Discussion: Culture Peers Review 2

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provide your response to the following:

One area that Systems Safety really doesn’t delve into much is that of corporate culture. The Management Oversight Risk Tree Analysis (MORT) can be used to discuss some of the areas where management may have failed but nothing really covers the culture of the company or organization. As we saw in the Challenger crash, the culture of pushing the launch even though multiple engineers said they should delay was a huge factor in why the explosion happened. In the end of the video on the Columbia crash (starting at 43:40 in the video), they discuss the culture at NASA and the fact that they knew a piece of foam had hit the wing and shattered on takeoff but didn’t give it a second thought. The reason for that is because if a long investigation came from it, the next launch might be delayed. NASA was being pushed by Congress to finish the space station and they did not want a delay.

So, for this week’s discussion there are two questions:

1. How did the culture at NASA contribute to both of these crashes?
2. Had the culture at NASA changed in the 17 years since the crash of the Challenger or was it just business as usual and they had just been “lucky”?

 

Classmate post that you need to post comment/ review on:

Both the Challenger and Columbia tragic accidents can be technically explained by its physical causes. The Columbia, by a breach in the Thermal Protection System on the leading edge of the left wing which started by insulating foam of the external tank which hit the wing 82 seconds after start. The Challenger, by the failure of the O-rings seals in the solid rocket boosters to contain the high pressure and hot gases.

However, this would be an oversimplification of what it was a more of a causal chain rather than a specific technical malfunction or human error.

NASA had a solid safety culture which started eroding after the end of the Cold War. NASA was a critical tool as a political objective in the US-Soviet competition to lead the space race. Once the Cold War was over, NASA was not a priority any longer, it had to justify its existence and cost, and was under pressure to operate under budgets and to become efficient enterprise. NASA was trying to do too much with too little (Columbia Accident Investigation, August 2003).  Cost reductions became inevitable, the budget was decreased by 40%. NASA’s budget, (in constant 2002 dollars) was reduced from 24,696 million in 165, to 11,643 in 1985.

During the launch of the Challenger, numerous engineers advised against the launch given the cold temperatures. Management under pressure to launch, requested “proof of an unsafe situation” to abort the launch, rather than “proof of a safe situation” to launch.

NASA’s managers got used to accept flaws as part of the norm and tended to ignore potential problems. Management was also discouraging dissenting views on safety issues and adopted a policy of seeing near-misses as successes rather than near failures. A strong cultural bias and overly optimistic rather than realistic safety thinking led to flawed decision making.

Although there were management changes and reforms after the Challenger’s accident, the culture remained unchanged, and it took another accident for NASA to revert to a culture of safety