It’s been 25 years since the space shuttle Challenger disaster, in which 7 astronauts—including Christa McAuliffe, America’s first teacher in space—lost their lives. At the time, investigations identified NASA’s culture as a key factor in the disaster.
After 9 years of research, Professor Diane Vaughn wrote The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA. Vaughn noted the role of NASA’s culture: “The decision to launch Challenger was, incredibly and sadly, a mistake embedded in the banality of organizational life. No fundamental decision was made at NASA to do evil; rather, a series of seemingly harmless decisions were made that incrementally moved the space agency toward a catastrophic outcome.”
17 years later came the Columbia disaster. And again, NASA’s culture was identified as contributing to the loss of Columbia and its 7 astronauts.
The Columbia Accident Investigation Board (CAIB) report pointed out that several factors of NASA’s culture had a direct impact on the failure of Columbia:
- NASA’s “Can Do” attitude, that was inspired by past successes and which discouraged individuals from stepping forward and suggesting “Can’t Do.”.
- Viewing near-misses as successes rather than near-failures.
- Management made erroneous assumptions about the robustness of a system based upon prior success rather than on dependable engineering data and rigorous testing.
- NASA’s safety culture no longer asked hard enough questions about risk.
- Evidence that the design was not performing as expected was reinterpreted as acceptable and non-deviant, which diminished perceptions of risk.
- The premium placed on maintaining an operational schedule, combined with ever-decreasing resources, gradually led Shuttle managers and engineers to miss signals of potential danger.
- Despite periodic attempts to emphasize safety, NASA’s frequent reorganizations in the drive to become more efficient reduced the budget for safety, sending employees conflicting messages.
- NASA’s strong cultural bias and optimistic organizational thinking undermined effective decision-making.
- The free exchange of information was discouraged and new information was resisted.
The CAIB report identified 6 actions that NASA must take in order to change their culture. I think they are applicable for any organization that is wants to ensure that their safety efforts are not being undermined by their culture.
- Maintain Sense Of Vulnerability
- Combat Normalization Of Deviance
- Establish an Imperative for Safety
- Perform Valid/Timely Hazard/Risk Assessments
- Ensure Open and Frank Communications
- Learn and Advance the Culture
The CAIB report warned that unless NASA made changes to its culture, “the scene is set for another accident.” At the same time, the investigators repeatedly said that, based on NASA’s past performance, they expected the NASA bureaucracy to resist such a transformation. “The changes we recommend will be difficult to accomplish — and will be internally resisted.”
That’s true for all organizations. Changing the culture is difficult and is usually resisted. But that’s no reason not to try. Organizations do so at their own risk.