The Pre-Mortem: Avoiding Catastrophic Failure.

If you knew you were going to fail catastrophically, would you carry forward with your plans, or would you change course?

How can you know if you're going to fail catastrophically, right? To borrow the old cliche, you're not a rocket scientist, are you?

Today's lesson is on how to avoid catastrophic failures with a simple process--and is also about rocket scientists and their failures.

In 1986, I sat in a crowded school gymnasium to watch the liftoff of the Space Shuttle Challenger. Our school was tracking the launch because onboard, there was a public school teacher, Christa McAuliffe. I'll never forget the awe of the shuttle lifting off, nor the horror of it subsequently exploding. The teachers quickly turned off the TV and shuttled us back to class--an unavoidable tragedy having occurred.

Only it wasn't an unavoidable tragedy.

If you dig into that disaster, it was preventable. The shortest explanation is that the shuttle was launched in weather colder than it was designed for. Because the weather was cold, the rubber o-rings used to seal critical components in the rocket boosters--literally used to keep rocket fuel under seal--had shrunk and were not properly sealing. At launch, these o-rings let rocket fuel escape the booster and the explosion resulted.

This failure was predicted. The engineers who had designed the rockets knew that the failure was going to happen. They had warned NASA and asked that the launch be delayed to warmer weather. The night before the launch, one of the scientists solemnly told his wife that the shuttle was going to blow up. Their concerns were overridden by NASA and by their employer, both of which were eager to uphold an ambitious launch schedule. NASA failed to listen to the subject matter experts--literal rocket scientists--and as a result, seven astronauts died. It pales in comparison, but NASA also lost hundreds of millions of dollars of equipment.

How do we learn from this avoidable tragedy?

At the start of every project, we have a team of subject matter experts on hand--the people who are the most familiar with the project, the moving pieces, the risks and rewards. You've heard of a post-mortem--the examination that happens after a death to determine why someone or something died. Instead of a post-mortem, we do a pre-mortem.

A pre-mortem is the concept of holding a meeting to review the project and look at the hazards, the risk factors, the areas of greatest exposure. It's a meeting held for the specific purpose of asking what can go wrong, and what can be done to mitigate that risk. Sometimes, we get so focused on meeting a schedule or delivering a project that we fail to see the risks piling up. A pre-mortem is designed to have a sole focus on risks, so we can make an informed decision about whether we should continue with a project and to as what we can do to reduce the level of risk.

Sometimes, a pre-mortem shows that the project is well-planned and ready for a metaphorical launch. Sometimes, it shows vulnerabilities that were not earlier identified, and allows an opportunity to meaningfully intervene and enhance the project (or at least protect against known risks).

I don't use the example of the Challenger explosion lightly, or flippantly. That moment is etched into my brain as a tragedy--one of those things that I'll always remember--where I was, what I was doing, the mood in the room going directly from elation to grief. Had the team responsible for that launch done a pre-mortem, had they listened to the experts, had they evaluated the risks and responded...seven people might still be alive today. The stakes aren't always this high on our work, but they can be. When you have a critical project, try the pre-mortem. Ask your subject matter experts--the rocket scientists of whatever project you're working on--what can go wrong. Find your hazards and mitigate them.