Why did the Columbia astronauts die? To answer this question, the Columbia Accident Investigation Board has gone far beyond the technical issues of what went wrong. Harold Gehman, the retired admiral who chaired the independent commission, has made no secret that his intent was to find out WHY the technical decisions were wrong, and for that, his group has attacked the issue of NASA’s culture of decision-making.
In fact, when asked at a press conference how much of his final report could have been written BEFORE the disaster, Gehman thought momentarily and replied, “Probably most of it.”
Why NASA — and its supposedly independent watchdog teams — failed to see the patterns is still another issue of “culture.”
'The smartest people'
Perhaps the most salient characteristic of the “NASA culture” is that its managers act as if they are proverbial “rocket scientists.”
In late 1999, following the loss of a fleet of unmanned Mars probes, a NASA official was asked at a press conference about what the repercussions might be. Would anyone lose their jobs over such performance, a reporter asked?
There would be no such consequences, the official replied. “After all,” he explained, “who would we replace them with? We already have the smartest people in the country working for us.”
Experienced space workers, both those still inside the program as well as retired, say this widespread attitude of being too smart to need outside advice has created a culture resistant to — and indeed often contemptuous of — outside advice and experience.
One insider e-mailed that NASA’s attitude reminded him of that of a teenage male who thinks he’s bulletproof and nothing can hurt him. “The ‘failure is not an option’ attitude breeds people that take it literally,” he wrote, “and think not only that it’s not an option but that in reality it’s not a possibility.” As a result, he concluded, “If you NEVER consider the possibility, you’ll never consider the ways to get you there.”
This led to an “air of positiveness,” a pressure to believe that a “can-do” attitude could do anything.
The only game in town
Anyone who felt differently risked being branded “not a team player”. Even if you filed an anonymous safety complaint, management could find out who was the author. Make a big mistake, and afterwards it was “nobody’s fault,” but warn of a big mistake in advance, and you were “dead space meat.”
And the hazards of being branded a “whiner” were severe. Unlike in other professions — medicine, law, engineering — where people who wind up shunned or blacklisted in one area can find equivalent employment elsewhere, NASA is practically the only “space game” in town and vindictive management often had a long reach.
There is just this one small niche, and if you spoil your reputation there, your life-long passion for space flight work may be doomed forever. So you “go along” in the hopes that things may get better, while ever so slowly, as the proverb goes, your face grows to fit the mask you must wear.
The culture can also be powerful because it is so pervasive, since it is rarely exposed to outside influences. Unlike the space team that conducted Apollo, recruited from a dozen major pools of experienced workers, most workers at NASA today have only worked at NASA since graduation. Some retired military officers are brought in at headquarters — mostly because they are good at “following orders” of the officials who hire them — and specialists are brought in as needed, but they are far from the levers of power within NASA. This encourages an inbred “groupthink” that is not conducive to disagreeing with what management wants.
“How is the culture going to change when you are bringing in people that have been trained to accept and have only worked with one cultural style?” an insider e-mailed. “AND that is the cultural style that got you into trouble.”
“No one could ever oversee management process internal to NASA effectively, and the external oversight organizations were equally ineffective,” a senior NASA safety official told MSNBC.com. “I firmly believe that unless they change the status quo regarding the NASA culture that nothing will really change in substance, only in appearance.”
In recent years, some people within the program sensed the direction things were headed. One veteran, still on duty, e-mailed: There were times that several of us talked about how the atmosphere was reverting to a pre-Challenger style even a couple of years before Columbia.”
Fundamental change needed
The cultural prescription for recovery must include some fundamental — not merely formalistic — changes in “culture.” NASA needs a special guru for culture, like the now-disbanded Associate Administrator for Plans and Policies, with real teeth to rub the faces of the “rocket scientists”” in the mess they’ve made. Outside visiting lecturers are nice, but hiring more outside personnel — people from other cultures who won’t fit into the way NASA “does business” — would also help, in creating a diversity of culture instead of mere skin-deep demographics.
Most of all, a NASA that has a real future needs to cling to its true past. All of its workers need to understand the bitter nature of human errors that have been made before, and the real reasons — not the facile and face-saving excuses — that led to setbacks and disappointments and disasters in the past.
Without this appreciation for history, the proverbial warning about expensive repetitions will hold true. And the costs will mount, while the limitless possibilities that NASA promises will remain unfulfilled.
James Oberg, space analyst for NBC News, spent 22 years at the Johnson Space Center as a Mission Control operator and an orbital designer.