Can 'normalisation of deviance' help to explain a catastrophe?

40 years ago, NASA experienced one of its most devastating disasters. The Challenger space shuttle disintegrated just 73 seconds after launch, killing all seven crew members. How had this happened? And did the culture of NASA have anything to do with it? In this episode, we dig into a concept called 'normalisation of deviance', which has been touted as an explanation for this incident, as well as the Costa Concordia cruise ship disaster and a clinical drug trial that left six people in intensive care. So what is 'normalisation of deviance'? How does it happen? And given its potential for harm, is there anything we can do to prevent it? If you enjoyed this episode, check out the latest season of Science Friction, The Challenger Disaster https://www.abc.net.au/listen/programs/sciencefriction/challenger-legacy-episode-one-launch-fever/106220244 (which is also produced by our senior producer James Bullen!) Guests: Dr Nejc SedlarLecturer, University of Aberdeen Professor Sidney DekkerProfessor, Griffith University Credits: Presenter: Sana QadarSenior producer: James BullenAdditional reporting/production: Fiona PepperProducer: Rose KerrSound engineer: Roi HubermanYou can catch up on more episodes of the All in the Mind podcast with journalist and presenter Sana Qadar, exploring the psychology of topics like stress, memory, communication and relationships on ABC Listen or wherever you get your podcasts. More information: A qualitative systematic review on the application of the normalization of deviance phenomenon within high-risk industries https://www.sciencedirect.com/science/article/pii/S0022437522001827. Sidney Dekker — Drift into Failure. https://sidneydekker.com/booksChallenger: the disaster five people saw coming. https://www.abc.net.au/news/science/2026-01-28/space-shuttle-challenger-disaster-nasa-explosion-video-engineers/106162902The Challenger Legacy — Science Friction. https://www.abc.net.au/listen/programs/sciencefriction/the-challenger-legacy/106262264Has NASA learned anything from the Challenger disaster? https://www.youtube.com/watch?v=eKwdG0e6hiQWhen to trust your gut instinct, and when to ignore it https://www.abc.net.au/listen/programs/allinthemind/when-to-trust-gut-instinct-when-to-ignore-intuition/103374880A deviation from standard design? Clinical trials, research ethics committees, and the regulatory co-construction of organizational deviance https://pubmed.ncbi.nlm.nih.gov/28078974/

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  Forty years ago, the Challenger space shuttle exploded 73 seconds after launch over the skies of Cape Canaveral in Florida.

• 0:49Speaker 04

  We have a report from the flight dynamics officer that the vehicle has exploded. Flight director confirms that we are looking at checking with the recovery forces to see what can be done at this point.

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  All seven of the crew were killed, including Krista McAuliffe, who was set to become the first teacher to ever fly to space. It was an unprecedented disaster for NASA, America's space agency.

• 1:13Speaker 05

  We've never lost an astronaut in flight. We've never had a tragedy like this.

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  Then, nearly two decades later, another disaster for NASA. This time, it was the space shuttle Columbia. It broke apart, re-entering Earth's atmosphere after 16 days in space, killing another seven astronauts.

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  Their families shattered. The space programme has been dealt a terrible blow.

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  In the wake of those twin mishaps almost 20 years apart, there was a search for what had gone wrong. Beyond the mechanical failures of each incident, could the culture of an organisation like NASA and the natural, sometimes fallible, way in which humans think, go some way to explaining what had happened?

• 1:57Speaker 07

  You are not aware of it happening, and that is where the big danger of normalisation of deviance really lies.

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  Every single step is in itself sensible, defensible, can be made to make sense and probably even invisible to most people who work inside the system.

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  And could similar patterns explain disasters across different industries? From sinking cruise ships to train derailments?

• 2:23Speaker 09

  The captain of the stricken Italian cruise ship, the Costa Concordia, says the rock that ripped the hull of his ship wasn't on maritime charts. A safety feature common on trains across Australia has been dismissed by a train crash inquiry in New South Wales as being basically ineffective.

• 2:41Speaker 03

  From ABC Radio National, this is All in the Mind with me, Sana Qadar. Today, a look at how disasters can happen and what it all has to do with the way that humans think.

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  All in the Mind's senior producer, James Bullen, is in the studio for this one. Hi, James.

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  Hi, Sana.

• 2:59Speaker 03

  So what actually happened to Challenger in Colombia? Like, what actually caused these disasters on the day?

• 3:05Speaker 10

  So for Challenger, it was the O-rings. These were rubber rings which connected different parts of the shuttle together. And in the cold temperatures at launch, it meant that they didn't work as expected and they split the shuttle apart those 73 seconds after it took off. And then in Colombia, it was a foam strike. So foam fell off the fuel tank of the shuttle as it launched and hit the wing. It went up to space, everything was fine, except 16 days later when it came back. The damage to the wing meant that heat in re-entry destroyed the shuttle and killed the crew.

• 3:40Speaker 03

  Yeah, I remember that disaster. I mean, I was a teenager back when that happened and it was horrifying to watch.

• 3:45Speaker 10

  Yeah, just shocking seeing it split apart as it kind of crossed the sky. Those foam strikes and those O-ring issues, they were both known by NASA, by management, by engineers for years prior to these disasters.

• 3:58Speaker 03

  Wow.

• 3:59Speaker 10

  And that is kind of the core of this whole story, this idea of normalisation of deviance.

• 4:06Speaker 03

  That's a really captivating title, "Normalisation of Deviance".

• 4:08Speaker 10

  It is a really captivating title and it's an idea that we've been working on in another series from ABC Radio National called "The Challenger Legacy", that's with the reporting of Fiona Pepper and Dr Carl as well. The core idea of normalization of deviance was coined by an American sociologist Diane Vaughan in the 90s during her own analysis of the Challenger disaster. Others have been working on it since.

• 4:41Speaker 07

  So normalization of deviance is effectively a concept that encapsulates, let's say, the process of how certain behaviours or actions that were once considered wrong or devious in some way gradually become accepted as part of the norm of an organisation or of a system. And this acceptance is primarily driven by production pressures, let's say, or pressures to optimise certain operations in combination with the fact that previous engagements in such behaviours did not lead to significant perceived negative events or consequences.

• 5:17Speaker 10

  This is Dr Nate Sedlar. He's a lecturer in psychology at the University of Aberdeen in Scotland and a researcher into normalisation of deviance.

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  In the context of Space Shuttle Challenger, we had several years prior to the mission, the Challenger mission, where the erosion of the O-rings were noted. However, they did not negatively impact on the success of the mission. Therefore, there was a new norm established that the seriousness of O-ring erosion was no longer considered a major deviation. It was not considered a serious enough cause to effectively cancel the mission.

• 5:56Speaker 10

  Nate says normalisation of deviance can happen in any industry, but the places where it's perhaps more likely and where the consequences can be catastrophic are those high-risk, complex industries where people's lives are at stake. Think spaceflight, aviation, healthcare.

• 6:16Speaker 07

  Healthcare is one of the sectors that has really embraced specifically the concept of normalisation of deviance as of late because it is such an intricate, complex system with so many rules and procedures that need to be followed, with the consequences of something going wrong being potentially deadly.

• 6:39Speaker 03

  So the question I'm left with after hearing that is, aren't those rules and those procedures in place specifically to prevent things from going wrong?

• 6:47Speaker 10

  They are, but we don't always follow the rules right. And it's just kind of the way we function. We seek efficiencies, we maybe find shortcuts. And this normalization is often motivated by people wanting to do the right thing.

• 7:02Speaker 03

  Oh, yeah?

• 7:02Speaker 10

  Yeah, so going back to that healthcare example.

• 7:05Speaker 07

  A doctor would have to go through a list of various kind of steps in order to make a determination or to basically engage in a certain procedure. However, the doctor is very confident that they do not need to do all of those steps and that they can actually resolve this issue with this patient much quicker by essentially skipping those steps. And that is something that can become somewhat normalized. Same goes, for example, with, let's say, hygiene elements of washing your hands every single time after a certain procedure or even just meeting with a patient. Those kind of things might be considered overbearing and in some cases might become

• 7:47Speaker 07

  impossible if the cleaning station is inoperable, is not well stocked, or whatever, that causes the people to, again, deviate from that procedure on one occasion.

• 7:59Speaker 10

  Then, over time, people start to think...

• 8:01Speaker 07

  It was okay when I did it then, nothing bad happened, and I was actually able to save time by doing that. Again, this is, these are very minor things that can happen. And it is one of those things where it's difficult to necessarily say they are not engaged in any malicious manner. This is not something that doctors would do and go, I want to cause any harm to anyone. It is something that is engaged in because of the circumstances that they are in and because they ultimately wish to optimize what they're doing.

• 8:35Speaker 03

  Okay, so this is precisely why, you know, in broadcasting, we have a saying, this is not brain surgery. And I am so grateful for that because when stuff goes wrong in our jobs, it's generally okay, nobody's going to die. But I can totally see how this kind of thinking would seep in to people and actually have a real effect on people's lives.

• 8:52Speaker 10

  Yeah, yeah, when lives are on the line, that's when this normalization of deviance starts to become a really big problem.

• 8:59Speaker 03

  But it is interesting to realize that, you know, it can be because they're not trying to do the wrong thing. They're trying to actually do the right thing. They're trying to see more patients. They're treating people more quickly and making judgment calls.

• 9:11Speaker 10

  Yeah, 100%. And another area that really surprised me that Ned's talked about was firefighters.

• 9:19Speaker 07

  That cultural aspect of we are here to save people, we want to prioritize that as much as possible. It allows for greater justification of deviating from procedures that you believe are actually impeding you in some way. A lot of the times, the deviations that they engage in, or at least the paper that we reviewed talked about, was the fact that firefighters did not wear the required personal safety equipment that they are meant to. And the rationale that the firefighters gave for deviating from that was that that equipment was too heavy and prevented them from being able to save people within the building.

• 10:04Speaker 07

  Obviously, the counterargument to that from chiefs and safety experts that designed the personal safety equipment is, but you are more likely to injure yourself, to basically get trapped yourself. So you should be wearing that equipment. However, that argument only goes so far when the personal experience of the firefighter is, it makes me slower, I feel more in danger and I feel helpless. I am not able to help this person. I know from experience that if I do not wear that equipment, I feel like I can save more people.

• 10:39Speaker 03

  That is fascinating. This is not where I thought a conversation about normalization of deviance would take us.

• 10:43Speaker 10

  Yeah, the unexpected areas where it crops up and how it kind of links to social or cultural kind of identities at work, like firefighters, healthcare.

• 10:54Speaker 03

  And values, like how values influence what goes wrong sometimes.

• 10:58Speaker 10

  Yes, yes, definitely, yeah.

• 11:01Speaker 10

  And there are kind of other factors at play as well, I suppose. There's the incentives that a business or an organisation kind of sets up.

• 11:10Speaker 03

  Yeah, those are the more obvious ones you would think of.

• 11:12Speaker 10

  Yeah, it's kind of that faster, better, cheaper, want it all, yep. But there is another phenomenon that does come into play here, and it's called local rationality.

• 11:24Speaker 08

  Local rationality is the idea that what people do makes sense to them at the time, given their goals, given their knowledge and given their focus of attention.

• 11:30Speaker 10

  Sidney Dekker is a professor at Griffith University in the School of Humanities, Languages and Social Sciences. His background is in psychology and he's published several books looking at risk, safety and complex systems.

• 11:44Speaker 08

  People don't come to work to do a bad job. And that's not just NASA engineers, thanks, anybody, you know, a nurse in a hospital, people. We have to assume that people don't come to work to do a bad job. And so that's another way of saying local rationality. Now, why these decisions are locally rational is, one, because they solve a real problem, right? We can keep flying. They work against the background that would otherwise generate anxiety. Oh, my word, what do we do with the schedule pressures this and that? We're supposed to go up, this satellite needs to get up, right? And customers paying for this thing or whatever it may be. And so not only does it solve a real problem, but it deals with anxieties and other constraints that surround a system like this. What's interesting is that when it comes back, it appears successful.

• 12:26Speaker 08

  And so not only is it local rationality for that decision, but it's a local rationality that then feeds into the rationalisation of the next decision.

• 12:35Speaker 10

  One concept Sidney has researched and written a book about is something he calls drift into failure. It shares some similarities with normalisation of deviance and can also help us understand how failures occur in complex systems. Like Nate's, Sidney sees this drift as a fundamental, inevitable part of how humans operate.

• 12:56Speaker 08

  There is something fundamental to drift and adaptation in human behavior and the way we relate to the world as it is dynamic and changes around us. If we wouldn't do that, we would have no adaptive advantage and we would have died out a very long time ago. So the idea of drifting has everything to do with the idea of getting used to things. And people are in fact very good at that. They're very good at normalizing that which was slightly abnormal yesterday and going, oh, okay, well, yeah, that's probably normal. And in fact, probably stop asking questions about it. So yes, it is fundamental to human nature to even survive in a dynamic world, whether

• 13:39Speaker 08

  it's looking after patients on a hospital ward, whether it is pumping oil out of deep water, whether it's flying space shuttles, or even flying jet liners, right? And so, and the reason for that, James, is that as Jens Rossmann and one other theoretician in this space so beautifully said, you know, we're always adrift. We're not only adrift toward a safety boundary, but we're adrift in this space that is bounded on three sides. And so one is the safety boundary, and if you go across that, yeah, you have an accident and the system fails. But there's two other ways, says Jens, in which that system can fail. And you're bouncing around this envelope all the time. So the two other ways are a workload boundary, and the third one is a financial boundary.

• 14:23Speaker 08

  And so you can make it really, really, really, really safe, but then you're probably paying so much that you're going to fail that way. Or you're going to make it really, really, really safe and say, before we do surgery, we have 50,000 checklists that we go through to make sure absolutely sure. Well, right, I mean, ambulance ramping, patient waiting lists, I mean, the system will fail because of the workload that it creates for itself, right? So we're always adrift by having to manage and thus sacrifice one of these things against another. And so, yes, I think it is very safe to say that there is no human system that works in a complex dynamic world that is not somehow adrift all the time.

• 15:06Speaker 10

  Nate Sedler has reviewed the common factors that cause normalization of deviance. Production pressure is the key one. Unrelenting pressure driving people in an organisation towards some goal, perhaps having to let safety fall by the way to reach it. Leadership also plays a role. Then there are the cognitive biases we humans all tend to experience, like availability bias and our use of heuristics.

• 15:32Speaker 07

  It's availability bias, where the past events that we have observed, that we know about, if we only know about events where someone has engaged in that behaviour, or we ourselves have engaged in that behaviour, and they have all led to a positive outcome, where we might have even been praised for optimising that behaviour, for getting more work done on that day because we cut corners. Well, and nothing bad happens as a result of it, then we're more likely to engage in it. Because, well, our biased perception of it was the result of this behaviour is positive, so we are more likely to repeat it.

• 16:07Speaker 10

  Plus, we don't like spending our precious cognitive resources on constantly evaluating decisions. That's just human.

• 16:15Speaker 07

  We often rely on set rules or just basically do what we have always done in the past. Because we are ultimately cognitive misers. We want to preserve as much cognitive energy as possible because attending to every decision that we make in our day to day life to the full extent of analysing all the benefits and all of the costs or the potential risks of doing that decision, that would be exhausting. And we do not have that cognitive energy to be able to do that. So as a result of that, we basically use heuristics. We use these kind of shortcuts. And the easiest one is do what we have done before. Do what has worked in the past.

• 16:59Speaker 07

  We are more likely to simply repeat what we have done before because engaging in any kind of additional assessment of that decision, we do not see any reason for it unless the context changes, unless there is something that kind of stops us in our track and we go, let's reassess this. Then that engagement in that kind of deeper thought processes can occur. And even with the limited knowledge, we might be able to reassess what we are doing.

• 17:29Speaker 03

  From ABC Radio National, you're listening to All in the Mind. I'm Sana Qadar. Senior producer James Bullen has today's episode. And at the top of this episode, we heard about the Challenger disaster, which is the space shuttle that exploded after launch back in 1986. James, how well does normalization of deviance explain what happened there?

• 17:51Speaker 10

  It is one explanation for sure, in that they knew that these O-rings were a problem. It didn't cause any immediate damage in kind of the shuttles that launched before Challenger in 86. And so they kind of waved it away and thought it wasn't actually an issue when it definitely was. But some people don't like that explanation for the disaster.

• 18:11Speaker 03

  All right.

• 18:12Speaker 10

  They push back against it because they see it as excusing personal responsibility or the kind of on the ground decisions that individuals made.

• 18:22Speaker 03

  Right.

• 18:22Speaker 10

  In the lead up to the launch.

• 18:24Speaker 03

  Okay, so for people who aren't familiar with the story of Challenger, what were some of those decisions?

• 18:29Speaker 10

  So the night before the launch, engineers who had been involved in making the shuttle met with NASA and expressed some of these worries, these concerns about the O-rings. But because they were on a schedule, because there were budget pressures, because they wanted to prove that this would be a successful space programme, they went ahead with the launch anyway.

• 18:48Speaker 03

  So there were significant organisational reasons leading to this, not just a subtle normalization of deviance over time, which I suppose also was caused by these organisational pressures.

• 18:57Speaker 10

  Yeah, it's a bit of a snake eating its head type situation. Yeah. But definitely there were massive organisational, structural kind of pressures.

• 19:06Speaker 03

  Hmm.

• 19:07Speaker 10

  Leading up to these decisions.

• 19:09Speaker 03

  And so are there other examples of disasters that are seen to have been caused by normalization of deviance?

• 19:14Speaker 10

  Yeah, there's a, there's quite a few. In the literature, one that gets analysed is the Costa Concordia. This was that Italian cruise ship, the luxury cruise ship that ran aground off the coast of Italy, capsized, 32 people died. The normalization of deviance angle there is that they had kind of normalized this routine of coming close to the coastline and saluting people on the coastline to kind of show off the cruise liner. And that's when they ran into the rocks.

• 19:45Speaker 11

  The captain had been performing a sail past salute of Italy's Giglio Island and went too close. The ship lost all power and tilted on its side.

• 19:55Speaker 10

  Another one is this Northwick Park drug trial. So

• 19:58Speaker 03

  I haven't heard of this.

• 19:59Speaker 10

  This was in the UK. It was six men who were in a clinical trial. They all got dosed with this experimental drug and then had a kind of massive adverse reaction to it. They were hospitalized. One of them lost his fingers and toes.

• 20:14Speaker 03

  Oh, my gosh.

• 20:15Speaker 10

  Yeah, shocking. And they worked out after the events that they should never have been dosing everyone at the same time with this experimental drug. Six people at once.

• 20:26Speaker 12

  They are suffering from major organ failure.

• 20:29Speaker 13

  Six men remained seriously ill in hospital after taking part in

• 20:33Speaker 10

  The original protocol had suggested that they should just do one at a time. And it makes way more sense to just do one, see what happens, then go to the next. Yeah. But for perhaps budget reasons, perhaps time reasons, they started doing it like this and it led to this pretty catastrophic result.

• 20:52Speaker 03

  All right. So we've heard how these kinds of errors can arise and some of the cognitive quirks and system complexities that allow them. How then do you stop them from happening?

• 21:02Speaker 10

  Yeah, Sidney and Nate have some ideas about that.

• 21:05Speaker 08

  What successful systems do is they actually stay uneasy about their success because failure happens because you are successful. And I think this is a key lesson of accidents that are traceable to drift into failure.

• 21:21Speaker 10

  That's Professor Sidney Dekker from Griffith University again.

• 21:25Speaker 08

  They failed because they were successful. They didn't fail because they were already breaking down very visibly and had incidents and accidents and things all over the place. No, no, no, they were successful. Deepwater Horizon, a whole year with no incidents or injuries whatsoever, right? Which is probably not true, but you know, at least they were telling themselves that. Look at us being so successful, right? And then you blow stuff up and kill a lot of people and create the biggest oil spill in the history of humanity. And so, so, so that really is the first one. Stay uneasy about your success. When you are in a period when apparently nothing goes wrong. That's not proof that things are safe.

• 22:10Speaker 10

  That doesn't mean you don't recognise success. But be a little sceptical of it, Sidney says.

• 22:16Speaker 08

  Celebrate it for all, for all I care, right? Go, oh, hey, aren't we great? Look at us go, sure. But then ask some questions. What is it that we didn't do? What have we sacrificed to get here? Because we can't be, you know, faster, better and cheaper all at the same time. Something will have to give. And so what gave? What did we not do, right?

• 22:38Speaker 10

  Professor Sidney Dekker says another thing organisations that avoid adrift into failure do is listen to the intuition of their people.

• 22:46Speaker 08

  They listen to not just data. They listen to discomfort. They feel their gut and they go, it doesn't really feel good. I'm not liking this approach into this airport. I'm not liking how this jet is looking or right. Which is very difficult to then bring back to the boss and say, boss, I got some bad news. What do you mean? Well, I, we're not going to do this mission because it doesn't feel good. You don't make friends doing that, right?

• 23:15Speaker 10

  It seems counterintuitive or almost a scientific not to follow the data. So what supports following discomfort in this way?

• 23:24Speaker 08

  You could call it sort of the parameterisation problem. That if you want to run all of your decisions of what to do on a system based on data that you somehow measure, it means first of all, that you know what you are out to measure and, and why you want to measure it. And that you in fact have a way to measure it, that you can stick a probe into something or right? And then measure whatever it is that you need to measure, the pressure, you know, some velocity, some derivatives and whatever it may be. What we see in, in socio-technical systems, take a midwife. Right, we're studying this and, and, and all of a sudden we're in a, we're in a situation where

• 24:04Speaker 08

  the midwife announces rather loudly and then they're the kind of nurses that are, at some point when they, when they say that something needs to happen, it's not a negotiation, right? It's not a proposition for, oh, let's kick that around the room a little bit, right? No, this needs to happen. And all of a sudden she says, this baby needs to get out now. And we're all scrambling around looking at data going, what do you mean? Maybe heart rate looks fine.

• 24:29Speaker 03

  That example is really fascinating because it brings me back to an episode we did of All in the Mind a couple of years ago now. It was on this exact topic. It was about gut instinct. And the researchers we spoke to in that episode said that when someone has, you know, a lot of experience and expertise in an area, their intuition and their experience may pick up on things that the data isn't picking up on.

• 24:50Speaker 10

  Yeah, there really seems to be something about intuition.

• 24:53Speaker 08

  And the literature is picking up on this more and more that adds a whole bunch of additional parameters and probably combinations of parameters to this panoply of data that we already collect from these systems and to base our decisions on. So, yes, there is definitely support in the literature, James, that suggests that we should be acutely aware of intuition steering people to places where they go, hmm, what's that smell? I'm not sure. I haven't seen that yet. Right? And because you may be in a situation where that isn't picked up by whatever data trace the system is capable of producing for you.

• 25:33Speaker 10

  We mentioned earlier that some people don't like the idea of normalization of deviance. They see it as absolving people of personal responsibility where sometimes it can look like the choices of individuals lead to disaster.

• 25:47Speaker 07

  Yes, and that is a concern that we absolutely wish to address. It is not necessarily about letting anyone off the hook. It is about, however, about recognizing the situation that people are put under. What the aim of any incident investigation, accident investigation ultimately is, is to prevent the disaster from occurring again in the future. Not to lay blame, not to assign who was at fault or to punish anyone within such a context, but how do we make sure that this does not happen again in the future? Whether someone was qualified to be in the position that they are in can be considered

• 26:32Speaker 07

  part of that system. It is considered an aspect of was the person trained well enough? Were they aware? Were they able to take on the responsibility that was afforded to them?

• 26:43Speaker 10

  Sidney Dekker broadly agrees.

• 26:45Speaker 08

  No questions that are much more oriented toward learning are the ones that say, who's impacted by this? Who's impacted by this event? And you'll find immediately that whoever signed off on it is pretty impacted. I can tell you that from experience with lots of second victims in all kinds of industries. The second question is, what do they need? Everybody who's impacted, what do they need? A very compassionate question. What do you need in order to deal with the impact that has been caused to you? And then the third question is, whose obligation is to start meeting that need? Well, maybe you come back to the person who signed it off. Yeah, but maybe not. Maybe there's all kinds of other people who carry the obligation to start meeting that need. What it does, James, is it flips the accountability question from a backward looking one that

• 27:30Speaker 08

  says, you know, okay, well, let's trace back and use all of our hindsight to find exactly who signed off, what, where, when, and thereby violated this, that or the other thing, and we're going to punish that person for that thing in the past. Instead, it says, no, no, no, accountability is forward looking. It lies in the future. It asks questions about who's going to do what now, based on what we've learned and how are we going to know that that's going to happen? And to make accountability about what needs to happen now, instead of accountability about what happened yesterday.

• 28:02Speaker 10

  Sidney says those second victims, the ones left behind in a disaster. Are people we can learn from too.

• 28:10Speaker 08

  Second victims are those who have a role in running that system, flying the airplane, being at the bedside in hospital, or for that matter, being an engineer involved in the launching space shuttle Challenger. Those second victims have a very particular kind of suffering that we see, James. What they have is feelings of guilt, remorse, feelings of responsibility, but also an authority-responsibility mismatch, where they feel responsibility but weren't given the authority to really act on it. And so, again, second victims are an incredible source of information about the inside and indeed the intuitions of how these systems work and fail.

• 28:55Speaker 03

  That was Professor Sidney Dekker from Griffith University. You also heard from Dr Nate Sedlar from the University of Aberdeen. This episode from All in the Mind was from senior producer James Bullen, with additional reporting and production from Fiona Pepper.

• 29:11Speaker 03

  Thanks to producer Rose Kerr and sound engineer Roi Huberman. I'm Sana Qadar, and just before I go, if you want to hear more about the Challenger and Columbia disasters, the behind-the-scenes story of the engineers who tried to stop these disasters from happening, you should head over to our sister podcast, Science Friction. They have a series running right now called The Challenger Legacy with Dr Carl and Fiona Pepper, and it tells this story. Here's a little snippet for you.

• 29:43Speaker 14

  This is AM. Good morning. I'm Red Harrison. And as we go to air, NASA is about to hold a news conference on what is tragically America's worst disaster in space.

• 29:52Speaker 15

  On January 28, 1986, the space shuttle Challenger exploded in the sky, killing all seven crew on board. It was an unthinkable occurrence.

• 30:04Speaker 05

  We've never lost an astronaut in flight. We'd never had a tragedy like this.

• 30:10Speaker 16

  I remember going into my mum's place and then seeing it on her TV while we were having breakfast. Oh my god.

• 30:17Speaker 17

  I can still remember exactly how utterly incomprehensible I found it, that something like that had happened.

• 30:23Speaker 18

  We just thought it was taking off into space and then we couldn't believe it, it had exploded.

• 30:29Speaker 19

  I ran outside as fast as I could and I looked up in the sky and I saw a very strange contrail. Like it was just shocking.

• 30:37Speaker 15

  Millions of people all around the world were closely watching this launch because this was the first time that a civilian had ever been sent to space. And it wasn't just any civilian, it was a teacher selected to inspire young people, to teach them about space.

• 30:54Speaker 20

  Among those glued to the television screens to watch today's liftoff were Mrs. McCullough's pupils at the high school in the small New England town of Concord where she taught. Their tears turned to tears as the tragedy unfolded before their eyes.

• 31:09Speaker 16

  For those who were closely involved, those on the inside, even 40 years, that's four decades later, the launch is still vivid. It's like it was yesterday.

• 31:19Speaker 21

  He just put his hands down in his face and he just started crying. He sobbed.

• 31:24Speaker 22

  I just felt that we were the cause.

• 31:28Speaker 23

  There was stunned silence and I knew I had to say something. The thing I chose to say was.

• 31:34Speaker 04

  Flight controller's here looking very carefully at the situation. Obviously a major malfunction. We have no downlink.

• 31:49Speaker 15

  I'm science reporter Fiona Pepper.

• 31:51Speaker 16

  And I'm Carl Kruschniski, aka Dr Carl. I was a very baby Dr Carl back then. Taxi driver, physicist, engineer, trainee, doctor, and a wannabe astronaut. Absolutely obsessed with everything to do with the space shuttle programme. I remember what happened to the Challenger, but I'm also pretty sure I don't have every single detail correct.

• 32:14Speaker 15

  And I'm too young to remember it, but I've gone down the rabbit hole reporting this story and I can't believe some of the details of what I've learnt.

• 32:22Speaker 16

  Together, Fee and I want to tell you the story of Challenger.

• 32:27Speaker 15

  The story of what went wrong and what happened next.

• 32:31Speaker 17

  In the 40 years since the accident happened, it's hard for anyone who wasn't around before 1986 to understand exactly how inconceivable it seemed that NASA could fall victim to a catastrophe of this scale.

• 32:45Speaker 24

  He totally failed to elevate that issue. That, to me, is almost criminal negligence.

• 32:51Speaker 22

  My biggest regret in the whole episode, I wish I'd have said that there's a dissenting opinion here.

• 32:59Speaker 15

  But then, close to two decades after the Challenger disaster, another tragedy unfolds at NASA, killing another seven crew.

• 33:08Speaker 25

  America in shock as the space shuttle disintegrates minutes before landing. A 16-day mission ends in disaster, seven astronauts are dead.

• 33:18Speaker 16

  It's a story about NASA, about risk, complacency and ambition.

• 33:23Speaker 26

  When you dig deep enough, there's no question that the organisational culture was implicated in both the Columbia and Challenger mishaps.

• 33:33Speaker 27

  We know they made mistakes, bad mistakes. People have to live with it for the rest of their lives.

• 33:39Speaker 19

  As you explore these different accidents, there are so many of these lessons that come out, but they keep repeating themselves.

• 33:44Speaker 15

  And although it happened 40 years ago, it's extremely relevant today because NASA is on the verge of sending a crewed mission to the moon for the first time in over 50 years. And we're all wondering, have they learnt from their mistakes?

• 34:01Speaker 28

  NASA is trying to do too much and that's of great concern to me, especially as we look toward these hard and missed missions.

• 34:09Speaker 16

  This is The Challenger Legacy, a new season of science fiction from ABC Radio National.

• 34:14Speaker 15

  Weekly from Wednesday, January 21st. Follow Science Friction on the ABC Listen app or wherever you get your podcasts.

• 34:28Speaker 00

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