Executive Summary:
The Space Shuttle Columbia disintegrated over the skies of East Texas as it sought to return to earth on February 1, 2003. It was not the first such disaster for National Aeronautical and Space Administration (NASA). In 1986, Challenger exploded within minutes of launch; in 1967, Apollo caught fire on its launch pad. Each incident resulted in the lost of life. Why? What went wrong, and what can we learn from these tragedies? The lessons are several. Culture makes a difference. The agency's "culture of excellence" transitioned into a "culture of production" following the pronouncement that NASA would thereafter focus on reusable craft and routine operations. This latter culture did not put safety first in its value system. Organizations are susceptible to "the failure of success syndrome." They fall prey to hubris and under its spell miss important signals and make calamitous decisions.
The Columbia disaster reminds us that at the heart of any organization are human emotions enshrouded in a culture. Its culture is the product of a history that may extend quite far back in time. Nevertheless, the history and resulting culture of an organization are integral parts of the context in which it makes decisions and acts. They are co-producers––causes––of events. Ethical cultures produce ethical events; less ethical ones do not. One reason for this is that successful cultures become susceptible to hubris and carelessness. One antidote for organizational hubris is the highly reliable organization (HRO) model, based on the concept of mindfulness. These organizations are constantly aware of the possibility of failure, appreciate the complexity of the world they face, concentrate on day-to-day operations and the little things, respond quickly to incipient problems, and accord deep respect to the expertise of their members. They value knowledge and expertise highly, communicate openly and transparently, and avoid concentrations of power or corruption by setting up independent units with countervailing powers.
With respect to Columbia, and Challenger and Apollo before it, NASA's culture proved to be lethal. It did not adhere to precepts like those upon which HROs are based. Because the agency failed to follow ethical principles such as deep respect for knowledge, openness in communications, and independence in operations, the Columbia disintegrated as it sought re-entry over the skies of Texas. From this tragedy, however, we can distill a few important lessons for the future. |
