accident could have happened. What had failed?

Feynman’s account of this investigation is revealed in his book, What Do You Care What Other People Think? (W.W. Norton & Company, 2001). The root cause analysis led him down several paths, and his research revealed that there were multiple complex and related causes of the explosion. Feynman’s conclusion actually prompts more questions than answers. It reflects a scientist’s reluctance to present a decisive conclusion in the absence of adequate objective evidence. However, his discussion illuminates several practices that led to the failure—practices that have probably continued, unchallenged and unabated.

It’s remarkable to note the persistence with which he pursued the problem. Although it doesn’t exactly mirror the 5 Whys process, it certainly reflects the dogged determination to continue asking until a satisfactory answer was uncovered.

His final report to the commission, which was inserted as an appendix to the commission report, is the subject of the chapter in his book titled “Afterthoughts.” It contains several observations that are relevant to any quality management system. They are particularly germane to ISO 9001:2015.

Communication

Feynman’s most insightful comments relate to communication. There was lack of communication between engineering and management and between NASA and the suppliers of the O-rings. He theorized that part of the reason could very well be that information relating to actual and potential failures was routinely ignored or refuted. This resulted in the engineers simply giving up, figuring that because no one was listening, there was no reason to provide the information.

The chapter in the book preceding “Afterthoughts” describes multiple conversations that illustrate this breakdown in communication. Information wasn’t provided, or it wasn’t shared, or it was ignored, or it never made it to the people who needed to know. In some instances, the attitude was essentially: “Don’t tell me; I don’t want to hear about it.”

ISO 9001:2015 recognizes the pitfall inherent in ineffective communication, as clause 7.4 addresses specific requirements for both internal and external communication. It provides direction relating to what to communicate, how, when, by whom, and to whom. Feynman’s observations would suggest that the communications network was rife with obstacles and omissions.

Top management responsibility

Feynman observes that top management distanced itself from responsibility for the disaster. Their tactic was to deny any knowledge of a problem with the O-rings. As he puts it: “ ... soon the attitudes begin to change: information from the bottom which is disagreeable—‘We’re having a problem with the seals; we should fix it before we fly again’—is suppressed by big cheeses and middle managers who say, ‘If you tell me about the seals problems, we’ll have to ground the shuttle and fix it,’ or, ‘No, no, keep on flying, because otherwise it’ll look bad.’”

These are Feynman’s observations. Although he does not assert that there is objective evidence of wrongdoing, he intimates that, based upon what he observed during the commission’s investigation, management attitude and practices contributed to the problem.

It’s interesting to note that ISO 9001:2015 has language requiring top management to assume accountability for the quality management system. Specifically, clause 5.1.1 states that “Top management shall demonstrate leadership and commitment with respect to the quality management system by (e) ensuring that the resources needed for the quality management system are available” and “(g) ensuring that the quality management system achieves its intended results.”

Although there are multiple other nondelegable requirements relating to responsibilities in the clause, these are the two most pertinent to the event. Management failed to provide the necessary resources to solve the problem, and it abdicated responsibility for the result.

Data and decision making

Decisions were made using questionable data. Feynman states that “... the shuttle, therefore, flies in a relatively unsafe condition, with a chance of failure on the magnitude of one percent.” He goes on to say, “Official management, on the other hand, claims to believe the probability of failure is a thousand times less.” Feynman’s assertion is based on mathematically valid computations using empirical data, but management made decisions based on the commitment to put a teacher/astronaut into space on schedule. The final sentence summarizes Feynman’s thoughts on the subject: “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.”

Although there are several references to analysis of data in ISO 9001, the most pertinent citation comes to us from ISO 9000:2015, which is the normative reference for ISO 9001:2015. Clause 2.3.6 states, “Decisions based on the analysis and evaluation of data and information are more likely to produce desired results.”

Feynman’s investigation and conclusion lead us to another big question that is, again, pertinent to ISO 9001. Where was the consideration of risk? The potential and actual risks are myriad and include potential failures resulting from:
• Inadequate study of the longevity of components
• Inconsistent information from various departments
• Geographic constraints (Houston and Cape Canaveral were far apart before the advent of the internet)
• Incomplete or skewed data
• Lack of understanding of real and imminent consequences
• Poor communication
• Poor leadership

The list is brief. Any brainstorming session could easily yield dozens more by simply looking at the traditional 5 Ms and the E—material, manpower, machinery, method, measurement, and environment.

A demoralizing catastrophe that took the lives of brilliant and courageous pioneers and set NASA’s program and our nation’s aerospace aspirations back decades might have been averted if there had been more consideration of risk.

Feynman’s book is a great read. His commitment to scientific investigation, his intolerance for obfuscation, and his courage to challenge unsubstantiated convention is refreshing and inspiring. When next you feel daunted by a root cause analysis think of Feynman and the O-ring.

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About The Author

Denise Robitaille’s picture

Denise Robitaille

Denise Robitaille is the author of thirteen books, including: ISO 9001:2015 Handbook for Small and Medium-Sized Businesses.

She is chair of PC302, the project committee responsible for the revision to ISO 19011, an active member of USTAG to ISO/TC 176 and technical expert on the working group that developed the current version of ISO 9004:2018. She has participated internationally in standards development for over 15 years. She is a globally recognized speaker and trainer. Denise is a Fellow of the American Society for Quality and an Exemplar Global certified lead assessor and an ASQ certified quality auditor.

As principal of Robitaille Associates, she has helped many companies achieve ISO 9001 registration and to improve their quality management systems. She has conducted training courses for thousands of individuals on such topics as auditing, corrective action, document control, root cause analysis, and implementing ISO 9001. Among Denise’s books are: 9 Keys to Successful Audits, The (Almost) Painless ISO 9001:2015 Transition and The Corrective Action Handbook. She is a frequent contributor to several quality periodicals.