..

"
~~.

AS A MATTEROF

Febru~ J, 2003, was a tragic day in the annals of space exploration. Only
utes fi:om touchdown at the Kennedy Space Center in Florida, the U.S.
Shuttle Columbia (NASA's mission STS-107) disintegrated upon reenterj~g
earth's atmosphere. The otherwise successful 16-day scientific research'
~; ended in catastrophe. Lost was the entire seven-member crew: Commander
Husband, Pilot Willie McCool, Mission Specialists Michael Anderson, Dave Bro~,.'
LaurelOark, and Kalpana Chawla, and Payload Specialist Dan Ramon from Israel~
, Within hours,the Columbia Accident Investigation Board (CAIB) was formed. Its
chaimlan, retired Adniiral Harold W. "Hal" Gehman Jr.,headeda team of 13 committee
members along with a staff of 120adnrinistrative aSSistants and 400 NASA engineersto ,~~
deternrine precisely what happened and why, and to recommend ways of avoiding a
reoccurrence.Alrilost sevenmonths later, on Au~ 26,2003,the board's findings were
releasedin a hi~y detailed,seven-volumereport. As one might expectgiven the nature
of the investigation, the report contained copious technical details of engineeringflaws
that Jed to the shuttle's physical failure. The immediate cause of the accident was a
breach in the thermal protection systemresulting from a piece of insulating foam that
separatedfrom a fuel tank and hit part of the left wing shortly after launch.
But, according to the board, the stage for these technical troubles was set by a
more fundamental cause-deeply rooted problems in the organizational manage-
ment of NASA's Space Shuttle Program itself One might not expect to @d an OB
focus in a government-initiated, post,disastertechnical report, but it m~sperfect
488 sense.After all, people engineered the project, so any weaknessesin tbe~ they

~
 The Columbia
"
made bound;;to
ence.Tragically,th~ydid~Add to this an organization~lculture that
tionable comprotnisesand the ine!ficient organizational design
whole,and youha.v~ther~cipefor failure'cIndeed,theboard con;cluded
lernsinherentin~ASA's 9rga~atiQna1man~gementhad as muchtt;>dQWi~,.the;-::;.:~.:
accidentasthe physicalcausest~emselv~s.Untilthesewere rectified,
flights could not be resum~d safey.
l c'
c ,;;1\. :" ."-: ::~ !"i~::'..'~"~~,
!d:;~f"'{jjc¥~;i;-::;,,~~"!f!f';
The board'sanalyse~which.IWill summarizehere,illustratekeyaspec~9,(
nizational b~haviorin.,ac~io~~ s~ecifi~~lly,,the ~onsequence~
many of the lInportantpnnclples Identified mthis book. In this~al:tn~r,th~"CAIBcc~~c.
report servesasa useful basisfoLintegratingmany of the mawr concepts~tt9m:tb~ji~~"3):~
field of organizationalbehavior in dramatic fashion.If we c~
lessonsfrom this tragedy,then perhapsfuture lives will '"'"

astronautswill not have died in vain.This integrative caseis

those DB-related lessons.Specifically,this casewill focus on three
tional problems(eachof which includesseveralspecificsubproblems)identified'by '~tf'~"!'_~
CAlli: (1) Time pressureeroded decision-makingquality, (2) misc9~uniS~tion' ~
was rampant, and (3) a culture of overconfidenceeclipsedattention to safetY.Ig
I provide insight into how theseproblemscameinto being,I be~ by describingthe
political environmentwithin which NASA wasoperating. .

Political Conditions Setting the Stage

for Organizational Problems
Not operatingin a vacuum,all organiZationsare responsivetoextemaIforces acting
on them (see Chapters1 and 14). Specifically,becauseit is a govemmentagency,
many of the forces NASA facesare political in nature.In the c-aseof the Columbia
accident,thesepolitical pressuresled to the creation of orgarnzationalconditions
ffiat proved disastroUS.
'i~ Ever since the Soviet Urtion launched its unmanned Sputniksatellite:6,n
October 4, 1957,0.S.politicians pushedfordontinanceinspace: explorafio~~The
cbmpetitivezeal of ''the spacerace"'reachednewhei~tswhen Presiden~Kennedy
predgedto senda man to the moon and bring him safelyback to earth by the end of
the 1960s.Amassfug the most sophisticatedadvancesin technologyand engirieenng
t'aJentwith unprecedentedbudgetary support, thai goal was reachedin July 1969,
"linofficially declaringthe United Statesthe winner of the spacerace.Adding many
(mbresuccessfulmissionsto its record in the two decadesthat followed, NASA-its
~ijUman
',C(-, SpaceFlight
. Program, in particular- becamesynonymouswith cutting-
;yd:getecfuiologIcal excellence.
~,1;'!Things changed in the late 1980s.TheColdWarende.d,and along with it was lost
the
i,,"""
source of the strongest pressure to maintain dominance in space exploration-
::tbe"drgency of the historic strugglebetWeenthe world's two superpowers.With no
!~quallystrong political objective to replace it, Congresscut NASA's budget.Arid
~.tfifu
-. . NASA, the SpaceShuttle Program'sbudget
~_t.,c,~ - wasslashedby about40 percent,
:.~~eJ990s-repeated1y
c, ., raided to compensate for overrunsin the more glamorous
,lDtemational Space Station Program.

~
 In response,the agency'soptions were clear;It either:could
to this new stateof affairsby downscalingits plansorcontinu~:'
requiring it to be more efficient than ever.Buoyedwith optimismfroPi
success
andthe self-imagethat it canovercomeseenlingly.. ,;

NASA ()fficialselected toless.

p~h"Faster,
aheadWith itscheaper"
programs althou~,'tbi~now
accomplishing morewith better, , :~.; " ,

the post-Cold War era, but nobody at the agencywas used to workingthaf
NASA'sgreatestsuccesses
cameat afune whenthe fundingrequir~d '"

pr~j~ctsin the safestpossible,ma~eressentially was

efficIently wasnever stressedrelative to safety..
The new external
thosepriorities.This manifesteditself in severalkey ways..
.BCctw~n IfJ93 and 2002,the spaceshuttle workforce was downsiZedf~:-
,(s~eCh~pter14),
~... ,
~KeySpace Shuttle Program responsibilities, mcludmgsafety oversigpt,
souicedto private C<?~panies
(~ee
. ~apt~r;1.4).. .-".
. Alon'g with the relentless presSUre to increase the rate of space fligh{~;the'
effects "of these practices on managerial fuIictioningwere considerable:lncre:ased
titiie pressure coupled With reduced reso~rces
within NASA and between NASA and outside compames.As fewer people were,. ;c

expectedto do more work than ever,the agency'semphasison safetyslipped.But,~

insofar asit had a stellar record of success-especiallyin the Apollo pro~am,",wbj~h:';
repeatedlylandedmen onthemoon~safety cameto b~takenfor~anted.. i~,\..!.,,~
.. ~'c
Although suchcomplacencyis understandable,it is hard to believe that.iew,if',
any,~hanges.inmanagementpracticewere made;inthe ~e~athoft4e.-Ja,nu~ry28, ;
1986,explosIon of the sh~ttle Challenger,The lDlDlediatecauseof that accIdent,
which resulted in the dyath of seyenas~o~auts,wasjudgedto be the failure of~
rubber O-~g,.that..~ea1ed two lower segmentsof the right solid rocket booster.~s
resultedin a 32-monthdelay and a $12billion investmentin new technologybefo!e ~3~;c
retumingthe shuttl~tofligpt. But, asin the caseof the Columbiaaccident,the body :~1
investigaMgthe Challenger accident-pamed the Rogers Commission, after Presi~ ~
dent Regan'sjormer secretary p( state, who headed it - found that the ppysical
cause.ofthe accident~ad roc;:>ts
in~esame fund~ental managementproblems-
c, '-
misco~umcationresulting from intense pressure anq an efficient orga$ational
. ..
structur~. It IS largely beyausethe managen~ lessonsto be learned fr~m the
Challengerdisasterwere never heededthat the Columbia disasteroccurred;."And
with this in mind, the CAIB has emphasizedtberole of managerialproblemsin the
accident.I now will describethese.

As noted in Chapter 10,many factorscontribute to the making of poor-qualitydeci-

sions,including a commonlyoccurringone- time pressure.This wasone of the most
important problemsthat led to the Columbiadisaster.In this case,the time pressure
wascausedby top NASA officials to ready Columbiafor an impendingproject- the
launch of STS-120scheduledfor February 19,2004..This date wasconsideredvital,
"etched in stone,"insofar asthe Columbiawasgoing to carry a major sectionof the

~
 The Columbia Space Shuttle Disaster 491
International Space Station called Node 2, completing the core of that vessel
Severalworkers interViewedby CAIBreported that management'sfocus on hold:;;
ing firm to that date.ledsafetyconsiderationsto be compromised.Becausedelaysin
anyone missionnecessitateddelaysin future .launchdates,workers had a senseof
"being under the gun."With razor-thin marginsin schedules, managerswere unwill-
ing to do anYihirig'that sldweclthings down.ThIs took the form of severalpractices
that compromisedthe quality of decisions.

Training Was Compromised ~

One of meet severetime pressurec~e m the

', ,. , ~ ,
form of inadequatetraiiilitg (seeChapter3) for flight controllers (theseare the ~di-
victuals you usually see on television stationed in front of massive displays a,t
Mission Control). Intact, sevenflight' controllers used on STS-I07lacked proper1
certification.Five of thesewere scheduledto work on subsequentririssions, without~
completingthe proper recertification process. '

Not only were thesevital specialiStsat Mission Control not properly trained;
but also'theirmanagerswere too busyto notice.One reasonfor thiSreported:bythe
board is that many of NASA's managerswere themselvesnot properly trained.
According to its report, "NASA does not have a stan4a~dagency~wide. ~a~~er
planning processto prepare its juriior and ririd-levelmanagersfor advancedroles"
(p. 223).(Careerplanning is discussedin Chapter4.) -,

Deviance Was Normalized

When the spaceshuttle wasdesi~ed,it wasspecified~t,it;$externa1_Aot.~~ea
debrisand that the orbiter not b~hit by debris.Bo~ eventso~e9 ~ou~elr,~ow~
ever.In fact,foamw~sshedand debrishit.~e qrbiter on ~13missiq%;Yet,~~sausen?,
seriousprobl~msres~tecd,suchocc~ences <;aWe to be,mtefJ?reted.~routine.,Th~Y
wereconsideredsomethingto be addressedin th~ coursepf!read~gthe cr~ ,to;!;its
next missionins~eadof,~~ inent hazardto the v~hicle~d cre~:TheC~r~e?rt
.nqtesthatshuttle pro~ammanagersi~ored their9WDrulesbyre~te:rvre~~!o~
probl~msas posing what NASArefecrred to as~n "accept~bl~~!iSk"~st~a~ ofa
"~afety-of:fli~t issue."According to ~e bo~d, the key to t~practic~ of..','n~~~:
~g deviance"was the result of intensepressureto meetfligQt sch~d~les.Becau~e
adhering to its own rules would have m,eaptde)ayingscheduledlaunche~NASA
managersfound it convenientto i~ore them in the nameofex~dience.

life at NASA Was Highly Stressful '...

One of the most apparentwaysin which time pressurecan contribute adverselyto

job performance- especiallythe making of bad decisions- is by creatinglevels of
.stresswith which peoplehavedifficulty coping (seeChapter4).This appearsto have
'beenthe casein the SpaceShuttleProgram.When NASA committedto maintainits
projectsdespiteCongress~s reluctanceto boost its budget~the agencywasforced to
nnd
'1,
places to cut costs.One of the most obvious possibilities Wasto closeone or
;moreof its severalhumanspaceflight centerslocatedaroundthe country.However,
merethoughtsof doing so met with strongresistancefrom both contractors:and the
~ongressionaldelegatloll~ of the states in which those centers are located. With
~j+
 these"off limits," NASA's leaderswerefo~cedto cut drasticallythe
force asthe primary meansof lowering the shuttle's operating costs.
steadily throughout the 1990s.The result washigher levels of stressamong
employees,which stemmedfrom severalsources. ,-
. . .
. Worke~were overburdened
for the reductionin the sizeofwith
thehigher workloadsasthey struggJed
workforce. - .::,
'.

.
-'c,~'( f;:
. Those whq survived the layoffs were left feeling highly insecure abouith~
with the agency. - ,r;~:~~ -;
c' .-':,. :::
~

. Becausethereweremanychangesbeingmadein the natureof work' ..

~, -r"

as workers
were were
expected to reassigned),
do. workers felt considerableuncertainty
' abo:ut'"What
: ':!.'c;L~;,

, ; J;(Q'1t
By 2(xx),it had become clear to NASA that the workforce redu~tiops~h~L4
too far.Asoneofficial p~t it, "Five ..
skill imbalancesand an overtaxedcoreworkforce.
the workload and stress[on ~ose] remaininghave increased,~th,a
increasein the potentialf9r impactsto operationalcapacityand $afe~

~v.
Miscommunication Was Rampant ,
,l~;:;'c;,.
, ':o'~;~,," ,
The CAIB report revealed several sources of miscommunication am6jig"'(N~~:~,i",
officialsthat appearto havecontributedto the shuttle~s
demise. \'.":~}':':?;

:!:'('ff;tr~;f}.~".'.'
Opportunities to Voice ConcernWere limited and Stifled 'f:i!~~:c:,.. , ,-"

To begin,it is clear that becausemembersof the Mission ManagementTea~We;re

overconfident,they failed to meet on a daily basisasrequired.Doirig so might have': ~ 'c'

madeit easierfor concernsabout the foam debris to be heard.However,theb?~d

reportsunsettlingevidencethat evenwhenthe MissionManagementTeamdid::..:
meet,lea'dersnoticeablyrushedthe proceedingsalong,makirigitimpossibletoiiiise ',::
i, anys'f)iety-of-ffightlssues.
Furthermore,they "createdhugebariiersagainStffissent~-,c:'
I" in~ opinio.nsby statirig precon~ei~edconclusionsbasedon subje~tiveknowl~dg~7
",and e~nence, rather than on solid data" (p..192).The
c
sameapplied to the opera-r:-:
'c c
tions of the Inission'shi~yspecialized debris assessment team.Here, the word of
one particular high~raIikirigofficial was taken at face value even if he lacked the
appropriateexpertiseor evidence.Among othersiri this group,"the requiremenifor
data wasstringentand inhibitirig, which resultediri information that warnedof dan-
ger not beirig passedup the chairi" (p. 202).Engineers,who are supposedto have'an
easyjob of bringing safetyproblemsto managers'attention,facedobstaclesto doing
so.They "found themselvesin the unusualposition tha(thesituation wasunsafe~a
reversalof the usualrequirementto prove that a situation is safe" (p. 169).
Insteadof encouragingdissentirigideasto be heard,which is usuallyconsidered
a useful way to avoid groupthink iri decisionmaking (seeChapter 10),NASA offi-
cialsstifled suchefforts.Although NASA managerstold the board confidently that
"everyonewasencouragedto speakup about safetyissuesand that the agencywas
responsiveto those concerns" (p. 202),it found evidenceto the contrary.In fact,
somemembersof the Debris AssessmentTeamreported that raisirigcontrarypoirits

~
 The Columbia Space Shuttle Disaster 493
about the safety of the shuttlewouldlead them to be singled out for ridicule by
peersand managers.This lead the CAIB to concludethat "managersdemonstrated
little concemfor missionsafety"(p.1.92).

Vital Information Was Ignored

Communication problems came not only in the form of discouraging dissenting
information from being voiced but also by way of allowing information to get lost or
ignored as it worked its way up NASA's organizational hierarchy (see the discussion
of this communication problem in Chapter 8). For example, while Cohtmbia was in
flight, two engineers who were aware of Columbia's debris strikedevelopedaIter-
native landing plans that could have been used had the riSk been deemed suffi-
ciently great. Unfortunately, their concerns never reached officials on the Mission
Management Team, which had operational control ov~r Columbia.
Repeatedly, efforts to communicate dangers associated With foam striking the
thermal protection system were ignored as they were "rolled up"the hierarchy..As a
resUlt,shuttle program managersheard little about it in their daily briefin~ ~s ~ffec~
tively desensitizedthem to the problem, resultiDg in missed opportunities to fix it. "In
perhapsthe ultimate example of engineering concernsnot making their way upstream,
Challenger astronauts were told that the cold temperature was not a problem, and
Co,lumbiaastronautswere told that the foam strike wasnota problem" (p.202).
A further opportUnity to base decisions on useful information was ignored by
failing to use independent checks on the decision-making process as required.
According to NASA guidelines, a flight readiness review issuppose~tobe con~
ducted byanindepend~nt team ba~edontheiranatysisof availabledata.about the
flight. In the caseof STS-107, this process was characterized by the niission manage-
~ent team'schaijperson as being "lousy"insofar as the rationale to fly was "rubber-
stamped" by officials who missed signals of potential danger because they suc-
cumbed
c ' to time pressure.
t" The CAIB blames NASA's leaders for these problems directly;Itst~testhat
t1iey~had a greater obligation than managers "to create visible routesjorthe, engi-
neering community to express their views and r~ceive informatioii"{p. 169).
~Because'they failed~to meet this duty, the report continues, leaders "not only
f~locked the flow ,of,information to managers, but they also prevented the down-
~tream flow of information from managers to engineers" (p..-169).Tomanagers who
;claim that they did not hear the engineers' concerns, the board replies bluntly that
~Were"not asking or listening" (p. 170). Unfortunately, this left members of the
Debris AssessmentTeam without any basis for understanding the reasoning behind
Mission Control's decisions,thereby weakening their acceptanceof those decisions
,~~sdiscussedin Chapter 10).,

1~.~e,CAm'sreport concludesthat many of the communicationproblemsthat led to

~be~evlumbia accident were inherent.in the organizational structure of NASNs
:,ShuttleProgramitself.-An organizationchart (seeChapter13) showinghow
uhitwasorganized at the til11eof lh~ accidentis shownin FigureC.l.

~
(Source: Columbia Accident InYeStigat!on Board, 2003; Volume " p. 1L)

NASA mademany of the organizationalchangesrecommendedby the Rogers

Commission report. Among these,the agencymoved managementof the Space
Shuttle Program from the JohnsonSpacecenter in Houston to NASA headquar-
ters in Washington,DC. The intent of this movewasto avoid many of the communi-
cation problemsthat were cited asresponsiblefor the Challengeraccident.Then,in
1996,this move was reversed by NASA Administrator Daniel S. Goldin, a self-
proclaimed"agent of change"(p. 105).His rationale was that headquartersshould
 .
TheCol~mQia
concernitself only with strategicdecisions(seeChapter~lQ)~d ,-

gramsshould b~rnn from the agency's~ariousfield centers.-ThIs

conflict (see ChapterJ) insofar. as it put the MarshallSpaceCept.er
Kennedy SpaceCenter under control of the JohnsonSpace~Center"Wit4
previouslyoperatedat an equallevel.Thi$createda
andKennedydid not.readilyaccepttheleadrole of ,,::'~
Oneof thekeystructuralproblemsuncovered by the CAIBlS that:NASAJsctoo "- "~,,: ~
. comm.umcatlon
complexto m~ke effiCIent . . possible.~ the .'c-.". .,0., '-",
'2~~
""","

the years,reqwrements were put mto place that made It unclear to many employees:'c'_';li;,j;,{;~; "'~;
to exactly whom they were expectedto report certain kinds of information.The!:~:~~I~!:~~~Vi::&
.. ,,"c+':,,'I: :~'"
?*
wasa seriouslack of coordination with respectto safety-no centralizedcl~~g,: B
houseexistedfor information about saf~ty and responsibility over it. The various gfp~illl
units that sharedtheseresponsibilitiesat the time of the accidentfailed to coordinate 't ~;::r:;
'".e~-.'

their responsibilitiesin any organizedfashion.The board referred to theseroles as j t,,'

"uncoordinated,""conflicting," and "resUltingin erroneousinformation" (p.188).Its ./
indictment of organizationalstructureis clear:"No one offlceor personin Program
managementis responsiblefor developingan integratedrisk assessmenL. ..Thenet
effect is that many Shuttle Program safety,quality, and missionassuranceroles are
neverclearlydefined"(p.188).

A Culture of Overconfidence Eclipsed Attention

to Safety
From its inception,NASA's orgatiiiationaIcUlture(seeChapterU) wasqh~Ctenzed '"
, '."
by "can-do" values~d "tenacityin the face of unprecedentedchaIIeng~s.After~?i!
wason an historic,quest-not only to,.5:lirPasstheS?~e.t
alsoto reachthe moon.On July 20,1969,whenApollo 11 successful1rl~ded9n.~e
~oon, the dramatic successreinforced NASA's organizati?~~l c:4I~~re.NASA
~~ployeesb~lie:vedthey worked at"a~~e~tplac~," oriethatw~ 'VieWe~~~"~hi~y
~~ccessfulor~ation capableof achie~gseemingIyiinpossiblefeatS','~d "the best
organiZationthat ~uman
' beingscowQcreatetoa~oiIiplishselecte~goals"(p.l02}.
,
, . .
G~lture Was Resistant to Change , ,

Although there may have been a sound basisfor these cultural beliefs in the 1969s,
'),:thingschanged quickly thereafter. With a secure victory in the spacerace, Congress
}~felt less compelled to allocate generous budgets to NASA. At the same time, NASA
i;moved
co from launching vehicles that were'designed to be used only once 10 the
;'~'Space
,', . Shuttle
accessProgram
to space. and
Thelaunching
NASA ofvehicles that
the 1970s waswere
far reused to provide more
more bureaucratic. The
focus on designing new spacecraft at any expense was supplanted by
.,demandsof flying a reusable vehicle repeatedly on an ever-tightenmg budget.
:Despite these new realities, the culture at NASA did not adjust.."NASA per-
maintained a vision of their agency that was rooted in the glories of an ear-
;tiJne,even as the world, and thus the context within which Jhe space agency
, changed around them" (p. .102). Because.NASA'5culturen~"ercfully
to the Space Shuttle PrograDl, .ten.~iunresulted.EmpJoye~s; continued;tQ

~
 496 INTEGRATIVE CASE

. - -"-""-'c'"
-
~~

beli~vethat the agenc;ywasstill a "prefectplace,~'le~diIig them t9

rejecting evidence to the contrary (see Chapter;,14}...lrtthe"'"
.
Challengeraccident,however,this proved difficult. Yet,:NASNs ,
culture
wassostrongthat it led managersto misperceive'realityin
totheii beliefs (see Chapter 3). As managersstrove:tomaintaiIitheir .
organization,"they lost their ability to :acceptcriticism~:leadingthemto
recommendationsof many boardSand blue-ribbon
amongcthem",(p.102), Aild,of course, by ignoring these '
ageng :insulateditself from corrective influencesthat werenecessarytQfix
lemS(this is the kind ofthii1g that occursiIi the courseof gI;oupthink~see
10);This1ed to~'flawed decisionmaking,self~deception,iIitroversionanda
ishedcuriosity about the world :outsidethe 'penectplace?"(p.':1()2)~
NASA-.evenwariiedthatsuchcbmplacency"could:1eadto~ . .c.
".,

SafefYCulture Was Broken .

In its report the CAffi asks,"How could NASA have missedthe Signals
was sending?" (p. 184):The answer,it
detection of the dangersposed by foam was impeded by 'bllild spots'~in:NASA's
safety culture" (p.124)~Managersrepeatedly told the board that the foam posed
"no safety-of-flight issue:"(p. 184),.but its o\Jfn~~stigation r~yealed ot~er~ise. :
SpecifiCally;"Shuftle Piogram managementmade'enoneousassuriiptionsab6utthe,;
robustnessof a systembasedon prior successrather than on dependap!!;;eh~e~r,i
ing data and rigorous testing" (p:l04). Furthermore,"Shuttle Pro~am safetype!-
c",ic,_,c.c,i;..",;;; ""h;':".".."j
sonnelfailed
".. i c .., ", to adequate,1yassessano,mali~s
~dftequentlyaccepteq cntl~_~s~ :,:1,
" ..'
Wtt.h~#t;qu~~tative~or ql1;a~titap,ve~upp~~, "'".
c even'~herithe
!., c) Cc " , ,,' ~

c6mrehensiveassessmeIitswe:reavan~.bl.e'~(
:177): Hence,

'..
~asb,dlY~~~Oken. ':" ',.,' "';\ :"p, ;":':' :~i
"Akey'~anifestation:pfthis
: c ~ '" " '"
piob~e:rpmay,.' be seen in the way inw~c~Shp~!!e
.; c:, , ,..} j...
,,"~~,
-""
Pro'gfammanagers responded totequ'estS
, 'j'" , ". forlmagery
~ from the Debns. Assessme~t c . '!

t the spacecraft).IIisteadof proVldmgthis informatIon

{in.c~¥ge ot~ss~ssingthe~pact:°.f q~b;~~o~
freely,asexpected,managers ~'c
:~

!':"mademembersof the Debris AssessmentTeam.provethat there was a threat to

saferyinY9lvedbefq~ethey would consent1odoing so.AccordiIigto the board,this
is preciselythe opposite of what would occur in a safety-consciousorganizational
culture.TypiCally,.
in organizationsthat deal rouririely with mattersof life and death,
the burden of proof comesin1he form of establishingthat conditions are safe.IIi
this case,however,NASA inverted this burdenofprooL

Checks and Balanceson Safety Were Absent "

One particularly troublesomemanifestatio~tgfNASA's deeplyentrenchedcultural

beliefm its own prowessand invulnerability wasits willingnessto eliminate the sys-
tem of checksand balanceson safety functions that was a hallniark of the Apollo
program. Historically, two completely independent engineering teams cross-
checked one another to prevent catastrophic errors. Although this practice was
expensive,it was highly effective. Over time, however,NASA managerscame to

~
 The Columbia Space Shuttle Disaster
497
believethat the desi~'of the spaceshuttle wassufficientlymature,-making it "oper,;
ational"rather than "developmental"and makiUgthe redundantproceduresuMec:
essary.Basedon the culture of successand supported by intense budgetarypre~f :
sures,this cost-saVingmove wasreadily justified. "';,
Despite this,many of NASA's top engineersprotested.For example,in a letter
to President Clinton on August 25, 1995,senior Kennedy SpaceCenter enginee~
JoseGarciaclaimedthat eliminating this systemof checksand balancesconstituted
"the biggestthreat to the safety of the crew sincethe Challengerdisaster"(p. 108).
Likewise,a report by the Shuttle IndependentAssessmentTeamdated March 2000
cautioned against the "success-engendered safety optimism" that permeatedt4~
agency,cautioningthe SpaceShuttle Program to "rigorously guard againstthe ten-
dency to acceptrisk solely becauseof prior success"and by "the desire to reduce
costs"(p.114). 'J
'
Ultimately, NASA n;tanagers "won" t~s battle (if you cancall it that). The engi I
neers'
-
concernsaboutrIsk and safetyultlDlatelyweredefeatedby management's
belief that foam could not hurt the orbiter and by its zeal to keep on schedule. The
rest, as they say, is history.

Conclusiqn
The Columbia Accident Investigation Board Report makes it clear that NASA's
organizationalproblemscontributed greatly to the shuttle'saccident.~o one single
managementmistakewasresponsiblebut rather it wasthe co~binedeffect of many.
"Each decision,taken by itself, seemedcorrect, routine, and indeed,insignificant
and unremarkable.Yet, in retrospect,the cpznwativeeffec~wasstUnning"(p. 203).
Indeed, it appearsto be the case,.asthe board concludes,that "NASA has shown
very little unders.t~ding of the inner workings of its own Qrganiz~t~9c~'~;(p.2Q2).
.With an eye toward'the well"beingof tomorrow's astronauts,and with the benefits
..ofmannedspac~exploration in mind, I hope that recommendationsfrom the CAIB
report are taken seriously.I alsohope that readersof this book will heedthe lessons
:learnedfrom this caseso as to avoid tragicmisjudgznentsabout key OB issuesm
their own organizations. ,

:easeNote
F
'(;QlumbiaAccident Investigation Board (2003,August). Volume 1.Washington,DC: U.S.
i;; Government Printing Office. All page references are for quotations from this report.
~t Report alsois availableon the World WideWebat www.caib.us.
~..