One
of the most studied organizations in the world is the National Aeronautics and
Space Administration, or NASA as it is known colloquially. Because of NASA’s
unique mission as an agency, spaceflight, it is an organization that must deal
with excessive risk-taking and the gravest of consequences whilst toeing the
line of government bureaucracy and red tape. These two polar opposites have a
pull on the agency that few other organizations in the world experience and as
such the agency is an interesting case study on organizational learning,
especially in the wake of major malfunctions that led to the loss of two space
shuttle crews in-flight.
NASA has experienced two in-flight malfunctions
which have led to the loss of a crew: the explosion of the space shuttle Challenger and the disintegration of the
space shuttle Columbia. Challenger
was lost in flight on January 28, 1986 during launch when a rubber O-ring on
the solid rocket booster failed and caused ignited propellant to breach the
hull of the shuttle’s external fuel tank, causing an explosion and breakup of
the orbiter. The temperature at launch was unseasonably cold for the launch
site at Cape Kennedy, Florida and the manufacturer of the O-ring had repeatedly
warned NASA engineers of the risk of the rubber freezing and possibly
generating propellant “blowback” during ignition. The explosion killed all
seven astronauts onboard Challenger and halted the Space Shuttle program for
two years while an investigation was conducted by a Presidential panel chaired
by former Secretary of State Williams Rogers, or the Rogers Commission as the
panel is known colloquially. The Rogers Commission determined a historical
culture of complacency in contingency planning combined with pressure from
various sources outside of the agency on the shuttle’s launch schedule led to
the ultimately fatal circumstances of Challenger’s launch.
Before the loss of Challenger, NASA had never lost a
crew in-flight and only suffered one other fatal accident to a spacecraft, the
loss of Apollo 1 in a ground fire in 1967 that killed three astronauts. A
similar panel was convened then and warned NASA of the same hamartia the Rogers
Commission reiterated nineteen years later, one summarized by Dr. Diane
Vaughn’s iconic phrase in a paper examining NASA after Challenger:
normalization of deviance. In short, organizational learning is hindered by the
capacity of an organization to rationalize deviant behavior to the end that the
culture that pervades does not consider the behavior deviant. In NASA’s case,
Apollo 1 was a result of moving too quickly in an attempt to defeat the Soviet
Union in the Space Race. Shortcuts learned in earlier spaceflight programs were
used to design the Apollo capsule and the safety culture devolved as the
collective pressure began to build on the agency to deliver a man to the moon
before the Soviets.
Flash-forward to 1986, where normalization of
deviance reared its ugly head again as NASA attempted to launch spacecraft at a
record pace. The safety culture, now comfortably removed from Project Apollo
and fifty launches into the shuttle program, accepted the O-ring risk as nominal
and green-lighted the launch. In many organizations a near-fatal accident is
enough to permanently change the learning culture of a firm interminably much
less the death of three crew members. However, with death so close to each crew
on launch, orbit, and reentry; NASA seemed to have forgotten how scarring that scene
was amidst the successes of landing ten men on the moon with a much-improved
Apollo capsule and fifty successful shuttle launches. While this is not a
common situation for organizations to encounter, when the stakes are highest
the collective knowledge obtained by an organization should include the
necessary precautions to prevent fatalities at the highest level. Unfortunately
for NASA the cycle of deviance continued and seventeen years after Challenger
impacted the Atlantic Ocean in pieces, Columbia’s loss reminded NASA of the
cost of forgetting failure.
Space Shuttle Columbia suffered irrecoverable damage
to her left wing during liftoff of the STS-107 mission. A piece of foam from
the left strut of the external fuel tank that separates the orbiter from the
tank broke off and punctured a hole in the heat shield on the left leading wing
of Columbia. During the orbiter’s sixteen days in orbit the wing was not
checked for damage and on February 1, 2003 Columbia began descent into the
Earth’s atmosphere for reentry and landing. During reentry a blanket of ionized
air surrounding the orbiter due to friction from the entry velocity of the
spacecraft and temperatures can reach in upwards of 3,000 degrees. To prevent
vehicle disintegration a heat shield made up of carbon heat tiles and thermal
blankets surrounds the orbiter’s critical components and absorbs the heat
generated by reentry.
The aforementioned puncture in Columbia’s heat
shield proved fatal to vehicle and crew as temperature sensors in the orbiter’s
left wing detected a sudden heat spike and were shut down around 200,000 feet
before landing. The Columbia Accident Investigation Board (CAIB) theorized that
a flow of superheated plasma entered through the puncture in the left wing,
overloaded temperature and pressure sensors in the wing and wheel wells, and
then melted the aluminum assembly of the wing. With the wing assembly melted, a
complete structural failure of the shuttle was imminent. Columbia began to disintegrate
and was separated from the left wing outward. The crew was most likely killed
by asphyxiation due to loss of life support systems or trauma incurred when the
crew cabin separated from the orbiter and exposed the crew to lethal G-forces.
Vehicle breakup occurred across a swath of the Southwest United States
stretching from Arizona to Louisiana. Within minutes of Columbia missing her
landing time at the Kennedy Space Center NASA activated the Space Shuttle
Contingency Action Plan (CAP), a plan developed after the loss of Challenger
that deals with the loss of an orbiter.
Much like the aftermath of the Challenger accident,
a board was convened to determine the cause of vehicle loss and illustrate the
failures in organizational learning that led to the mishap. Instead of a
Presidential panel, the CAP allowed for the NASA Administrator to appoint a
chairman of the accident investigation panel. Admiral Hal Gehman chaired what
came to be known as the Columbia Accident Investigation Board, or CAIB. In a
report eerily reminiscent of the Rogers Commission report seventeen years
prior, CAIB highlighted the normalization of deviance which had become
commonplace at NASA after a return to nominal operation. In the case of
Columbia, the deadly deviance was not a frozen O-ring but rather the shedding
of external tank foam that was observed on every shuttle launch. Every orbiter
before Columbia had launched and returned safely with no damage suffered on
ascent thus chalking the potential damage up to an acceptable risk as the
elimination of foam would require a complete redesign of the external fuel
tank, a project that would delay the shuttle program years and cost taxpayers
millions of dollars and NASA millions more in lost payloads. NASA simply did
not see the potential damage to the orbiter as enough of a risk to justify a
complete shutdown to the shuttle program. In the end this normalization of
deviance indeed cost NASA millions of dollars and a halt to the shuttle
program, but also the irreparable loss of seven astronauts. The report also
decried once again the safety culture at NASA, stating that despite lessons
learned from Challenger, many personnel did not speak out on safety matters, as
stopping a program with so much financial capital could signal the end of a
career. CAIB concluded the organizational culture at NASA, further atrophied by
the decentralization of leadership and competing interests across multiple
states, was unacceptable and once again required an overhaul of the organization
of the agency including the creation of a separate safety office which reports
directly to an administrator who holds the ability to bring all projects to a
halt in the name of safety.
With an otherwise stellar safety record in manned
spaceflight NASA is a dynamic agency which learns by necessity. Every trip into
orbit is a new chance to solve the universe’s undiscovered mysteries. However,
in a massive stroke of irony, an organization that lends its very mission to
learning about spaceflight is not very good at learning about itself. NASA has
practiced an organizational philosophy that believes it is better to fix
problems after a mishap than identifying them beforehand and working to correct
any problems before an accident occurs; a pattern of deviant behavior that was
born out of a breakneck effort to defeat the Soviets. Coupled with the massive
pressure on NASA from the public and federal government at large, first
politically due to the Cold War then fiscally due to the enormous cost of
maintaining a fleet of orbiters many Americans see as no more complex than a
U-Haul van, cracks in the proverbial heat shield of organizational learning
have led to catastrophe in the past and if not corrected fully, will prove to
be just as fatal as the agency looks to the International Space Station, the
Moon, Mars, and beyond.
