The Nimrod Review - Official Documents

The Nimrod Review
454
who are governed by cost, schedule and mission accomplishment goals”. 34 The CAIB recommended
the establishment of an independent Technical Engineering Authority which would be responsible
for technical requirements and all waivers of them. It would build a disciplined, systematic approach
to identifying, analysing and controlling hazards throughout the life cycle of the shuttle system. As
a minimum, the authority would: develop and maintain technical standards; be the sole waivergranting
authority; conduct trend and risk analysis at the sub-system and enterprise level; own the
effective analysis and hazard reporting systems; conduct integrated hazard analysis; decide what is
and is not an anomalous event; and independently verify launch readiness, approve rectifications
set out in CAIB’s report. This technical authority was to have no connection to, or responsibility for,
schedule or programme costs.
Other observations following the CAIB
17.35
The following observations following the CAIB report are also valuable:
17.35.1 By Brigadier General Duane Deal: “If reliability and safety are preached as “organizational bumper
stickers”, but leaders constantly emphasize keeping on schedule and saving money, workers will
soon realize what is deemed important and change accordingly. Such was the case with the shuttle
program.” 35
17.35.2 By Diane Vaughan: “Although all mishaps, mistakes, and accidents cannot be prevented, both
of NASA’s accidents had long incubation periods, thus they were preventable. By addressing the
social causes of gradual slides and repeating negative patterns, organisations can reduce the
probability that these kinds of harmful outcomes will occur. To do so, connecting strategies to
correct organisational problems with their organization system causes is crucial.” 36
The Herald of Free Enterprise (1987)
17.36 In his report into the Zebrugge Disaster, in which a passenger/car ferry The Herald of Free Enterprise sank
off Zebrugge on 6 March 1987 because the bow door had been left open, Sir Barry Sheen acknowledged
the shipboard (or ‘active’) errors of the Master, the Chief Officer, and the Assistant Bosun, but said that the
underlying or ‘cardinal’ faults lay higher up in the company. Sir Barry Sheen had the following observations
about the part played by Townsend Thorensen’s management in the catastrophe, in which 193 passengers and
crew died: 37
“At first the faults which led to this disaster were the aforesaid errors of omission on the
part of the Master, the Chief Officer and the assistant bosun, and also the failure by Captain
Kirk to issue and enforce clear orders. But a full investigation into the circumstances of
the disaster leads inexorably to the conclusion that the underlying or cardinal faults lay
higher up in the company. The Board of Directors did not appreciate their responsibility
for the safe management of their ships. They did not apply their mind to the question:
What orders should be given to the safety of our ships? The directors did not have any
proper comprehension of what their duties were. There appears to have been a lack of
thought about the way in which the HERALD ought to have been organized for the Dover/
Zeebrugge run. All concerned in management, from members of the Board of Directors
down to the junior superintendants, were guilty of fault in that all must be regarded as
sharing responsibility for the failure of management. From the top to bottom the body
corporate was infected with the disease of sloppiness.” The failure on the part of the
shore management to give proper and clear directions was a contributory cause of the
disaster. 38
34 CAIB Report, page 184.
35 See Brig Gen Duane W. Deal, USAF, Member of CAIB Board, ASPI article ‘Beyond the Widget’.
36 See Diane Vaughan’s article “System Effects: On Slippery Slopes, repeating Negative Patterns, and Learning from Mistake” in “Organization at the
Limit: NASA and the Columbia Disaster”, William Starbuck and Moshe Farjourn eds. Blackwell, 2005.)
37 Formal Investigation in the m.v. Herald of Free Enterprise (Report of the Court No. 8074) (1987) into the Zeebrugge Disaster on 6 March 1987 (Mr.
Justice Sheen sitting with Assessors).
38