Coaching Letter #114

Hi, I hope you’re well. My dad reminded me that today is the 50th anniversary of the Apollo 13 accident that nearly resulted in the loss of the spacecraft on its way to the moon. The book Lost Moon (Lovell and Kluger, 1994) and the movie based on the book, Apollo 13, are favorites of mine. I think we can learn a lot from the incident about leadership, and about systems, which are all that’s in the news at the moment.

The fault in the fuel cell that caused the explosion aboard Apollo 13 was present ever since its manufacture. It takes seven pages for the authors to describe the entire sequence of events that led to the explosion on board Apollo 13; here is my attempt to summarize: it began with a change in the voltage of the heating system to handle the higher voltage that was used on the launch pad instead of the lower voltage that was used in the spacecraft. The change was not made in the switches in the thermostat in the oxygen tanks, and not only was this error made, but the mistake was not caught in inspections by the manufacturer, the contractor, or NASA. The thermostat was designed to prevent the oxygen tanks from heating to over 80 degrees, but during testing, when the thermostat did reach that temperature and tried to open, the 65 volts that surged through (instead of the 28 volts it was built to handle) fused it shut, allowing the temperature to climb to 1,000 degrees. There was also an instrument panel that would have shown the technicians that there was a faulty thermostat if the temperature rose above 80 degrees, but the thermometer didn’t go above 80 degrees, so no one knew that the thermostat was faulty; and no one knew that the temperature had reached so high, so no one knew that the Teflon insulation had burned away leaving exposed wiring; so that when the oxygen tanks were stirred as part of routine procedures during the space flight, a spark from the exposed wire ignited the remaining Teflon and led to an explosion that blew apart the tank and one side of the ship. This latent condition did not come to light until the third order to stir the oxygen tanks during the mission.

This is the short version of what happened and why. By my estimate there were a dozen separate steps in the sequence of errors and omissions that led to the explosion. I have used this case in classes I have taught because Apollo 13 illustrates several crucial aspects of systems, including the distance in time and/or space between cause and effect; the unintended consequences (externalities) of all decisions that we frequently only notice when one of the consequences is catastrophic; and the unpredictability of complex systems. In particular, there is the idea of the high probability of low probability occurences; one of the reasons why we are so bad at thinking about risk in the “the chances of that happening are so slim” category is that we live in a highly complex world. The chance of one particular set of events leading to disaster seems very small, but because the number of possible events that could interact to cause a disaster is so high, the odds that something bad will happen is also high. Thus, the chance that that particular set of problems would line up to cause the explosion on Apollos 13 was pretty slim, but there are so many potential problems waiting to happen in space flght that it should not be surprising when something catastrophic happens. And that is also true in our increasingly globally interdependent world.

The last thing I want to mention about Apollo 13 is the human factor. The characteristics of leadership and teamwork that are in play during a crisis make the difference between no incident, a mitigated disaster, and a total systems failure. Because educators don’t often deal with life-and-death situations, we don’t always think of our work as carrying the same import as flight controllers and pilots and doctors and nurses. But what we do is very high stakes, impacting the lives of students for the rest of their lives, and the leadership and teamwork that we engage in could not be more crucial, especially now.

There are lots of clips on YouTube about Apollo 13, but here’s a  quick 5 minutes from the BBC which I like because most the voices are of Jim Lovell’s family talking about the experience from their point of view. Enjoy.

As always, if there is anything I can do for you, please let me know. Love, etc., Isobel

Isobel Stevenson, PhD PCC
Connecticut Center for School Change
istevenson@ctschoolchange.org
860-576-9410
@IsobelTX
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2020-04-13T08:49:39+00:00