Management role in Columbia tragedy
I was glad to see the article “Their mission became our mission” by astronaut Tom Jones in the January issue. It was an excellent summary of the loss of [the space shuttle] Columbia, the investigation to find the cause, and the training of new NASA employees regarding lessons learned. I believe the lessons learned from Columbia, as well as the loss of Challenger, should be much broader than just NASA, and should extend to all organizations.
Although the article discussed various technical, communication and management failures for the Columbia tragedy, I want to stress the root cause of the failure: management. To support my contention, it is necessary to briefly recount the accident investigation from my perspective. I was a member of the Sandia National Laboratories team that was asked by NASA to help find the cause of the failure. The Sandia team interacted with NASA management and staff during the investigation from February to August 2003.
From the day of the event, Feb. 1, there was suspicion that it could be due to the impact of foam on the wing leading edge. Insulating foam and ice had been regularly torn from the bipod ramp area on several previous shuttle flights. Even though early studies during the investigation began to support the argument that foam impact could cause serious damage to the wing, NASA management was adamantly and loudly against this cause. The turning point came when the flight data recorder was found on March 19. The flight data clearly showed the rapidly increasing temperatures near reinforced carbon-carbon, or RCC, wing panel 8 on the left wing. Management would still not accept that the cause could have been something that was dismissed as “accepted risk” for years. They needed proof that foam could knock a hole in the RCC leading edge. NASA enlisted Southwest Research Institute to conduct experiments firing foam blocks at the leading edge. After a number of shots did not significantly damage the RCC, management redoubled their belief that foam impact was not the cause. Then, on July 7, essentially on the last planned shot at SwRI, the foam blasted a hole through the RCC. There was no longer a basis to deny the cause. In summary, if the flight data would not have been available and experiments would not have shown that major damage could occur, NASA would still be denying the real cause for the catastrophe.
This recounting of history from the trenches of the investigation is not just directed at NASA management, but management of all organizations. Whether it be Volkswagen management involved in the emissions scandal, the Takata airbag scandal or the Flint, Michigan, water scandal, the root cause is failure of management to be open to and to address issues that are brought to their attention. These types of failures are not technical failures per se, but failures in management to develop an organizational structure and internal culture that allows and promotes bad news to travel upward through management and ending with the organization’s leadership.