The importance of detail and organizational culture

History of the day 1986.1.28. Challenger Space Shuttle Explosion.

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◇ The importance of detail and organizational culture

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On January 28, 1986, the space shuttle Challenger explodes in midair about 73 seconds after liftoff. All seven crew members, including Captain Kobe, were killed inside.

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According to a report on the results of the accident, the cause of the accident was a malfunction of the outer wall of the solid fuel booster attached to both sides of the external fuel tank, which caused the fuel gas to erupt. 

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In other words, it was an accident that started with a small rubber ring called O-ring, which was only 10 cents. (Parts stuck in joint to prevent fuel leaking)

 

For more reason, the rubber ring lost its flexibility in sub-zero weather and the fuel gas leaked out of it, eventually causing an explosion.

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Even worse, engineers were aware of the dangers of "O-ring" in advance. Each time I did an experiment, I raised an objection. But senior officials ignored the opinion. Even on the day of the accident, engineers insisted on delaying the launch, fearing that temperatures below zero and O-ring would not perform. However, NASA officials went ahead with the Challenger launch.

 

Officials thought the launch could no longer be delayed because it had already been delayed 10 times.

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Details, organizational culture, and an obsession that everyone is waiting for as well as their superiors have cut the chain of safety. The occurrence of an accident can be said to be linked to many safety links. A tight ring must be firmly connected to withstand the tension. But the breaking ring has problems at its weakest point. The opening of the ring does not break easily as the details and organizational culture become stronger.

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For your information, a group called Europe sang a song called The Final Countdown as a tribute to the Challenger explosion.

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◇ 覆車之戒

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This means that the cart after the cart is turned upside down, and that the cart after it is carefully guarded against the failure of the foreman.

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In similar terms, there is a sense of wariness.

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前車之鑑 

The lesson of the cart that passed first is to learn from the failures of the past and prepare them for failure again.

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In the early days of the letter, Ga-ui, a well-known political commentator, pointed out the seriousness of the partitioning of the bag in an article titled "Jeonsan Temple," and argued that if local forces were left to do so in the mediation, the world would be in a situation of being re-divided.

Ga-ui said about the causes of the collapse of the Qin Dynasty. 

"The second-generation lake of the Jin Dynasty was tyrannical and severe in punishment, killing people recklessly, killing people, and not counting those who were killed or injured by him."

Ga-ui said he hoped the Han Dynasty issue would learn a lesson from the fall of the Jin Dynasty and not step on the subway line. 

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"As the saying goes, when the cart before it is overturned, the cart that follows it is a lesson ( " If we don't prepare ourselves, as we can now see the trail of the destruction of the Qin Dynasty, we will also fall, as will the cart that follows." 

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In Jeonggwanjeongyo, Lee said, "If you make a mirror out of bronze, you can tidy up your clothes. If you use ancient history as a mirror, you can see the rise and fall of the world and the cause of the dynastic change. If you use people as a mirror, you can clearly see your own gains and losses." 

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If you don't know history, you have no choice but to repeat the failures of the past.

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* Safety is further removed, and the more opportunities are found, the more likely it is to be safe. - Brian Tracy.

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* We are in danger not because we do not know it will happen, but because we believe it will not happen.

- Mark Twain.