Viewpoint

Managerial Insights from a NASA Tragedy

One of the things I say to participants in our global leadership programme (The New Frontier: Succeeding as a Global Leader) is "Don't just look at successes, failures and best practices in your own sector or region of the world. Get outside of your industry, culture, and organisational cages. Find rich examples of what has worked or not worked in unusual places. Always be asking, 'Can we learn anything from this, or this, or that?'" Some airlines, for example, have studied how they might speed up the process of getting planes in and out of airport gates by looking closely at Formula One pit stop activities. Others have looked at hospices to understand more deeply the nature of caring for others.

Recently, the Columbia Accident Investigation Board published its findings on the last space shuttle disaster. On February 1, 2003 the Columbia space shuttle broke apart as it re-entered the earth's atmosphere. All seven astronauts lost their lives.

The physical cause of the accident was a breach in the Thermal Protection System on the leading edge of the left wing. This breach was caused by a piece of insulating foam that broke away from the external tank just 81.7 seconds after launch. What the Accident Board also reported was that ". . . the management practices overseeing the space shuttle programme were as much a cause of the accident as the foam that struck the left wing." Although NASA is a public body (but with increasingly private sector participation) we should all be asking if we can learn any lessons from what happened. Here are some insights I took from the report.

Clearly (re)define your mission based on current realities and aspirations

During the Cold War, NASA's mission was clear - beat the Russians to the moon. That mission mobilised and focused the NASA team and they produced truly remarkable results. After the Cold War was over, the political agenda that fueled NASA's mission was gone, and no other pressing political agenda took its place. Its mission was never redefined, and as a consequence it was continually subject to very restrictive budget constraints while also being pushed and pulled between different priorities. Without a clear and focused mission, the agency found itself trying to do too much with too little. Make sure your mission is clear and your resources are consistent with what you are trying to do. And if you don't know what you're trying to do, start making demands on those who should.

Mischaracterisation of your 'product' can cause real damage

Is the shuttle a developmental vehicle or an operational vehicle? Is it a continuous experiment or a work horse? As part of an effort to gain more cost efficiencies, the idea of privatising the shuttle programme was studied. An advisory committee recommended this step in what came to be known as the Kraft Report. In that report, it was argued that the shuttle was a mature and reliable system "about as safe as today's technology will provide." Consequently, the shuttle came to be perceived as an operational rather than developmental vehicle. As a result, NASA believed it could turn increased responsibilities for operations over to a single prime contractor and reduce its direct involvement in ensuring safe operations. It also believed it could use the shuttle to carry out regular operational missions without a constant engineering focus on trying to understand the mission-by-mission problems (including foam problems) that occurred. Much closer engineering scrutiny would have been made if the shuttle had been properly categorised as a developmental vehicle. So, don't fool yourself into thinking you're ready when you're not. Lives may not depend on your product or service, but your brand reputation might.

Keep your eyes on the heavens, but your feet on the ground

Given its remarkable past achievements, NASA's culture had evolved into one with a fiercely can-do, 'failure is not an option', attitude. While this had many positive attributes, it also caused problems. NASA people found it difficult to admit that something 'can't' be done or 'shouldn't be done, or that acceptable margins have been cut too much, or that resources were being stretched too far. Nobody would want to stand up and say, "We can't meet that schedule." Combined with downsizing and budget cuts, this culture created huge strains. One experienced observer of the space programme described the shuttle workforce as "The Few, the Tired." Past successes had created a powerful image of NASA as the "perfect place." It was difficult for NASA employees to recognise that it was not perfect, and as a consequence the agency lost its ability to accept criticism. This led to "flawed decision making, self deception, introversion, and diminished curiosity about the world outside the perfect place." Beware of a cultural resistance to objective criticism. Make sure minority opinions are heard and respected.

Stay alert to the changing experience levels and competencies of your staff

A decade of downsizing and budget tightening had left NASA with a less experienced staff (as well as older equipment). Here is an actual and very surprising quote, from the Accident Board's report: "NASA has recently recognised that providing an adequately sized and appropriately trained workforce is critical to the agency's future success" (my italics). Need I say more?

Uncertainty is a fact of life, but don't make it worse than it has to be

One of the problems over the past decade has been prolonged confusion about the shuttle's future - was the shuttle programme to be retired or were there going to be two or more decades of use? The uncertainty resulted in limited and inconsistent investments rather than adequate and clearly aligned ones. The NASA workforce was confused by mixed messages. I once knew a manager who had read in an article stating that we lived in times of great uncertainty. From that day, her management philosophy seemed to be, "Uncertainty is a fact of life, so I'm going to stop trying to allocate priorities or give direction, and just act randomly. Because that's the way things are!" Make sure that your managers don't abdicate their responsibilities for managing even when the future is uncertain. It's in such times that leader-managers are needed most.

Don't let past experience fool you - do the analysis

Programme managers and the Mission Management Team had become used to foam losses from the external tank, and - perhaps because of scheduling and cost pressures - did not believe, or want to believe, that foam striking the vehicle was a critical threat. When Columbia was struck, conclusions about the damage were based largely on judgment and prior experience rather than analysis. No one in management questioned the view that foam loss was an 'acceptable risk' rather a safety-of-flight issue. Among managers a pattern of acceptance to foam problems dominated the conventional wisdom - even though there was no real engineering justification for this view. Previous success was used as a justification for accepting increased risk. When someone says, "It didn't cause a major problem last time," watch out.

Get your internal cultures and organisational levels listening and talking to one another

The accident report clearly shows that there was a 'cultural fence' between mission managers and working engineers. Managers tended to only accept opinions that were in agreement with their own. After the accident, programme managers said that if the engineers had safety concerns, they were obligated to communicate those to management. Engineers had many concerns, but they never reached the Mission Management Team. In relation to a request for imagery of the shuttle's damage, the report states, "Management seemed more concerned about the staff following proper channels . . . than they were about the analysis." Layered and bureaucratic regulations stifled information flow. Management's failure to recognise the danger to the shuttle meant that the question of mounting a rescue mission - which was feasible - was never raised. There were at least eight missed opportunities for recognizing the real damage to the shuttle and taking appropriate action. Make sure your communication channels are open up, down, and across the organisation.

Change can be good, but continuous turmoil can be deadly

The shuttle programme operated in a turbulent environment involving budget cuts and downsizing. NASA employees felt 'under the gun', and this situation wasn't helped by new demands involving Space Station assembly missions. The partnership created problems that impacted both programmes. One employee described his work manifest as "changing, changing, changing" all the time. As in any system, you can never do just one thing; one small change ripples throughout the system. One space station worker in describing the situation said ". . . we had a train wreck coming." You don't want to be working on the edge of chaos all of the time. Make sure change is balanced with stability. Healthy systems need both.

Make sure your organisational structure and management practices don't inadvertently work against the achievement of your mission

One of the aerospace executives at NASA was a strong believer in the management principles advocated by Edward Deming. The executive attempted to apply some of these principles to NASA including that of ensuring that the corporate HQ did not exert bureaucratic control over a complex organisation. HQ should set strategic directions and provide the operating units with the authority and resources needed to do the job. Those carrying out the work in the various centres should have primary responsibility for quality. What happened was a return to the flawed management structure that existed before the previous Challenger accident - management isolation; lack of integration and failure to develop into a learning organisation; project managers in the centres feeling more accountable to centre management than to the programme management; and consequent failures in communication and decision making. The challenge is to thoughtfully consider the roles of both centralisation and decentralisation. Let the mission determine appropriate management structures and practices. Some management principles are effective in some contexts, but not others. We also must not allow slogans like "Faster, better, cheaper" - introduced into NASA by the same executive - to substitute for calm reasoning. Slogans cripple the thought process.

Transferring insights from one context to another should always be done cautiously. If there is one overriding lesson we can all learn from the Columbia disaster it is to be very, very alert to cultural resistance in our organisations. There were many 'echoes' between the Columbia tragedy in 2003 and that of the Challenger shuttle explosion 17 years earlier. Despite changes made, resignations, retirements, and laying-off of personnel after Challenger, damaging features of the old culture persisted. We must recognise that change must be addressed at two levels - the surface changes of behaviours, structures, processes, systems, etc., and the deeper level of mental models, assumptions, and mindsets. If we don't go deeper, change is often an illusion.

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