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Home » Useful White Papers » Lost in Space: What Happens When The Rocket Scientists Mess Up |
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Lost in Space: What Happens When The Rocket Scientists Mess Up
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September 10, 2003
-- Brig. Gen. Charles Baldwin, STS-107 Memorial Ceremony at
the National Cathedral, February 6, 2003.
As we look back on the anniversary of Lewis and Clark, we marvel
at the spirit of adventure that compelled them to explore the
unknown. We are lulled into thinking that contemporary explorers
are safe, that they don't risk their lives to know the great
beyond. But that illusion was shattered this past February 1,
when the Space Shuttle Columbia disintegrated over the skies of
Texas.
BUILDING ROCKETS IS HARD
Part One of the report of the Columbia Accident Investigation
Board, released this past month, begins with the sentence
"Building rockets is hard." This is most assuredly a true
statement.
Creating and operating a space program involves the need for
an incredible degree of innovation and creativity, along with
a requirement to establish and follow complex processes that
allow execution of the mission while minimizing chances for
failure. On February 1, 2003, the failure by NASA to employ
sound process over a long period of time at both the
organizational and programmatic levels resulted in the loss
of the Space Shuttle Columbia and the lives of Rick Husband,
William McCool, Michael Anderson, David Brown, Kalpana Chawla,
Laurel Clark, and Ilan Ramon.
A basic premise behind ADASTRO is embodied in our motto
"Business IS Rocket Science" and our belief that building a
successful and profitable business in today's competitive
economy requires innovation and process not too unlike that
employed by the rocket scientists. But it remains important
to remember that sometimes even the rocket scientists make
mistakes. It is my hope that looking at how the rocket
scientists deal with failure, and the lessons they learn
from it, will offer Apogee readers valuable lessons that
they can apply to their businesses.
When something goes significantly wrong for a rocket
scientist, the first thing that they do is work to deal with
the situation from an operational perspective to achieve the
best feasible outcome. The next step is to conduct an
investigation. In the case of the Columbia tragedy, where it
very quickly became clear that a complete loss of mission had
occurred and there was nothing further that could be done to
help the crew, the next step was to lock the doors and secure
the data. This was followed just minutes later by the
initiation of the process that led to the creation of the
Investigation Board.
The same basic principles can apply to many business situations
in which one encounters a failure--you archive the data so that
no information is lost, and then you investigate the situation
to understand both immediate and root causes. The objective is
not to find someone to blame--it is to understand what really
happened (which very often turns out to be different than what
appeared to happen), to turn the failure into an opportunity for
learning, to improve your organization and its practices, and to
realize value from the experience.
The investigation may be done in-house for more routine business
matters, while the most serious situations (such as ones which
might involve a loss of life, or legal proceedings) may require
an investigation by external and independent experts. Obviously,
the process is very different when investigating why a marketing
campaign failed as compared to investigating an industrial
accident, but in either case a process designed to realize value
from the failure can and should be designed along the lines
described above.
DANGER WILL ROBINSON, DANGER
The report by the Columbia Accident Investigation Board found a
physical cause for the loss of the Columbia to be a breach in
the Thermal Protection System on the leading edge of the Shuttle's
left wing, caused by a piece of insulating foam which separated
from the External Tank during liftoff and struck the wing. During
re-entry of the Shuttle, this breach allowed superheated air to
melt the structure of the wing, eventually resulting in a loss
of control, failure of the wing, breakup of the Orbiter, and
death of the crew.
The Investigation Board went much deeper than looking
just at the physical causes of the failure--they also looked at
organizational and cultural issues at NASA that had allowed a
serious situation to occur that caused loss of life, and at the
way in which the seriousness of the issue went unrecognized by
senior management even after warning signs were recognized
during previous missions and as well as during the flight of
Columbia itself.
What the board found was not pretty--significant cultural
issues at NASA allowed safety to be compromised. The
Investigation Board explained that "Organizational culture
refers to the basic values, norms, beliefs, and practices
that characterize the functioning of a particular institution.
At the most basic level, organizational culture defines the
assumptions that employees make as they carry out their work;
it defines 'the way we do things here.' An organization's
culture is a powerful force that persists through
reorganizations and the departure of key personnel."
Many of the cultural problems at NASA were deemed to be the
inevitable results of 1) an attitude of arrogance from senior
NASA management that discouraged action on many safety concerns,
along with denial that a safety situation existed; 2) a lack of
vision, direction, and mandate from the last four presidential
administrations; and 3) a congress that underfunded complex
projects, earmarked funds based on geographic location of the
expenditure and for unwanted special interest projects,
changed priorities based on political rather than scientific
motivations, and is indifferent unless something goes wrong.
These are the very same factors that motivated me to leave the
aerospace industry ten years ago... today the situation has
clearly deteriorated even further.
While I have not been a practicing astronautical engineer for
the last decade, my past relationships have continued to bring
me close ties to NASA and the Columbia mission. Former Secretary
of the Air Force Dr. Shiela Widnall, who was a member of the
Columbia Accident Investigation Board, is a professor in the
department at M.I.T. from which I received my doctorate. One of
my classmates from my doctoral program, Dr. Dan Heimerdinger,
assisted the Investigation Board and is a co-founder of Valador,
Inc., the board's primary contractor to support the investigation.
Another classmate, Dr. Paul Ronney, is now a professor at USC and
was the principal investigator on one of the experiments that was
aboard the Columbia mission (see: http://carambola.usc.edu/Columbia.html). Dr. Janice Voss and
Dr. Greg Chamitoff, two other former classmates, are astronauts
(who were, thankfully, not aboard the final Columbia mission).
Those in congress that control NASA's purse strings seem to be
much more intent on finding someone to blame than to figure out
how to improve NASA and move forward. If they are really
interested in finding someone to blame, they might do best by
looking in a mirror, as the way that congress has in the past
and continues to deal with NASA is a more serious root cause
of NASA's problems than the actions of any specific individual
at NASA.
NASA Administrator Sean O'Keefe says that he has read the
investigation report and that he "gets it." I have doubts that
he truly does, although I do believe he really is trying to
"get it." Ultimately, implementing real solutions will be complex,
and it will be congressional support, along with NASA's actions,
rather than words, that will prove or disprove NASA's ability to
make meaningful changes.
BOLDLY GOING
I believe it is essential that NASA finds the way to get it right.
Not only is NASA's existence critical to answering key questions
about the universe and to helping maintain the scientific and
engineering leadership of the United States, but it is also
important to keep in mind that every dollar that NASA spends is
spent on Earth. That investment drives the education and employment
of a workforce that has beneficial spinoffs in thousands of
directions and which enables the economy of the United States to
remain the strongest in the world. Were it not for the experience
and education I received in conjunction with NASA, you would not be
reading this article now.
NASA has a brand that is associated with the future and technology
in a manner unlike any other brand in the world. While that brand
may be damaged, it is clearly salvageable. It remains to be seen if the requisite changes at NASA,
in Congress, and from the President will occur that are necessary
if NASA's mission is to be engaged.
You cannot shape the future unless you truly understand the
present from which you are starting. When was the last time your
business went through the process of really trying to understand
the basic values, norms, beliefs, and practices that characterize
its operations? There really is no way to conduct such an assessment
from within--it requires someone external and unbiased to the
organization to come in and conduct an assessment. Each time I have
been involved in such a process, the results were both surprising
and extremely valuable.
Business IS Rocket Science. If you work to understand your
organization's culture and learn from its mistakes just like a
rocket scientist would, you will maximize your opportunities,
increase the value of your business, and shape the best possible
future for your organization.
The Columbia Seven lit the world with their passion. May the
brilliance of their light fill each of our hearts.
Additional Reading
Corporate success stories offer lessons for NASA
The Right Stuff
NASA's culture problems not unique
Inertia and Indecision at NASA
Excerpts from report of the Columbia Accident Investigation Board
The Columbia Accident Board Report
The author gratefully acknowledges the contribution of Jane Walker to some of the exposition in this essay.
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