Monday, April 20, 2015

And we know of your anguish. We share it.

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.

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