Leadership for Intelligence Professionals   

An Example of the Difficulty of Changing an Organizational Culture

On 28 January, 1986, the Space Shuttle Challenger blew up shortly after launch killing all the crew

The disaster resulted in a 32-month hiatus in the shuttle program and the formation of the Rogers Commission, a special commission appointed by President Ronald Reagan to investigate the accident. The Rogers Commission found that NASA's organizational culture and decision-making processes had been a key contributing factor to the accident. NASA managers had known that contractor Morton Thiokol's design of the rocket boosters contained a potentially catastrophic flaw in the O-rings since 1977, but they failed to address it properly. They also ignored warnings from engineers about the dangers of launching on such a cold day and had failed to adequately report these technical concerns to their superiors. The Rogers Commission offered NASA nine recommendations that were to be implemented before shuttle flights resumed.

Author Diane Vaughn has pointed out that the cause was not be simply a failure of the O rings or problems of cold weather, or even poor performance on the part of engineers who designed them and protested the launch decision.  It was a cultural failure, and indeed the clash of cultures among different elements of the organization that caused a lack of organizational will to negate the risk of failure of the O rings.  There was a “work culture” based on the discipline and methodologies of scientific positivism; a can do “production culture” based on priorities which emphasized redundancy and had overconfidence in it, and an overall culture of “structural secrecy” in which danger signals were weak, routine and sometimes censored. 

After the Space Shuttle Columbia disaster in 2003, attention once again focused on the attitude of NASA management towards safety issues. Thus, in 2003, The Columbia Accident Investigation Board  concluded that NASA had failed to learn many of the lessons of Challenger.  That board of investigation, in their report on the Columbia went on at length about how the culture at NASA, despite policy pronouncements and procedures, had inhibited the organization from learning lessons about improving the interface and communication between engineers and safety personnel on one hand and managers decisionmakers on the other, which were made evident by Apollo 13 and the Challenger disasters.  In particular, the agency had not set up a truly independent office for safety oversight; the Board felt that in this area and that "the causes of the institutional failure responsible for Challenger have not been fixed," and that the same "flawed decision making process" that had resulted in the Challenger accident was responsible for Columbia's destruction seventeen years later.

In response, NASA hired Behavioral Science Technology Corporation to assess the agency’s culture. The resultant report released in April 2004, found that "Open communication is not yet the norm, and people do not fell fully comfortable raising safety concerns to management." Again on 17 August 2005 seven of the 26 members of the Stafford-Covey Return to Flight Task Group working on the effort to return the space shuttle to active service released a statement saying that the culture inside the space shuttle program remains arrogant, sloppy and schedule driven and that managers still rely on the logic that technical glitches are acceptable if they haven’t caused a catastrophe on previous shuttle missions.   

Sources

Report of the Presidential Commission on the Space Shuttle Challenger Accident (Rogers Commission) 1986.

Diane Vaughn, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA. 

Report of the Board of Investigation of the Columbia Mission Failure, 26 August 2003.