Bill Gurley: Searching for Feynman

Bill Gurley argues that catastrophe investigations should establish root causes and lead to changes that prevent recurrence, rather than stop at assigning blame. He describes CAPA, which he calls “Captive and Preventive Action,” as a five-step process: detect a problem, investigate it, confirm its root cause, correct it, and prevent it from happening again. The search for root causes, he says, requires technical scrutiny as well as attention to institutions and decisions that allowed hazards to persist.

The January 1986 Challenger disaster illustrates that combination: an O-ring failed in cold conditions, and an institutional failure preceded the launch when a subcontractor’s objection was shut down the night before. Richard Feynman cleared his calendar for six months, visited NASA facilities, and demonstrated on live television how the O-ring material failed. Gurley says the commission’s report later softened Feynman’s findings; Feynman tried to remove his name, and his notes were included in Appendix F. Gurley presents Feynman’s persistence as a model for investigators willing to follow evidence even when it challenges an organization’s account.

Gurley cites other disasters to show how technical vulnerabilities can compound with failures to respond. At Surfside, Florida, 98 people died in the June 2021 condominium collapse; he points to saltwater corrosion beneath the pool deck that damaged structural columns, alongside design problems, poor maintenance, and inaction on an inspection report. The NIST investigation took five years, while a 37-person Miami Herald reporting effort won a Pulitzer Prize; Florida and other states subsequently changed condominium rules. In the Boeing 737 crashes, Gurley says fitting a larger engine to the existing design contributed to an imbalance addressed with MCAS, software pilots were not told about. A faulty sensor could trigger MCAS to push the plane down. He says that almost everyone knew MCAS was at fault 45 days after the first crash, in October 2018, yet Boeing and the FAA did not ground the plane before the second crash in March 2019.

He also describes Katrina and Fukushima as preventable disasters in which institutional conduct obstructed accountability. Katrina’s 2005 levee failures caused 1,800 deaths and $125 billion in damage; investigations produced 90 recommendations, and Gurley says the resulting changes were followed by seawalls holding for 20 years. At Fukushima, tsunami water overtopped a 5.7-meter seawall and disabled generators, despite documents anticipating tsunamis of 10 to 15 meters within a 30-year window. For Gurley, these cases show why investigations must turn warning signs into corrective action rather than merely document them afterward.

Gurley argues that COVID-19 merits an equally serious root-cause inquiry, citing 15 million deaths and $45 trillion in global costs. He says he expected a major newsroom investigation, congressional committees, an independent commission, and a substantial victims’ lawsuit, but considers those efforts absent. He estimates COVID’s death toll was 3,000 times that of the five other disasters discussed, while emphasizing that the virus’s origins remain unestablished. He criticizes Francis Collins, Anthony Fauci, Peter Daszak, Jeremy Farrar, and Ralph Baric as “blockers,” arguing that their connections to virology research and prior support for gain-of-function research compromised their impartiality. These are Gurley’s allegations, not established conclusions in the synopsis.

Gurley says the Proximal Origin paper was written in about a week rather than produced through an investigation, and argues that it and a similar Lancet paper diverted attention from a possible lab leak. He says he takes no position on COVID’s origin and supports investigating animal spillover alongside other possibilities. He highlights the EcoHealth Alliance Diffuse proposal, which surfaced three years after the pandemic began and, he says, proposed inserting a cleavage site at the S1S2 junction of a bat coronavirus to increase transmission in animals, linking researchers at Duke, the University of North Carolina, and Wuhan, including Shi Zhengli. In a survey of scientists, 22% had heard of the proposal and 78% had not; Gurley says an AI assessment treated it as a high-priority lead and that the University of North Carolina and North Carolina are withholding relevant documents. He calls for an independent commission focused on root causes and preventing another pandemic, not prosecution or partisan conflict; he has funded U.S. Right to Know, supports research into animal origins, and says he has zero confidence the country would handle another pandemic better given declining trust and misinformation.