When conference call participants from NASA and Thiokol later spoke with investigators and gave interviews, they repeatedly brought up the “weak engineering position,” as one put it. Their statements comprised a repetitive chorus: “Unable to quantify”; “supporting data was subjective”; “hadn’t done a good technical job”; “just didn’t have enough conclusive data.” NASA was, after all, the agency that hung a framed quote in the Mission Evaluation Room: “In God We Trust, All Others Bring Data.”
“The engineers’ concerns for the most part were just based on a few photographs they took of joints they pulled apart that had soot trapped in there,” McDonald told me. “One was at a cool temperature, and one was at a rather warm temperature. Roger Boisjoly thought the difference was absolutely telling a story, but it was a qualitative assessment.” NASA’s Mulloy later argued that he “would’ve felt naked” taking Thiokol’s argument up the chain of command. Without a solid quantitative case, “I couldn’t have defended it.”
The very tool that had helped make NASA so consistently successful, what Diane Vaughan called “the original technical culture” in the agency’s DNA, suddenly worked perversely in a situation where the familiar brand of data did not exist. Reason without numbers was not accepted. In the face of an unfamiliar challenge, NASA managers failed to drop their familiar tools.
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Psychologist and organizational behavior expert Karl Weick noticed something unusual in the deaths of smokejumpers and “hotshot” wilderness firefighters: they held on to their tools, even when ditching equipment would have allowed them to run away from an advancing fire. For Weick, it was emblematic of something larger.
In Montana’s 1949 Mann Gulch fire, made famous in Norman Maclean’s Young Men and Fire, smokejumpers parachuted in expecting to face a “ten o’clock fire,” meaning they would have it contained by 10 a.m. the next morning. Until the fire jumped across the gulch from one forested hill slope to the steep slope where the firefighters were, and chased them uphill through dry grass at eleven feet per second. Crew foreman Wagner Dodge yelled at the men to drop their tools. Two did so immediately and sprinted over the ridge to safety. Others ran with their tools and were caught by the flames. One firefighter stopped fleeing and sat down, exhausted, never having removed his heavy pack. Thirteen firefighters died. The Mann Gulch tragedy led to reforms in safety training, but wildland firefighters continued to lose races with fires when they did not drop their tools.
In 1994, on Colorado’s Storm King Mountain, hotshots and smokejumpers faced a Mann Gulch situation when a fire jumped a canyon and erupted through a stand of gambel oak below them. The sound in the canyon was “like a jet during take off,” according to a survivor. Fourteen men and women lost the race with a wall of flame. “[Victim] was still wearing his backpack,” reads an analysis from the body recovery operation. “Victim has chainsaw handle still in hand.” He was just 250 feet from a safe zone. Survivor Quentin Rhoades had already run nine hundred feet uphill, “then realized I still had my saw over my shoulder! I irrationally started looking for a place to put it down where it wouldn’t get burned. . . . I remember thinking I can’t believe I’m putting down my saw.” Two separate analyses conducted for the U.S. Forest Service and the Bureau of Land Management concluded that the crew would have made it out intact had they simply dropped their tools and run from the start.
In four separate fires in the 1990s, twenty-three elite wildland firefighters refused orders to drop their tools and perished beside them. Even when Rhoades eventually dropped his chainsaw, he felt like he was doing something unnatural. Weick found similar phenomena in Navy seamen who ignored orders to remove steel-toed shoes when abandoning a ship, and drowned or punched holes in life rafts; fighter pilots in disabled planes refusing orders to eject; and Karl Wallenda, the world-famous high-wire performer, who fell 120 feet to his death when he teetered and grabbed first at his balance pole rather than the wire beneath him. He momentarily lost the pole while falling, and grabbed it again in the air. “Dropping one’s tools is a proxy for unlearning, for adaptation, for flexibility,” Weick wrote. “It is the very unwillingness of people to drop their tools that turns some of these dramas into tragedies.” For him, firefighters were an example, and a metaphor for what he learned while studying normally reliable organizations that clung to trusty methods, even when they led to bewildering decisions.
Rather than adapting to unfamiliar situations, whether airline accidents or fire tragedies, Weick saw that experienced groups became rigid under pressure and “regress to what they know best.” They behaved like a collective hedgehog, bending an unfamiliar situation to a familiar comfort zone, as if trying to will it to become something they actually had experienced before. For wildland firefighters, their tools are what they know best. “Firefighting tools define the firefighter’s group membership, they are the firefighter’s reason for being deployed in the first place,” Weick wrote. “Given the central role of tools in defining the essence of a firefighter, it is not surprising that dropping one’s tools creates an existential crisis.” As Maclean succinctly put it, “When a firefighter is told to drop his firefighting tools, he is told to forget he is a firefighter.”
Weick explained that wildland firefighters have a firm “can do” culture, and dropping tools was not part of it, because it meant they had lost control. Quentin Rhoades’s chainsaw was such a part of his firefighting self that he did not even realize he still had it, any more than he realized he still had his arms. When it became utterly ludicrous to carry the saw further, Rhoades still “could not believe” he was parting with it. He felt naked, just as Larry Mulloy said he would have without a quantitative argument for a last-second launch reversal. At NASA, accepting a qualitative argument was like being told to forget you are an engineer.
When sociologist Diane Vaughan interviewed NASA and Thiokol engineers who had worked on the rocket boosters, she found that NASA’s own famous can-do culture manifested as a belief that everything would be fine because “we followed every procedure”; because “the [flight readiness review] process is aggressive and adversarial”; because “we went by the book.” NASA’s tools were its familiar procedures. The rules had always worked before. But with Challenger they were outside their usual bounds, where “can do” should have been swapped for what Weick calls a “make do” culture. They needed to improvise rather than throw out information that did not fit the established rubric.
Roger Boisjoly’s unquantifiable argument that the cold weather was “away from goodness” was considered an emotional argument in NASA culture. It was based on interpretation of a photograph. It did not conform to the usual quantitative standards, so it was deemed inadmissible evidence and disregarded. The can-do attitude among the rocket-booster group, Vaughan observed, “was grounded in conformity.” After the tragedy, it emerged that other engineers on the teleconference agreed with Boisjoly, but knew they could not muster quantitative arguments, so they remained silent. Their silence was taken as consent. As one engineer who was on the Challenger conference call later said, “If I feel like I don’t have data to back me up, the boss’s opinion is better than mine.”