Blowing The Whistle

What’s been your experience with investigations?

Four decades ago, Nobel Prize winning physicist Richard Feynman wrote a book about his. Well, not exactly a book; half a book would be more precise. Feynman’s What Do You Care What Other People Think? was an autobiography of sorts: the first part was about growing up in New York and winding up as Group Leader for the Theoretical Division at Los Alamos on the Manhattan Project. 

Feynman must have seen the irony in that turn of events. If you’re a fan of last year’s blockbuster, Oppenheimer, you’ll find it interesting. What’s relevant here is the other part of the book: his first-hand account in serving on the Presidential Commission On The Space Shuttle Challenger Accident, better known as the Rogers Commission.  Feynman broke the story that O-rings on the solid rocket booster shrunk in cold temperatures by plunging one in a pitcher of ice water in front of a room full of reporters and TV cameras.

Made the point, didn’t he.

In capturing the public’s interest, no investigation compares. Challenger was the Space Program’s first inflight fatality event, witnessed live by millions. Four months later, the release of the Rogers Commission Report was the lead story on the nightly news. CBS News anchor Dan Rather described the launch as “… a triumph of bad politics over good science and data.”

If he read Feynman’s appendix in the report, Rather would not have said it anywhere near that way. Yes, pressure was put on NASA’s propulsion contractor to go along with a waiver to the minimum launch temperature requirements; yes, that pressure was motivated by a desire to please politicians and public, all of whom wanted to see space flight.

So, what else is new?

As Feynman saw things (and as he was so amazingly good at explaining them) the root of the failure was simply that those responsible for managing space science ignored the data and science when it got in the way of space flight. 

The Investigation Process

In What Do You Care, Feynman relates the back story as to how an outsider like he wound up going public with evidence proving the O-ring as the cause. His personal account of the investigation process should be required reading for anyone with a role to play in an investigation, starting with those choosing team members. 

As you would expect, the Presidential Commission was made up of political and aerospace insiders; the addition of a Nobel Prize winning theoreticalphysicist was window dressing. Obviously picked by someone unacquainted with him, thinking Feynman would be content to go along for the ride. 

Feynman’s wife convinced him to take the gig: “If you don’t do it, it’ll be twelve people going around from place to place together. If you join the commission, there will be eleven people…while the twelfth runs around checking all kinds of unusual things. There probably won’t be anything, but if there is, you’ll find it.”  

He did.

The Commission had its process; Feynman had his. Like a good scientist, Feynman began to form hypotheses, collect data, and against the wishes of Rogers, talk directly to the engineers. “They’d show up with their notebooks, all neatly organized, and proceed to … explain everything to me in the usual NASA way, with charts and graphs…all with bullets, of course.”

“You just don’t sit there while they go through what they think would be interesting; instead, you ask a lot of questions, you get quick answers, and soon you begin to understand the circumstances and learn just what to ask to get the next piece of information you need.”

Feynman wasn’t the least bit reluctant to dig into what he called “fishiness” either, by “asking my usual dumb sounding questions.” He appreciated that those he was talking to were thinking he was investigating the mistakes they made. “We were talking details, and that works wonders. To them it looked like I was a regular guy who knew about their technical problems.”

As to where Feynman got on to the problem with the O-rings, apparently members of NASA’s astronaut corps knew there was information showing they had no resilience at low temperatures. But nobody wanted to put their career at risk by going public; instead, the information was passed along to an intermediary, who cooked up a story about working on a car on a cold day and encountering problem with a gasket on a carburetor. That was enough to put Feynman on the case.

So much for blowing the whistle.

The TITAN

The newest edition to my collection is the Coast Guard’s investigation into the implosion of the TITAN while exploring the wreckage of the Titanic. You’ll remember that tragedy: five people perished in more than 12,000 feet of water, including Richard Stockton Rush, the submersible’s pilot, company owner and CEO.

At 327 pages, it’s more book than report. Credit the Marine Board of Inquiry for compiling an exhaustive collection of facts and evidence, performing fifty-six pages of analysis, and producing seven pages of conclusions based on those facts. 

If you’ve not read any of the reporting on the investigation findings, you’re probably wondering which of those usual suspects the Board pinned the blame on. Was it culture, compliance, design, operation, maintenance, cutting corners or poor management?

Pardon my cynicism on this aspect of the investigation process: years of reading reports on the high-profile events has had its effect. Typically, the root cause is found in something faceless: the system, the culture, the management, sometimes even “the City,” Case closed. Makes for a good headline; nobody reads the report, anyway.

Thankfully, the Titan investigation wasn’t one of those. You would do well to read the Board’s findings and conclusions, which are shocking in their breath and criticism: the untested design of the submersible, misrepresentation to licensing authorities, and wrongdoing at every step in its operation.  Their bottom line: “…Mr. Rush, in his dual role as CEO and as the acting Master or Pilot of the TITAN submersible exhibited negligence that contributed to the deaths of four individuals” and “… may have been subject to criminal liability…”.

Mr. Rush is now gone, his company ceased operations, rendering that moot. But at the time of the event, the Board described the operating reality: “OceanGate’s toxic safety culture, corporate structure and operational practices were critically flawed and at the core of those failures were glaring disparities between their written safety protocols and their actual practices.”

With things that bad, you might wonder why someone didn’t blow the whistle. Turns out the TITAN was the rare case where somebody did: the Director of Operations. After his inspection of the submersible’s hull, he raised numerous objections to its design and construction to the CEO. Shortly thereafter, he was fired. 

He then took the case to OSHA, as it was one jeopardizing employee and public safety. The regulator afforded him legal protection as a whistle blower and handed the case to the Coast Guard. Collectively they did nothing for five years, When the TITAN imploded, they launched an investigation.

Their report is chock full of criticism of Rush and OceanGate, but offers no explanation as to why nothing happened when someone blew the whistle.

Findings and Recommendations

If you’re a student of the investigation process, the most interesting part of Feynman’s story is what happened after the facts were gathered and findings and recommendations prepared. Feynman turned in his report; it got buried. He dug it up; it got lost again. Once found, someone had changed it. “It seemed my report was always missing, or half cooked. It could easily have been mistakes, but there were too many of them.”

One more example of fishiness.

That’s the point when Feynman blew the whistle. “Please take my signature off the report unless two things occur” he informed Chairman Rogers. In writing. 

Feynman felt he could always publish his version of what went wrong, “Personal Observations On The Reliability Of The Shuttle” exactly the way he wrote it. The conspicuous absence of the signature of the member who broke the seal story would undercut the credibility of the report. 

Long story short, those in power relented. Feynman’s personal observations were published as Appendix F – as written. His concluding sentence: “For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled.”

In my collection of investigation reports, there is no better concluding statement to be found. Thank you, Dr. Feynman, for setting an example both for the investigation process and blowing the whistle.

As For You

One thing’s for sure: you’ll never find yourself caught up in the affairs of the TITAN or the Space Shuttle, wondering when and how to blow the whistle. Both are officially out of business. Still there is wisdom in Mark Twain’s observation, “History doesn’t repeat itself, but it often rhymes.” It’s entirely possible that you might someday find yourself in one of those predicaments where blowing the whistle would be an option. 

Maybe you already have.

Blowing the whistle is the option of last resort; others are to be found along the way. Face that option, it’s as tough as it gets. When lives are at stake, it’s as important as anything gets. 

If there’s something to be learned from the experience of astronauts, deep sea explorers, and the best and brightest scientists, it’s that now is the best time to figure out your principles: when would you blow the whistle, and how.

Paul Balmert
August 2025