The Nimrod Review - Official Documents

17.33.2
17.33.3
Chapter 17 – Columbia and Other Lessons
“Years of workforce reductions and outsourcing have culled from NASA’s workforce the layers
of experience and hands on systems safety that once provided a capacity for oversight. Safety
and Mission assurance personnel have been eliminated, careers in safety have lost organisational
prestige and the program now decides on its own how much safety and engineering oversight it
needs.” 31
“NASA’s culture of bureaucratic accountability emphasised chain of command, procedure, following
the rules, and going by the book. While rules and procedures were essential for co-ordination,
they had an unintended but negative effect. Allegiance to hierarchy and procedure had replaced
deference to NASA’s engineers’ technical expertise”. 32
CAIB’s conclusions on organisational problems at NASA
17.34 The CAIB’s conclusions on the deep-seated organisational problems that it found in NASA included the following
thoughts:
17.34.1 Leaders create culture. It is their responsibility to change it. Top administrators must take responsibility
for risk, failure, and safety by remaining alert to the effects their efforts have on the system. Leaders
are responsible for establishing the conditions that lead to their subordinates’ successes or failure.
The past decisions of national leaders, the White House, Congress, and NASA headquarters, set
the Columbia accident in motion by creating resource and schedule strains that compromised
the principles of a high-risk technology organisation. NASA’s success became measured by cost
reduction and whether the schedule was met.
17.34.2 Changes in organisational structure should be made only with careful consideration of their effect on
the system and their possible unintended consequences. Changes that make an organisation more
complex may create new ways that it can fail. When changes are put in place the risk of error initially
increases as old ways of doing things compete with new. Institutional memory is lost as personnel
and records are moved and replaced. Changing the structure of organisations is complicated by
external budgetary and political constraints, the inability of leaders to conceive the full ramifications
of their actions, and the failure to learn from the past. Nonetheless, change must be made. NASA’s
blind spot was that it believed it had a strong safety culture. Programme history shows that the
loss of a truly independent, robust capability to protect the system’s fundamental requirements and
specifications inevitably compromised those requirements, and therefore increased risk.
17.34.3 Strategies must increase the clarity, strength and presence of signals that challenge assumptions
about risk. Twice in NASA’s history the agency embarked down a slippery slope that resulted in
catastrophe. Each decision taken by itself seemed correct, routine and indeed insignificant and
unremarkable, yet their effect was stunning. A safety team must have equal and independent
representation so that managers are not again lulled into complacency by shifting definitions of risk.
It is worth acknowledging that people who are marginal and not in positions of power may have
useful information that they do not express. Even when such people are encouraged to speak, they
find it intimidating to contradict a leader’s strategy or a group consensus.
17.34.4 Responsibility and authority for decisions involving technical requirements and safety should rest
with an independent technical authority. The CAIB said there were lessons to be learned from other
organisations that had been accident-free, including e.g. the US Navy Submarine and Reactor Safety
programs: 33 “Organisations that successfully operate high risk technology have a major characteristic
in common: they place a premium on safety and reliability by structuring their programs so that
technical and safety engineering organisations own the process of determining, maintaining and
waiving technical requirements with a voice that is equal to yet independent of Program managers
31 CAIB Report, page 181.
32 CAIB Report, page 200.
33 CAIB Report, page 182.
453