Background photos by Hyung Suk Kim. Other photos courtesy of NASA
NASA management focused so much on schedule that they did not listen to the engineers and their safety concerns. In trying to see the forest, management missed the trees.
structure, pressures, and culture can all play a part in design failures. In the past two decades, accident investigation in general has gone beyond looking at the immediate technical faults to examining latent, underlying vulnerabilities that can lead to an accident. The Columbia Accident Investigation Board (CAIB), tasked with determining the causes of the disaster, followed this trend as it assembled a large team of consultants with both technical and organizational science backgrounds. This included academics who had studied human error and accidents using organizational psychology. In its final report, the CAIB pointed to organizational reasons in the Columbia disaster. Three organizational pressures that exist for all companies are quality, schedule, and budget. At NASA, these came into sharp conflict during the 1990s due to a top-down organizational philosophy called “Faster, Better, Cheaper.” This philosophy, among other failures, was implicated in both the Challenger and Columbia accidents. The idea behind it was to make high-quality spacecraft on schedule (or faster than in the past) and within budget—something NASA has historically had trouble doing. From the CAIB’s perspective, NASA fell prey to these competing demands with safety losing out. I interpret this competition as a result of a
conflict between at least two cultures that divide NASA. When you walk into a room and know who is supposed to sit where, what tools you should use, and who you should ask for help, that’s all part of culture. When I started working at NASA, I had the misconception that NASA culture was one hegemonic, homogeneous force. In fact, many overlapping groups exist at NASA. Two of those groups are the engineers who handle design, safety, quality, and reliability and the middle managers who handle schedule and cost. The CAIB and my analysis hold that the conflicts between these groups are partially responsible for the Columbia disaster. Specifically, management rationalized that the foam strikes on the orbiter were normal, refused to listen to dissenting opinions from engineers, and focused on schedule. These decisions all contributed significantly to the Columbia disaster. Normalization of Deviance The term “normalization of deviance” was coined after the Challenger accident. It refers to a gradual process in which troubling, unsafe events begin to seem normal. Problems previously considered to be safety risks keep occurring with no negative consequences and so are no longer seen as risks.
Sensational Spring 2009 Ambidextrous
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