Beyond the widget; Columbia accident lessons affirmed

Air & Space Power Journal, Summer, 2004 by Duane W. Deal

Editorial Abstract: Circumstances surrounding the loss of the space shuttle Columbia affirm multiple lessons that emerged from analyses of similar tragedies of the past 40 years. General Deal takes a hard look at the findings of the Columbia Accident Investigation Board so that senior leaders of other high-risk operations can prevent similar mishaps and promote healthy organizational environments.

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THE DATE 1 February 2003 presented the world with images that will be forever seared in memories of all viewing them--images of the space shuttle Columbia's final moments as it broke apart in the skies over Texas. As tragic as the Columbia accident was, multiple lessons to prevent future accidents can be "affirmed" from the circumstances surrounding this accident. The emphasis is on "affirmed," because all of those lessons had been previously learned during the past 40 years through the analysis of other tragedies:

* April 1963, loss of the USS Thresher, while operating at the edge of several envelopes

* January 1967, Apollo I capsule fire on launchpad

* December 1984, Union Carbide pesticide factory tragedy in Bophal, India, resulting from insufficient attention to maintenance and training, and its leadership ignoring internal audits

* January 1986, loss of the space shuttle Challenger

* April 1986, Chernobyl disaster, where safety procedures were ignored during reactor testing

* July 2000, crash of a Concorde super-sonic passenger plane in Paris after multiple prior incidents

* September 2001, al-Qaeda attacks on the United States despite more than a decade of uncorrelated signals and warnings

* October 2001, Enron collapse, despite multiple warnings and indications

The lessons gleaned from these and other prominent accidents and disasters, management and leadership primers, and raw experience are the same lessons that should have prevented the Columbia accident. The saddest part is that some in the National Aeronautics and Space Administration (NASA) had simply not absorbed, or had forgotten, these lessons; the result was the deaths of seven astronauts and two helicopter search team members, as well as the intense scrutiny of a formerly exalted agency.

This article highlights many of the major lessons affirmed by the Columbia Accident Investigation Board (CAIB)--lessons that senior leaders in other high-risk operations should consider to prevent similar mishaps and to promote healthy organizational environments. Admittedly NASA-specific and greatly condensed, the specific Columbia-related vignettes and perspectives presented here are intended to provide the reader an opportunity to step back and contemplate how his or her organization has the potential to fall into the same type of traps that ensnared NASA. Due to NASA's size, complexity, mission uniqueness, and geographically separated structure, some specific lessons may not be applicable to all organizations; however, the fundamental principles apply universally, as many of these same conditions may be present in any organization.

Effective leaders recognize that every organization must periodically review its operations to avoid falling into complacency as NASA had done. They also recognize that it is far better to prevent, rather than investigate, accidents. To assist with that prevention, readers should carefully examine the situations in which NASA found itself, perhaps drawing relevance by substituting their own organization's name for "NASA," and affirm those lessons once again. These situations are organized and examined in the three categories of basics, safety, and organizational self-examination.

   We are what we repeatedly do. Excellence,
   then, is not an act, but a habit.

      --Aristotle

Sticking to the Basics

The reason basics are called basics is that they form the foundation for an organization's success in every field from plumbing to accounting to technology-intensive space launches. As NASA and the world shockingly discovered, deviating from basics can form the foundation for disaster.

Keep Principles Principal

Avoid Compromising Principles. In the 1990s, the NASA top-down mantra became "Faster, Better, Cheaper." The coffee-bar chat around the organization quickly became, "Faster, Better, Cheaper? We can deliver two of the three which two do you want?" While the intent of the mantra was to improve efficiency and effectiveness, the result was a decrease in resources from which the institution has yet to recover.

Leaders must contemplate the impact of their "vision" and its unforeseen consequences. Many must also decide whether operations should be primarily designed for efficiency or reliability. The organization and workforce must then be effectively structured to support that decision, each having a clear understanding of its role.

Leaders must remember that what they emphasize can change an organization's stated goals and objectives. If reliability and safety are preached as "organizational bumper stickers," but leaders constantly emphasize keeping on schedule and saving money, workers will soon realize what is deemed important and change accordingly. Such was the case with the shuttle program. NASA's entire human spaceflight component became focused on an arbitrary goal set for launching the final United States Node for the International Space Station. They were so focused, in fact, that a computer screen saver was distributed throughout NASA depicting a countdown clock with the months, days, hours, minutes, and seconds remaining till the launch of the Node--even though that date was more than a year away. This emphasis did not intend to change or alter practices, but in reality the launch-schedule goal drove a preoccupation with the steps needed to meet the schedule, resulting in an enormous amount of government and contractor schedule-driven overtime. This preoccupation clouded the institution's primary focus--was it to meet that date, or to follow the basic principles of taking all necessary precautions and ensuring that nothing was rushed?