Mike Mullane

Mullane will use the Space Shuttle Challenger disaster as an example of how a World-Class team can be victimized by incremental deviances from teamwork, leadership and safety best practices.

Challenger was a result of a catastrophic failure of the O-rings, Criticality 1 components used to form pressure seals between the four propellant-filled segments that comprise the twin solid fueled rocket boosters.  Even though there were multiple instances of leaking O-rings in the 24 missions preceding Challenger, launches were never suspended to give engineers adequate time to address the problem.  In hindsight, the serial justifications over a 4 year period to continue launch operations, reveal an incremental creep from best practices, i.e., a normalizing process.  Challenger proved to be a ‘predictable surprise’.  The following lessons will be extracted from the story of Challenger:

1. Normalization of deviance is rooted in decision-making while under job-related or personal pressures. Everybody is vulnerable. Procedural compliance will always be the best defense.  Make it a religion.
2. Maintain situational awareness.  Have a questioning attitude.
3. Risk has no memory.  Risk is not diminished by the frequency at which one is successful in taking the risk.
4. Beware of this thought process, ‘These are exceptional circumstances.  I must take the short-cut.  Next time I will do it right.’ One successful safety short cut provides this false feedback:  The absence of a negative consequence suggests a risk previously believed to be absolute is, in fact, manageable.  One short-cut opens to door to more.
5. Set challenging but attainable goals.  NASA’s shuttle launch goal of 24 missions per year proved to be unattainable and pressures that resulted from that goal were significant factors in the tragedy.

Mullane will introduce this discussion with a personal story from his USAF flying career.  At the time of the story, Mullane was a very experienced Weapons System Operator from the backseat of the reconnaissance version of the F-4 Phantom jet fighter but making his first flight in a swing-wing, supersonic F-111 jet.  Ultimately, he and the pilot had to make a last second ejection from the crashing jet.  This crash was due to crew error…including Mullane’s failure to speak up at a critical moment in the flight.

From this story he will develop these lessons:

• See something, Say something. Do something. We’re all in it together. In hazardous operations, the actions/inactions of a single individual can endanger everybody.  Take each other’s back.
• One person with courage forms a majority.  You count.  You are unique.  You might see something safety-related that nobody else sees. Never be a ‘safety passenger’ and assume somebody else will ‘take care of it.’
  Leaders:  Empower your teams so everybody does count.
• We all contribute to the safety culture of a team and will be accountable for our contribution. In hazardous operations, you may not get a ‘do-over’. OWN your safety responsibility.

This program will take the audience on a uniquely revealing, captivating and hilarious space journey. Using spectacular video and slides he will answer everybody’s space questions.