PublicOrgTheory

Almost six years after the disintegration of the space shuttle Columbia, NASA has released a 400-page report detailing very specific technical details of the shuttle’s (and crew’s) final minutes:

A new NASA report released Tuesday details the chaotic final minutes of Columbia, which disintegrated over Texas on Feb. 1, 2003. The point of the 400-page analysis is to figure out how to make NASA’s next spaceship more survivable. The report targeted problems with the spacesuits, restraints and helmets of the Columbia crew.

The article goes on to note a key point:

Columbia was the second space shuttle NASA has lost. The hole in its wing was caused by a piece of foam insulation that broke off the fuel tank and slammed into it at launch. The shuttle Challenger blew up shortly after liftoff on 1986, also claiming seven lives. Investigators in both accidents pointed to a NASA culture of ignoring problems that later turned fatal. [emphasis added]

The report itself, which was specifically addressed to matters of crew survival for future missions, notes the importance of adopting the insight yielded in the review of such tragedies:

By learning these lessons and ensuring that we continue the journey begun by the crews of Apollo 1, Challenger, and Columbia, we help to give meaning to their sacrifice and the sacrifice of their families. It is for them, and for the future generations of explorers, that we strive to be better and go farther.

The results of the investigations into the two shuttle accidents as well as the Apollo 1 fire demand a similar report on the antecedents, consequences, and progress in remedying the common root cause of all three disasters:  the dysfunctional culture of the NASA organization.  I proposed such a report to NASA executives earlier this year, suggesting a review by organizational scholars such as William Starbuck and Charles Perrow to compare the Columbia Accident Investigation Board’s organizational recommendations with progress against implementing them in the five years since.  There was little interest.

Organizational culture has a way of influencing behaviors in ways that would seem to guarantee repetition of past phenomena.  In NASA’s case, it would be easy to dismiss the loss-of-craft accidents that have occurred about every two decades by pointing out the agency’s near-perfect safety record and its numerous successful missions, including those to deploy the Hubble telescope, leadership in construction of the International Space Station, and a Mars rover program that has exceeded even the agency’s expectations.  Those are far points, and they are beside the point.  NASA has been given a gift–the enormous amount of feedback and support these investigations have yielded.  To ignore these lessons beyond superficial changes is to reinforce the very culture that produced them.  NASA has both the support and the resources to reform its culture, and the Constellation program creates a clear imperative to get it right.  Doing so would be a profound step in giving meaning to the sacrifice of these astronauts.

MORE:  The New York Times has been running a good series on the future of NASA, including this photo of the Orion capsule used in the Constellation program:

This report on the program’s progress comes early in yesterday’s article:

Technical troubles have dogged the design process for the Ares I, the first of the rockets scheduled to be built, with attendant delays and growing costs. And in an age of always-on communication, instant messages and blogs, internal debate that once might have been part of a cloistered process has spilled into public view.

…

The issues have become a focus of the members of the presidential transition team dealing with NASA, and the space program could undergo a transformation after Barack Obama takes office.

This appears a few paragraphs later:

Some inside the development program have complained that it is run with a my-way-or-the-highway attitude that stifles dissent and innovation. Jeffrey Finckenor, an engineer who left NASA this year, sent a goodbye letter to colleagues that expressed his frustrations with the program. “At the highest levels of the agency, there seems to be a belief that you can mandate reality,” he wrote, “followed by a refusal to accept any information that runs counter to that mandate.” The letter was posted to the independent NASA Watch Web site.

Call me cautiously optimistic.  Some of the cultural points above are echoed in the article, and the paragraph about stifling dissent and mandating reality reads like textbook groupthink.  Yes, such programs are necessarily complex.  No, that is not an excuse for ignoring the management style of the organization.