The Nimrod Review - Official Documents

Chapter 17 – Columbia and Other Lessons
elements and the evolution of an informal chain of command and decision making
processes that operated outside the organisation’s rules.”
17.5 The CAIB pointed out that “cultural norms” tend to be fairly resilient and “bounce back into shape” and that
beliefs held in common throughout an organisation “resist alteration”. The CAIB defined “organisational culture”
as follows:
“Organisational culture refers to the basic values, norms beliefs, and practices that
characterise the functioning of a particular institution. At the most basic level, organisational
culture defines the assumptions that employees make as they carry out their work; it
defines “the way we do things here”. An organisation’s culture is a powerful force that
persists through reorganisations and the departure of key personnel.” 7
Echoes of Challenger in Columbia
17.6 Only 17 years before, on 28 January 1986, NASA had lost the Space Shuttle “Challenger” in an explosion on
take-off as a result of a defective ‘O-ring’. The Presidential Commission investigating the Challenger accident
(1986) found that NASA had increased reliance upon contractors for safety, relegating many NASA technical
experts to desk-jobs whose role was essentially one of ‘oversight’ of contractor activities. NASA’s increasing
dependence on contractors served to undermine its in-house technical expertise. A 1990 review concluded that
“NASA did not have an independent and effective safety organisation”. It was dependent for funds from those
whose safety-related performance it was responsible for overseeing. 8
17.7 There were many ‘echoes’ of the Challenger accident in Columbia. Lessons had not been learned the first time.
This was one of the reasons which led the CAIB to concentrate on examining the organisational causes of the
Columbia accident.
12 parallels between Nimrod XV230 and Columbia
17.8
There are 12 striking parallels between the organisational causes of the Nimrod XV230 and Columbia accidents
and between the organisational traits and experiences of NASA and the MOD/RAF in the lead up to these two
accidents. I discuss these below.
(1) The attitude was ‘can do’ and culture ‘the perfect place’
17.9 NASA took great pride in its history and its “can do” attitude. 9 NASA saw itself as “the perfect place” following
the success of its Apollo programme. NASA had a “self confidence” about possessing “unique knowledge” as
to how safely to launch people into space. NASA did not take easily to criticism from outside, and tended to
react by imposing the party line rather than reconsidering it. NASA was not a ‘learning organisation’. 10 NASA
suffered from “flawed decision making, self deception, introversion and a diminished curiosity about the world
outside the perfect place”. 11
17.10
The same can be said of many parts of the RAF and MOD.
7 CAIB Report, page 101.
8 CAIB Report, page 179.
9 CAIB Report, page 101.
10 CAIB report, page 127.
11 CAIB Report, page 102.
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