Is by looking at another kind of crash: exploding Space Shuttles. This is Richard Feynman's appendix from the report on the Challenger; he was on the commission that investigated it, but refused to sign the final report unless his observations about NASA's safety culture were included. You should really read the entire thing, but this is the nut section:
It is true that if the probability of failure was as low as 1 in 100,000 it would take an inordinate number of tests to determine it ( you would get nothing but a string of perfect flights from which no precise figure, other than that the probability is likely less than the number of such flights in the string so far). But, if the real probability is not so small, flights would show troubles, near failures, and possible actual failures with a reasonable number of trials. and standard statistical methods could give a reasonable estimate. In fact, previous NASA experience had shown, on occasion, just such difficulties, near accidents, and accidents, all giving warning that the probability of flight failure was not so very small. The inconsistency of the argument not to determine reliability through historical experience, as the range safety officer did, is that NASA also appeals to history, beginning "Historically this high degree of mission success..."
Finally, if we are to replace standard numerical probability usage with engineering judgment, why do we find such an enormous disparity between the management estimate and the judgment of the engineers? It would appear that, for whatever purpose, be it for internal or external consumption, the management of NASA exaggerates the reliability of its product, to the point of fantasy.
The history of the certification and Flight Readiness Reviews will not be repeated here. (See other part of Commission reports.) The phenomenon of accepting for flight, seals that had shown erosion and blow-by in previous flights, is very clear. The Challenger flight is
an excellent example. There are several references to flights that had gone before. The acceptance and success of these flights is taken as evidence of safety. But erosion and blow-by are not what the design expected. They are warnings that something is wrong. The equipment is not operating as expected, and therefore there is a danger that it can
operate with even wider deviations in this unexpected and not thoroughly understood way. The fact that this danger did not lead to a catastrophe before is no guarantee that it will not the next time, unless it is completely understood. When playing Russian roulette the
fact that the first shot got off safely is little comfort for the next. The origin and consequences of the erosion and blow-by were not understood. They did not occur equally on all flights and all joints; sometimes more, and sometimes less. Why not sometime, when whatever conditions determined it were right, still more leading to catastrophe?
In spite of these variations from case to case, officials behaved as if they understood it, giving apparently logical arguments to each other often depending on the "success" of previous flights. For example. in determining if flight 51-L was safe to fly in the face of
ring erosion in flight 51-C, it was noted that the erosion depth was only one-third of the radius. It had been noted in an experiment cutting the ring that cutting it as deep as one radius was necessary before the ring failed. Instead of being very concerned that
variations of poorly understood conditions might reasonably create a deeper erosion this time, it was asserted, there was "a safety factor of three." This is a strange use of the engineer's term ,"safety factor." If a bridge is built to withstand a certain load without the
beams permanently deforming, cracking, or breaking, it may be designed for the materials used to actually stand up under three times the load. This "safety factor" is to allow for uncertain excesses of load, or unknown extra loads, or weaknesses in the material that might have unexpected flaws, etc. If now the expected load comes on to the new bridge and a crack appears in a beam, this is a failure of the design. There was no safety factor at all; even though the bridge did not actually collapse because the crack went only one-third of the way through the beam. The O-rings of the Solid Rocket Boosters were not designed to erode. Erosion was a clue that something was wrong. Erosion was not something from which safety can be inferred.
There was no way, without full understanding, that one could have confidence that conditions the next time might not produce erosion three times more severe than the time before. Nevertheless, officials fooled themselves into thinking they had such understanding and confidence, in spite of the peculiar variations from case to case. A mathematical model was made to calculate erosion. This was a model based not on physical understanding but on empirical curve fitting. To be more detailed, it was supposed a stream of hot gas impinged on the O-ring material, and the heat was determined at the point of stagnation (so far, with reasonable physical, thermodynamic laws). But to determine how much rubber eroded it was assumed this depended only on this heat by a formula suggested by data on a similar material. A logarithmic plot suggested a straight line, so it was supposed that
the erosion varied as the .58 power of the heat, the .58 being determined by a nearest fit. At any rate, adjusting some other numbers, it was determined that the model agreed with the erosion (to depth of one-third the radius of the ring). There is nothing much so wrong with this as believing the answer! Uncertainties appear everywhere. How strong the gas stream might be was unpredictable, it depended on holes formed in the putty. Blow-by showed that the ring might fail even though not, or only partially eroded through. The
empirical formula was known to be uncertain, for it did not go directly through the very data points by which it was determined. There were a cloud of points some twice above, and some twice below the fitted curve, so erosions twice predicted were reasonable from that cause alone. Similar uncertainties surrounded the other constants in the formula, etc., etc. When using a mathematical model careful attention must be given to uncertainties in the model.
Distressingly, this appears to be exactly what happened with the Columbia. Foam had come off the shuttle before, but never with disastrous results; NASA accordingly seems to have decided that it must therefore be safe to have the insulation break free. This heuristic was probably the best we could do as East African Plains Apes. In the modern world, however, we have better substitutes, like reason, if we'll only use them.
Of course, engineering a space shuttle, like the financial markets, is so complicated that we may never gain full understanding. The most dangerous thing is that we are so confident in our assessments of the uncertainties.
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