What Went Wrong? – A Question Worth Asking (wisdom from James Bagian)

James Bagian

Slate.com has a terrific interview up with James Bagian.  It is in their The Wrong Stuff: What It Means To Make Mistakes series.  This interview is titled: Risky Business: James Bagian—NASA astronaut turned patient safety expert—on Being Wrong by Kathryn Schulz.

Mr. Bagian was scheduled to be on the Challenger mission, and his crew was switched out.  He has studied failures/mistakes for many years.  His current job is director of the Veteran Administration’s National Center for Patient Safety. The entire interview its absolutely worth reading, but here is one brief excerpt:

You were part of the team that investigated the Challenger accident. Were you satisfied with how that investigation was handled?

Overall I didn’t have big problems with it. But one thing that was deliberately buried was what happened to the crew. I did that part of the investigation, and there was tremendous political pressure not to tell anyone what happened—not even the other people in the crew office. They didn’t learn for months, which was totally inappropriate. They wouldn’t even let us put in checklists about what to do in the case of a breakup similar to Challenger. (emphasis added). There’s ways you could probably survive it, but politically we weren’t allowed to discuss that for years, which to me is total hogwash. There are still many people that don’t understand that the crew of the Challenger didn’t die until they hit the water. They were all strapped into their seats in a basically intact crew module; their hearts were still beating when they hit the water. People think they were blown to smithereens, but that’s not what happened. And the problem with that is the same one we were talking about with regard to medicine: if you don’t learn what you can from a tragedy, you can’t mitigate that risk in the future.

The entire interview, without ever mentioning Atul Gawande’s The Checklist Manifesto, is an argument for such checklists – for multiple checks throughout the system – to reduce mistakes.

Studying what went wrong is truly worth the time…

Leave a Reply

Your email address will not be published. Required fields are marked *