The Challenger and Columbia similarities in management decision making with regard to the ill-fated shuttle mis- sion failures bear scrutiny. Key aspects of both tragedies include senior-level managers ignoring the advice from experts within the NASA organization leading to tragedy. NASA is typical of modern organizations in the tendency to relegate worker knowledge below that of managers and executives. The Columbia Accident Investigation Board has determined that the organizational/management culture was a key factor in the demise of the Columbia. The author argues that culture, although an important contributor to the tragedy, is inadequate for assessing the problem. Dif- ferences in knowledge between executives, managers, and the workers are key to unlocking the central problem of the NASA organization. The author uses and develops the theoretical approach that delves into multiple knowledges in organizations that is known as the “knowledge analytic.”

Keywords: organization theory; crisis management; decision making; NASA; Columbia; Challenger

INTRODUCTION AND THEORETICAL OVERVIEW

Once again, we have a tragedy involving a space shuttle.1 The Columbia reentry decision represents a further setback for the NASA space shuttle program. On the surface, the Chal- lenger and Columbia disasters appear to be fundamentally different. The Challenger exploded within a short period after lift-off because of a malfunction of an O-ring that failed to seal due largely to cold weather conditions. The Columbia exploded on reentry into the earth’s atmosphere 16 days after its launch. Foam had struck the wing at lift-off and caused the surface area to allow burn-through on reentry and this action caused the structure to be fatally weakened. Both accidents are similar, however, in the sense that managers responsi- ble for decisions that affected the safety and well-being of the astronauts were generally con- sidered somewhat less than acceptable.2 Like Challenger, where the Presidential Commis- sion on the Space Shuttle Challenger Accident (1986; commonly referred to as the Rogers Commission Report) determined that technical and management failures were responsible, Columbia demonstrates problems with the management culture persist.3 The Columbia Accident Investigation Board (CAIB) report (2003) laments the fact that “a pattern of accep- tance prevailed throughout the organization that tolerated foam problems without sufficient

AUTHOR’S NOTE: This article was originally presented at the 2004 Midwest Political Science Association Annual Conference in Chicago, IL, April 15-18, 2004, Panel Title—”31-10: Delegation, Decision-Making, and Oversight.”

Initial Submission: April 27, 2004

Accepted: July 23, 2004

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engineering justification for doing so” (p. 178). Safety procedures had fallen in importance in the consciousness of the organization as cost considerations became the primary concern. Due to budgetary cuts, NASA began to use private contractors in an intent to “streamline and modernize” so that the agency could “focus on research and development” (p. 179). The Space Flight Operations Contract of 1996 pointed to by the CAIB had the effect of eroding “NASA’s in-house engineering and technical capabilities and increased the agency’s reliance on the United Space Alliance and its subcontractors to identify, track, and resolve problems” (CAIB, 2003, p. 179). In any event, there is a consensus from investigators of both accidents that management problems were at the least partially responsible for the disasters and more likely were central to both tragedies.

Management decision-making theories as related to both tragedies are the focus of this article. Besides the CAIB report and Rogers Commission Report, numerous management decision-making theories have been presented concerning the Challenger launch decision4

and NASA’s overall management culture. Scholarly arguments have been presented that space travel by human beings is inherently risky and subject to disaster because of the inher- ent complexity of human and mechanical systems involved and their interaction.5 These the- ories6 tend to represent the “functionalist” paradigm put forward by Burrell and Morgan (1979). Other theories written by analysts concerning particularly the Challenger include radical structuralism,7 radical humanism,8 and interpretivism.9 Theories of management, particularly those tied to organizational culture, have been found directly in the CAIB report as “NASA’s organizational culture and structure had as much to do with this accident as the External Tank foam” (p. 177). The object of the article here is not to take issue necessarily with the idea of culture as an organizational failure addressed by the CAIB’s findings but to strengthen the analysis of the cause of failure by application of the “knowledge analytic” to the Columbia accident. The knowledge analytic falls clearly in the interpretivist camp and, as such, will be critical of the more common functionalist theories promulgated by other theorists dominant in attempts to analyze the management crises.

THE KNOWLEDGE ANALYTIC

The knowledge analytic is a concept based on the premise that where one is in the organi- zation, whether executive, manager, or worker, determines in large measure what knowledge they use to comprehend their work and role. The key problem in modern organizations is the compatibility problematic10 between the three primary knowledges used in the modern orga- nization, NASA included. Executive knowledge centers on the most abstract aspect of orga- nizational knowledge: mathematics.11 Executives are farthest away from the actual work—in this case study, the building, maintenance, and flying of the space shuttles—where worker (experiential) knowledge is paramount in importance. Executives know their work in terms of numbers and ask questions such as how many employees it will take to successfully accomplish the mission or task, how much it will cost, and how many missions can be suc- cessfully accomplished in a minimal amount of time. Managers in modern organizations try to apply the abstract mathematical models handed to them through the scalar chain in the organizational pyramid from the executives. Through the application of science, managers attempt to fulfill organizational orders from above by directing the employees of the organi- zation as to how to do the work to meet executive demands. Workers, as craftspeople, are far- thest away from the mathematical ideal of the executives and through experiential

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knowledge are closest to the actual work.12 Carnevale and Hummel (1996) describe “the resulting knowledge/work pyramid” as follows:

Executives know the ideal product; Managers know the means as objects. Workers work.

Another dimension of knowledge exists in the knowledge analytic. The idealism of the Congress, president, and general public also plays a significant role. The audience of the American public has the least direct knowledge of the intricacies of the NASA organization and yet influences indirectly events that transpire. As taxpayers, investors, and citizens, the public expects oversight and accountability from the institutional branches of government. Pressure on the organizational pyramid from this group may at times lead to a sense of urgency on behalf of decision makers. Oftentimes, too, decisions are justified and made on their behalf particularly by executive levels of the modern bureaucracy.

The knowledge analytic exists in nearly every modern organization. During times of orga- nizational crisis, decision making and judgment differences are accentuated, particularly in agencies that deal with life and death situations.13 NASA is no exception. The Challenger launch decision and Columbia reentry decision represent best the problems associated with management issues during organizational crises. The compatibility problematic (Garrett, 2001) between organizational levels leads to disaster in times of organizational stress and is central to the concept of the knowledge analytic.

In the next two sections, we will examine the historical circumstances of the problems involving the Challenger and Columbia accidents. The final section will include a structural and phenomenological comparison of the two decisions.

BACKGROUND OF THE CHALLENGER ACCIDENT

The Challenger launch decision is one of the most studied episodes of mismanagement in public administration and organizational theory. The launch on January 28, 1986, was made despite the efforts to halt it by the Morton-Thiokol (MTI) engineers on the day prior to the actual lift-off. Renditions of events leading to the launch include testimony given to the Rog- ers Commission by affected engineers and administrators, scholars, and journalists. Various interpretations may be categorized to include political, economic, and psychological pres- sure to launch (Garrett, 2001, p. 68). The consensus as to what physically occurred is con- tained in the final Rogers Commission report that concluded that the O-rings failed to expand properly between the Solid Rocket Boosters (SRBs) because the ambient air temperature was too cold for the O-rings to expand properly and allow hot gases to escape. The heat ema- nating from the escaped gases in turn caused the SRBs to explode.

The mismanagement charges of the Challenger launch decision stem from the after-the- fact analysis and investigation into how and why the go-ahead was made to launch when it was too cold.14 MTI engineer Roger Boisjoly and his colleagues recommended that the Chal- lenger not be launched due to the cold weather conditions. NASA managers Reinartz, Mulloy, and Hardy from Marshall Space Flight Center (MSFC) contradicted the recommen- dation (see Charles, 1996, p. 118; Garrett, 2001, pp. 69-70) and pushed for launch to proceed as scheduled. Boisjoly and the MTI engineers were ignored by senior MTI managers and the

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MSFC managers. Subsequent testimony by Boisjoly to the Rogers Commission on February 14, 1986, captures the reversal in launch logic (see Garrett, 2001, as adapted from the Presi- dential Commission on the Space Shuttle Challenger Accident, 1986, Vol. 4, pp. 674-676, italics added):

I first heard of the cold temperatures prior to launch at 1:00 o’clock [sic] on the day before launch, and from past experience . . . it concerned me terribly. . . . I was basically concerned with how temperature, low temperature, affects the timing function and the ability of the seal to seal. Low temperature—and I stated this for over a year—is away from the direction of goodness. I cannot quantify it, but I know that it is away from the direction of goodness. . . . I was then asked to support my position with data, and I couldn’t support my position with data. I had been trying to get data since October on O-ring resiliency, and I did not have it in my hand. . . . I had no direct input into the final recommendation to launch and I was not polled. [However,] we normally have to absolutely prove beyond a shadow of a doubt that we have the ability to fly, and it seemed like we were trying to prove, have proved that we had data to prove that we couldn’t fly at this time, instead of the reverse. (pp. 68-69)

Of course, the MFSC managers overruled the engineers at MTI and the decision led to the Challenger tragedy.

In the subsequent investigation, Rogers Commission member and physicist Dr. Richard Feynman investigated the differences between engineers and management in terms of their analysis of the probabilities of space shuttle failure and concluded that the knowledge dis- crepancies between the two groups could not be accounted for in scientific terms. Feynman (1988) conveyed the idea that variation in what engineers perceived as the odds of shuttle system failure (1 in 200) and Marshall Space Flight manager Mr. Lovingood’s analysis (1 in 100,000) amounted to a key failure in worker and management knowledge that was problem- atic (p. 34). Feynman receives credit for surmising the inability of management to reconcile its perceptions with those of the engineers (Garrett, 2001; Tompkins, 1993).

The template for executive/management knowledge usurping worker (experiential) knowledge has been exposed.15 The managers, consumed with questions involving numeri- cal data, ignored the practical work experience of the engineers. The question now becomes, What did NASA learn from the Challenger tragedy? We will respond to this inquiry in the following section.

BACKGROUND OF THE COLUMBIA ACCIDENT

In a space agency where safety is typically gauged by statistics and flight experience, can managers make sufficient room for an engineer’s hunch or intuition? (Spotts, 2003)

With regard to the question posed above concerning Challenger, we have seen that the answer is clearly “no.” With Columbia, we must conclude the same. Newspaper reporter Peter N. Spotts (2003) cites the testimony of Boston College sociologist Diane Vaughan:

During testimony before the [CAIB] panel this week, she noted that engineers, worried about the foam after Columbia’s launch, expressed concerns over e-mail about not having enough information to back them up. “Intuition and hunch didn’t carry any weight,” she said, adding that NASA’s emphasis on hard numbers discourages people from speaking up “in critical situations.”

Moreover, she maintained that . . . in Columbia’s case, engineers failed to treat repeated foam-insulation strikes on past missions as serious, even though the agency strives to avoid

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collisions between the shuttle and debris. What should have been seen as a problem was seen as routine, until disaster struck.

Vaughan’s analysis of the Columbia debacle is consistent with her extensive examination of the Challenger tragedy in The Challenger Launch Decision: Risky Technology, Cul- ture, and Deviance at NASA (1996). The effect on the notion of a failure of management culture was influential to the CAIB and the subsequent attempts by NASA to address per- ceived failures with regard to the incident (see Appendix). Vaughan’s analysis represents an improvement in the understanding of the Columbia accident. The focus of the CAIB into management culture, too, is an improvement over the Challenger disaster, with the notable exception of a Rogers Commission member, the physicist Richard Feynman, who is credited for discovering differences of knowledge between levels of the NASA organization (Garrett, 2001; Tompkins, 1993).

The CAIB focus on management is the key to understanding the Columbia disaster. After the launch of Columbia, with the subsequent tile damage caused by the falling foam at launch, NASA engineers believed that the breakage was significant enough to warrant satel- lite photographs to observe the area in question, as “analysts on the Debris Assessment Team were in the unenviable position of wanting images to more accurately assess damage while simultaneously needing to prove to Program managers, as a result of their assessment, that there was a need for images in the first place” (CAIB, 2003, p. 157). According to the CAIB report, there were eight missed opportunities to deal directly with the tile damage by NASA managers:

1. Flight Day 4. Rodney Rocha inquires if crew has been asked to inspect for damage. No response. 2. Flight Day 6. Mission Control fails to ask crew member David Brown to downlink video he took

of External Tank separation, which may have revealed missing bipod foam. 3. Flight Day 6. NASA and National Imagery and Mapping Agency personnel discuss possible

request for imagery. No action taken. 4. Flight Day 7. Wayne Hale phones Department of Defense representative, who begins identify-

ing imaging assets, only to be stopped per Linda Ham’s orders. 5. Flight Day 7. Mike Card, a NASA Headquarters manager from the Safety and Mission Assur-

ance Office, discusses imagery request with Mark Erminger, Johnson Space Center Safety and Mission Assurance. No action taken.

6. Flight Day 7. Mike Card discusses imagery request with Bryan O’Connor, Associate Adminis- trator for Safety and Mission Assurance. No action taken.

7. Flight Day 8. Barbara Conte, after discussing imagery request with Rodney Rocha, calls LeRoy Cain, the STS-107 ascent/entry Flight Director. Cain checks with Phil Engelauf, and then deliv- ers a “no” answer.

8. Flight Day 14. Michael Card, from NASA’s Safety and Mission Assurance Office, discusses the imaging request with William Readdy, Associate Administrator for Space Flight. Readdy directs that imagery should only be gathered on a “not-to-interfere” basis. None was forthcom- ing. (p. 167)

The argument that valuable scarce resources were being squandered was presented by NASA Mission Management Team Manager Linda Ham, who “raised concerns that the extra time spent maneuvering Columbia to make the left wing visible would unduly impact the mission schedule” and, according to notes taken at a meeting on Flight Day 7, “said it was no longer being pursued since even if we saw something, we couldn’t do any- thing about it. The Program [upper management] didn’t want to spend the resources” on the photo images of the damaged tiles (CAIB, 2003, pp. 153-154). In apparent denial

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about the costs of repairing, she “continued to explore whether foam strikes posed a safety of flight issue” (p. 154). Thus, Ham, attempting to reconcile the limited resources arguments from management higher up in the organizational pyramid to the safety demands placed on her mid-level management team by engineers and analysts, opted to go with the former rather than the latter.

Shuttle program director Ron Dittemore expressed the NASA program management view in the following press interview with New York Times reporter John Broder (2003):

Mr. Dittemore said the astronauts aboard the Columbia gave no sign that they were aware of the heat-related problems and expressed no concern about the unusual behavior of the ship on re-entry. He said that as trained pilots they were almost certainly monitoring the com- puter-driven instructions that were correcting for the unexpected drag.

“We know they are monitoring flight control systems,” he said. “We know that they’re moni- toring attitude. We train them to do that. As pilots, that is what they’re going to do.” However, he added, “We have no data, no communication, no evidence that the crew was alarmed.”

Speaking of the increased drag on the shuttle, Mr. Dittemore said it was “well within the abil- ity of the flight control system to respond to and to react.” But he went on to say, “It’s out of fam- ily in the sense that we’ve never seen it to this degree.”

In answer to a question, Mr. Dittemore said that after the insulation accident, officials had considered trying to photograph the shuttle—through satellites or large telescopes—to look for signs of damage. That approach was discarded, he said, because photos could not discern the severity of any tile problem, and because the astronauts were incapable of repairing tile in space. He added: “The best experts at our disposal concluded that it was a minor problem, not a signifi- cant problem. And when you added it all up, there was no need to take pictures to document any evidence because we believed it to be superficial.”

The agency had long ago decided that a complex space walk to repair tiles could end up doing even more damage to the space shuttle, Mr. Dittemore said, so the idea of training for that contin- gency was abandoned.

The CAIB found that a “pattern of acceptance prevailed throughout the organization that tolerated foam problems without sufficient engineering justification for doing so” (CAIB, 2003, p. 178). Mr. Dittemore resigned at the end of April 2003 before the CAIB published its report. However, he must have known what the outcome of the report was going to be, as

managers . . . failed to develop simple contingency plans for a re-entry emergency. They were convinced, without study, that nothing could be done about such an emergency. The intellec- tual curiosity and skepticism that a solid safety culture requires was almost absent. Shuttle managers did not embrace safety-conscious attitudes. Instead, their attitudes were shaped and reinforced by an organization that, in this instance, was incapable of stepping back and gauging its biases. Bureaucracy and process trumped thoroughness and reason. (p. 181)

On the issue of safety of flight, the Debris Assessment Team attempted to “obtain addi- tional imagery of Columbia,” which was denied by managers in the shuttle program (CAIB, 2003, p. 190). Furthermore, NASA engineers concerned about safety wrote e- mails expressing alarm about the tile problems at lift-off, but their concerns were not seri- ously considered.16

As we have seen in the Challenger incident, engineers with knowledge about their work, in this case the tile breakage and the problems with the shuttle reentry, were systematically ignored by NASA managers over the engineers in the hierarchy as “these emails did not reach the Mission Management Team” (CAIB, 2003, p. 192). The CAIB report laments,

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Status update meetings should provide an opportunity to raise concerns and hold discussions across structural and technical boundaries. The leader of such meetings must encourage par- ticipation and guarantee that problems are assessed and resolved fully. All voices must be heard, which can be difficult when facing a hierarchy. An employee’s location in the hierar- chy can encourage silence. Organizations interested in safety must take steps to guarantee that all relevant information is presented to decision-makers. This did not happen in the meetings during the Columbia mission. (p. 192)

Thus, one of the key findings of the CAIB, and an improvement over the general findings of the Rogers Commission report, is this: The organizational pyramid stifles effective communication in NASA. The CAIB is now tantalizingly close to the core of the prob- lem: the knowledge analytic.

THE CHALLENGER LAUNCH DECISION, THE COLUMBIA REENTRY DECISION, AND THE KNOWLEDGE ANALYTIC

We have now arrived at the point where we may fully consider the application of the knowledge analytic to the two cases. The knowledge of the engineers, MTI in the Challenger incident and NASA engineers in the Columbia reentry decision, was devalued in the organi- zational hierarchy. This tendency is plotted in Tables 1 and 2.

Pressure to launch and/or reenter the earth’s atmosphere was driven by executive-level concerns due largely to costs and deadlines. This pressure was further exacerbated in the case of Columbia by the actions of NASA administrator Sean O’Keefe, who was well known as a budget cutter and primarily concerned with keeping NASA’s costs down to a minimum.17

Midlevel managers such as Mulloy and Kingsbury in Challenger and Dittemore and Ham in Columbia face the pressure to perform the missions despite the warnings initiated from below, in each case the engineers involved in the shuttle program. The result in both instances was a failure of the NASA organization, beyond the scope of the actual technical problems in both tragedies, resulting in the deaths of the astronauts.

CONCLUSION

The CAIB’s analysis represents an improvement over the findings of the Challenger’s Rogers Commission in the sense that management culture is the key for the wrongful deci- sion making in the NASA organization. However, the analysis is still incomplete because, although the CAIB report touches on the problems of the organizational hierarchy, it is still imbued with the notion that management knowledge is ultimately superior to worker (expe- riential) knowledge and that experiential knowledge ought to be captured in its totality to serve management knowledge. This rational-scientific knowledge of midlevel managers cannot completely comprehend experiential knowledge nor grasp completely the abstract nature of executive knowledge. The compatibility problematic between organizational knowledges still persists. Only direct attention to this central problem of modern organiza- tions by all members will begin solving the organizational conundrum of the knowledge analytic.

Further research into the matter of the knowledge analytic is necessary. NASA has taken positive steps to organizational problem recognition in terms of its current emphasis on

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management culture through the criticisms offered by the CAIB.18 However, NASA needs to recognize the hazards of the knowledge analytic to prevent management failures in the future. As I have stated previously, “Respect for, appreciation for, and real interest in all members of an organization and their knowledge could result in improvements for partici- pants in public organizations and people receiving responsive and responsible services from public agencies” (Garrett, 2001, p. 83). This respect goes well beyond communication and to the core working knowledge that organizational participants bring to the table. Engineers and the lower level organizational members were ignored at critical junctures in the decision- making process. They had a chance to be heard but were not given due consideration for their knowledge expertise because of their placement in the organization. The modern manage-

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TABLE 1: Outline of Decision Making in the Challenger Case Study

A. Structural Outline of the 1986 Space Shuttle Accident:

Result: Normal Everyday Activity → Crisis → Challenger Explosion January 28, 1986

Decision Option Considered Critical Factor Affecting Rationalization and the Decision- (by managers) Decision Considerations Making Process (deliberation)

(a) Launch/no launch/delay (a) 36 degree Fahrenheit ambient temperature at launch; too cold, previous coldest tempera- ture was 53 degrees

(a) Relatively little emphasis was given to workers (engineers) involved in the work; they were ignored at critical times in the deliberative process

Launch option selected (b) O-ring deterioration: sheets of ice threatened shuttle orbiter; naval rescue operations within acceptable tolerance

(b) Belief that odds were in favor of success, based on mathe- matical models and science; decision to launch was mana- gerial and not based on worker experience; time limitations and scarce resources empha- sized in decision

B. Phenomenological Outline Based on Carnevale and Hummel’s Concept of the Knowledge Analytic Applied to the Challenger Launch Decision: Most abstract knowledge (farthest away from the actual work) →

Idealism—affiliated with investors and citizens [Congress, president, shuttle contract investors, scientists with interests outside of manned spaceflight, and the American public]

Rationalism—affiliated with chief administrators [NASA administrator Graham, Lucas, and other NASA offi- cials, particularly at the highest levels]

Science—affiliated with management scientists and mid-managers [midlevel managers such as Kingsbury, Reinartz, and Mulloy at NASA and Lund at Morton-Thiokol]

Realism—dominant among those who ultimately and directly produce the goods and services and those who use them [Morton-Thiokol engineers such as Boisjoly and Thompson, and the seven Challenger astronauts]

← Most realistic knowledge (closest to everyday work experience)

SOURCE: Originally published in Garrett, 2001, p. 80; and based on Carnevale & Hummel, 1996, pp. 17-18; Garrett, 1997, pp. 13, 188-189.

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ment pyramid needs to be overcome to prevent future disasters at NASA and, indeed, other organizations. NASA has taken steps in recognizing the shortcomings of its management culture, yet still has not fully grasped the implications of the knowledge analytic.

From an organizational theory perspective, the knowledge analytic, based on the philoso- phy of phenomenology, best captures the core nature of problems in modern organizations. Other theories, especially those based on functionalism that dominate academic discourse, are primarily concerned with executive knowledge (mathematics) or scientific management. More scholarly work from an interpretivist perspective is necessary for improvement in modern organizations, particularly in the area of crisis management.

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TABLE 2: Outline of Decision Making in the Columbia Case Study

A. Structural Outline of the 2003 Space Shuttle Accident:

Result: Normal Everyday Activity Crisis Rationalization and Deliberation

Decision Option Considered Critical Factor Affecting Rationalization and Deliberation (by managers) Decision Considerations (decision-making process)

(a) Land/no land/delay (a) Foam may have shattered reflec- tion panels protecting the shuttle structure

(a) Little emphasis given to workers’ e-mail messages expressing con- cerns about the safety of reentry to earth’s atmosphere; the engi- neers were ignored at critical times in the deliberative process

Land option selected (b) If (a) there may not have been anything that NASA could do short of military satellite photo- graphs (which were prohibitively expensive)

(b) Belief that odds were in favor of success, based on mathematical models and science; decision to land was managerial and not based on worker experience; time limitations and scarce resources emphasized in the decision

B. Phenomenological Outline Based on Carnevale and Hummel’s Concept of the Knowledge Analytic Applied to the Columbia Launch Decision: Most abstract knowledge (farthest away from the actual work)

Idealism—affiliated with investors and citizens [Congress, president, shuttle contract investors, scientists with interests outside of manned spaceflight, and the American public]

Rationalism—affiliated with chief administrators [NASA administrator O’Keefe and other high-level NASA administrators]

Science—affiliated with management scientists and mid-managers [midlevel managers such as Ron Dittemore, NASA shuttle program manager, Linda Ham, MMT manager, and others]

Realism—dominant among those who ultimately and directly produce the goods and services and those who use them [NASA engineers and the seven Columbia astronauts]

Most realistic knowledge (closest to everyday work experience)

SOURCE: Originally published in Garrett, 2001, p. 80; and based on Carnevale & Hummel, 1996, pp. 17-18; Garrett, 1997, pp. 13, 188-189.

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APPENDIX The Columbia Accident Investigation Board (CAIB) Findings

and NASA Proposals for Change in the Aftermath of Columbia

Key CAIB Findings The CAIB focused its findings on three key areas:

• Systemic cultural and organizational issues, including decision making, risk management, and communication;

• Requirements for returning safely to flight; and • Technical excellence.

This summary addresses NASA’s key actions in response to these three areas.

Changing the NASA Culture

The CAIB found that NASA’s history and culture contributed as much to the Columbia accident as any technical failure. NASA will pursue an in-depth assessment to identify and define areas where we can improve our culture and take aggressive corrective action. To do this, we will

• Create a culture that values effective communication and empowers and encourages employee ownership over work processes.

• Assess the existing safety organization and culture to correct practices detrimental to safety. • Increase our focus on the human element of change management and organizational

development. • Remove barriers to effective communication and the expression of dissenting views. • Identify and reinforce elements of the NASA culture that support safety and mission success. • Ensure that existing procedures are complete, accurate, fully understood, and followed. • Create a robust system that institutionalizes checks and balances to ensure the maintenance of

our technical and safety standards. • Work within the agency to ensure that all facets of cultural and organizational change are contin-

ually communicated within the NASA team.

To strengthen engineering and safety support, NASA

• Is reassessing its entire safety and mission assurance leadership and structure, with particular focus on checks and balances, line authority, required resources, and funding sources for human space flight safety organizations.

• Is restructuring its engineering organization, with particular focus on independent oversight of technical work, enhanced technical standards, and independent technical authority for approval of flight anomalies.

• Has established a new NASA Engineering and Safety Center to provide augmented, independ- ent technical expertise for engineering, safety, and mission assurance. The function of this new center and its relationship with NASA’s programs will evolve over time as we progress with our implementation of the CAIB recommendations.

• Is returning to a model that provides NASA subsystem engineers with the ability to strengthen government oversight of space shuttle contractors.

• Will ensure that Space Shuttle flight schedules are consistent with available resources and acceptable safety risk.

To improve communication and decision making, NASA will

• Ensure that we focus first on safety and then on all other mission objectives. • Actively encourage people to express dissenting views, even if they do not have the supporting

data on hand, and create alternative organizational avenues for the expression of those views.

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• Revise the Mission Management Team structure and processes to enhance its ability to assess risk and to improve communication across all levels and organizations.

To strengthen the space shuttle program management organization, NASA has

• Increased the responsibility and authority of the Space Shuttle Systems Integration Office to ensure effective coordination among the diverse space shuttle elements. Staffing for the office will also be expanded.

• Established a deputy space shuttle program manager to provide technical and operational sup- port to the manager.

• Created a Flight Operations and Integration Office to integrate all customer, payload, and cargo flight requirements.

To continue to manage the space shuttle as a developmental vehicle, NASA will

• Be cognizant of the risks of using it in an operational mission, and manage accordingly, by strengthening our focus on anticipating, understanding, and mitigating risk.

• Perform more testing on space shuttle hardware rather than relying only on computer-based analysis and extrapolated experience to reduce risk. For example, NASA is conducting exten- sive foam impact tests on the space shuttle wing.

• Address aging issues through the Space Shuttle Service Life Extension, including midlife recertification.

To enhance our benchmarking with other high-risk organizations, NASA is

• Completing a NASA/Navy benchmarking exchange focusing on safety and mission assurance policies, processes, accountability, and control measures to identify practices that can be applied to NASA programs.

• Collaborating with additional high-risk industries such as nuclear power plants, chemical pro- duction facilities, military flight test organizations, and oil-drilling operations to identify and incorporate best practices.

To expand technical and cultural training for mission managers, NASA will

• Exercise the Mission Management Team with realistic in-flight crisis simulations. These simu- lations will bring together the flight crew, flight control team, engineering staff, the Mission Management Team, and other appropriate personnel to improve communication and to teach better problem recognition and reaction skills.

• Engage independent internal and external consultants to assess and make recommendations that will address the management, culture, and communications issues raised in the CAIB report.

• Provide additional operational and decision-making training for mid- and senior-level program managers.

Examples of such training include Crew Resource Management training, a U.S. Navy course on the Challenger launch decision, a NASA decision-making class, and seminars by outside safety, management, communications, and culture consultants.

Returning Safely to Flight

The physical cause of the Columbia accident was insulation foam debris from the External Tank left bipod ramp striking the underside of the leading edge of the left wing, creating a breach that allowed superheated air to enter and destroy the wing structure during entry. To address this prob- lem, NASA will identify and eliminate critical ascent debris and will implement other significant risk mitigation efforts to enhance safety.

SOURCE: NASA’s Implementation Plan for Return to Flight and Beyond, 2003, pp. 11-15.

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NOTES

1. This article is an extension of an earlier work published in ARPA on Challenger (see Garrett, 2001). 2. Besides the aforementioned Columbia Accident Investigation Board Report (hereafter referred to as the

CAIB report), an examination of the Report to the President by the Presidential Commission on the Space Shut- tle Challenger Accident, or Rogers Commission Report, provides the basis for technical and management failures in both incidents.

3. This was the conclusion of the Columbia Accident Investigation Board headed by Admiral Harold Gehman. See, in particular, Chapter 8 of the report.

4. The best read concerning an outline of the Challenger tragedy may be found in McConnell (1987). 5. For example, see Heimann (1993) on building redundancy by setting up parallel circuits (akin to a circuit

board), whereas the streamlining of NASA led to serial decision making and a loss of safety concerns. See Romzek and Dubnick (1987) on the breakdown to organizational scalar chain. See Starbuck and Milliken (1988) on the “gambler’s fallacy” and “hubris.” For risk theorists, see the works of Vaughan (1996) on “normalization of deviance,” Perrow (1984) on “normal accidents” (this work is not about Challenger directly but serves as the basis for most of the risk theorists’ assessments), Karl E. Weick (1987) on the inevitability of “accidents [that] occur because the humans who operate and manage complex systems are not sufficiently complex to sense and anticipate the problems generated by those systems” (p. 112) and McCurdy (1986) and his theory of organiza- tional structure “decay.” These theories are categorized as functionalist in nature and tend to examine organiza- tional problems from a strictly management perspective.

6. For a comprehensive assessment of theories written concerning the Challenger launch decision, see Garrett (1997).

7. Radical structural theories concerning Challenger include Gouran, Hirokawa, and Martz (1986) on the rigidity of upper management and Holt and Morris (1993) on Marxist activity theory. These theories generally tend to point out the internal contradictions inherent to the NASA organization. Executives and managers tend to be viewed as having a completely adversarial relationship with workers in organizations.

8. Some radical humanist theories include Schwartz (1990) on psychoanalysis and the role of narcissism in organizations and also Adams and Balfour’s (2004) concepts concerning “masked administrative evil” and “arrogant-vindictive” management; Christiansen’s (1987) critique of the lessening of intuition and past experi- ence by Challenger managers; the loss of the roll of ethics in decision making (Boisjoly, Curtis, & Mellican, 1989; Goldberg, 1987); and Dombrowski (1995) on the issue of “locus of responsibility.” Radical humanist the- ories are somewhat concerned with the totality of the organization but tend to center on unethical or psychologically distorted management behavior.

9. Interpretivist theories include Garrett (1997, 2001) on the knowledge analytic, and Tompkins (1993) on Challenger and “organizational communication theory.” Feynman (1988), a physicist on the Rogers Commis- sion, offers an analysis where differences are found between engineers and managers at NASA in their knowl- edge of the work. Interpretivist theorists are concerned with all levels of the organization and the differences in working knowledge, primarily between executives, managers, and workers.

10. See Garrett (2001, p. 82) and Carnevale and Hummel (1996, pp. 47-48) for more elaboration of the con- cept. The differences between knowledge—mathematical, scientific, and experiential—represent the organiza- tional pyramid prevalent today.

11. The phenomenological philosopher, Edmund Husserl (1931/1969), refers to the tension between the quantitative knowledge versus knowledge based on experience as “the two worlds are present together but dis- connected, apart, that is, from their relation to the Ego, in virtue of which I can freely direct my glance or my acts to the one or to the other” (p. 94). What is instructive here is the emphasis in organizations placed by executives, managers, and workers. Executives represent knowledge in the arithmetical world at one extreme, whereas workers occupy the world of everyday experience, or the world of “real fact.” Managers find themselves trying to bridge the psychological gap and philosophical conundrum between the two worlds and frequently find themselves failing to successfully adapt.

12. See also Garrett (2001, p. 78). In recent conversations that I have had with Ralph Hummel, he elaborates the knowledge analytic where “direct experience is transformed into organized perceptions, or intuition, from the worker’s perspective, and pure categories of reason (executive idealism and management science) are trans- formed into concepts by reference to (workers’) intuition.”

13. See, in particular, Garrett (2003) on the use of judgment and decision making by executives, managers, and fire fighters in the aftermath of the September 11, 2001, crisis involving the New York City Fire Department and the Oklahoma City Fire Department’s actions after the Murrah Federal Building bombing on April 19, 1995.

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14. There are a number of problems besides the cold air temperatures including (a) rough seas that would cause any rescue efforts to have been hindered, and (b) ice sheets found on the walkway to the shuttle orbiter and the orbiter itself.

15. The best explanation of knowledge incompatibility is best illustrated by Schmidt (1993, pp. 526-527), where the grouter’s “feel for the hole” (putting in sufficient amounts of the substance to prevent the collapse of the dam) was at odds with the workers’ knowledge about their work (critical/passive).

16. See Wald and Broad (2003) for examples of e-mail messages sent by NASA engineers to managers. 17. The emphasis on budget cutting and cost reduction by O’Keefe is captured by Barstow and Moss (2003)

in the following:

Mr. O’Keefe initially lived up to his billing. By April 2002, NASA had decided to cancel three planned safety upgrades, including a plan to switch the shuttle’s auxiliary power unit from a highly flammable fuel to a safer electrical system. Officials said that project ran into serious technical problems, and its costs spiraled. As a result of the cancellations, the Bush administration proposed cutting some $530 million over six years from the budget for safety and performance upgrades to the shuttle; the money was no longer needed, officials said.

18. See the Appendix for the comprehensive listing of actions taken by NASA with regard to, especially, management culture. The emphasis by the Columbia Accident Investigation Board on management culture is a significant improvement over the status quo technical-rational orientation and empathy with the traditional sca- lar chain of command dominant in the NASA organization. Whether these “pyramid-like” tendencies may be overcome remains to be seen.

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Terence M. Garrett, Ph.D., is an assistant professor of public administration at the University of Texas–Pan American. His areas of interest include organization theory, crisis management decision making, and per- sonnel administration. His previous article, titled “The Waco, Texas, ATF Raid and the Challenger Launch Decision: Management, Judgment, and the Knowledge Analytic,” was published in The American Review of Public Administration.

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