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Part 1 of 2. A serious misconception has developed in recent months in the public, media and NASA regarding the Columbia Accident Investigation Board’s criticisms of NASA’s management.
Worse, that such a mistaken assumption about the CAIB report’s conclusions could persist both inside and outside NASA as it attempts to return the space shuttle to flight bodes ill for future space projects.
The problem centers on the overused phrase “broken safety culture,” as if that statement summarizes accurately the CAIB’s negative assessment of the agency.
Increasingly, recent news articles have focused on NASA’s problems by using this phrase, thereby presenting an erroneous simplification of what the CAIB report actually said.
Though the board did criticize NASA’s safety culture, its critique was far more fundamental, describing in detail the long-term and widespread failures of NASA’s entire management – not just its safety management – resulting not only in an inability to face squarely the important technical problems that directly caused both the Columbia and Challenger accidents, but also a failure to build an effective shuttle replacement, as well as properly manage the entire U.S. manned-spaceflight program.
In investigating the Columbia accident, the CAIB report noted how NASA’s management was beset by arrogance, preventing managers from responding to safety warnings or problems with an open mind.
According to the CAIB report, NASA’s history – going back to the triumphant Apollo era of the 1960s – encouraged everyone to regard the agency as “the perfect place, alone in its ability to execute a program of human spaceflight.”
As the report noted, “the NASA human spaceflight culture manifested … in particular a self-confidence about NASA possessing a unique knowledge about how to safely launch people into space.”
In reality, the CAIB found NASA to be a place of “cumbersome organizational structure, chronic understaffing and poor management principles.” Management routinely “deferred to layered and cumbersome regulations rather than the fundamentals of safety.”
The board’s report also noted how “NASA’s Apollo-era research and development culture and its prized deference to the technical expertise of its working engineers was overridden in the space shuttle era by ‘bureaucratic accountability’ – an allegiance to hierarchy, procedure and following the chain of command.”
Even more disturbing, the report noted how NASA’s management often “operated outside (its own) rules, even as it held its engineers to a stifling protocol.”
This dichotomy between perception and reality led to “flawed decision making, self deception, introversion, and a diminished curiosity,” as well as an “inadequate concern over deviations from expected performance” by everyone at NASA.
Insulated within this fantasy can-do culture, NASA managers refused to deal honestly with problems or outside criticism.
To address this problem, the CAIB report emphasized that without a careful and significant restructuring of NASA’s management, it would be difficult if not impossible for the agency to proceed successfully into the future.
“The board strongly believes that if these persistent, systematic flaws are not resolved, the scene is set for another accident,” the report said.
Today, more than two years after the loss of Columbia and less than two months before the shuttle’s scheduled return to flight, the question still remains: Has NASA’s arrogant and unrealistic management culture actually changed?
Unfortunately, a brief look at the some of the agency’s important management decisions in the pasttwo years is not encouraging.
Consider Administrator Sean O’Keefe’s decision to cancel a shuttle mission to service the Hubble Space Telescope.
Actually made in December 2003 – 10 months after the Columbia accident and four months after the release of the CAIB report – his decision demonstrated once again the arrogance and insular nature of NASA’s top bureaucracy.
Though NASA officials publicly claimed to have completed a risk analysis of the mission before making the decision, interviews by NASA historian Steven Dick with O’Keefe and all of participants involved in the decision showed no analysis was ever done.
Then O’Keefe and the management at the Goddard Space Flight Center, spent a year advocating a difficult and ill-advised robot mission to Hubble, even though numerous outside experts – including a distinguished panel of the National Academy of Sciences – told the agency the chance of success was “remote.”
Consider also President George W. Bush’s ambitious initiative to return to the moon by 2015.
In helping Bush formulate his space-exploration plan, NASA’s management recommended retiring the shuttle fleet in 2010, but scheduled the first manned flight of the crew exploration vehicle – the shuttle’s replacement – in 2014.
This inexplicably created a four-year gap, during which the United States would have no way of transporting astronauts to the International Space Station.
Worse, NASA made this decision knowing it would be forbidden from paying for Russian Soyuz spacecraft under the terms of the Iran Nonproliferation Act.
NASA has taken no action in the past three years to deal with this situation, even though in 2006 the agreement with the Russians to provide lifeboat capability at the ISS ends, leaving NASA with no other option should it need to rescue Americans from the station.
Last, there is NASA’s current plan to replace the shuttle with the CEV. In an effort to manage construction as closely as possible, NASA would require the contractors that build the spacecraft to submit 129 different monthly, quarterly, annually, and continuously updated reports, covering everything from safety to how each contractor organizes its workforce.
What makes NASA’s approach disturbing is how much it resembles NASA’s past dependence on “bureaucratic accountability,” as noted by the CAIB report.
Rather than allow contractors the freedom to work and innovate, NASA has decided to burden them with endless paperwork under the assumption NASA must review their work in tedious written detail to determine whether the work is being done correctly.
These reports have almost nothing to do with increasing safety or good engineering. Instead, they seem to have everything to do with bureaucrats covering their behinds.
The reports will increase costs, slow development, stifle innovation and, if anything, distract designers from the tasks at hand – a factor that might contribute to a lack of safety.
In each of these cases, the resistance of NASA’s management, under O’Keefe’s leadership, to deal with these issues has been worrisome. It was just such previous behavior by management that the CAIB report criticized.
It must be noted not everything is bad at NASA. The agency has made some significant and positive changes. For example, O’Keefe reshaped the agency’s bureaucracy significantly.
Instead of having departments labeled Code M or Code Q and organized in a confusing manner, NASA now has four clearly defined departments, focused respectively on science, exploration, shuttle operations and aviation research, and all arranged under a sensible organizational structure.
Furthermore, the agency finally is beginning to take action to reduce or eliminate its many centers scattered across the country. Though these centers provide jobs in a variety of congressional districts, many have proven to be of limited utility to NASA in recent decades.
In analyzing the causes behind the Columbia accident, the CAIB report chose to take a holistic approach to NASA’s failings, trying to get to the heart of management shortfalls and thus recommend more sweeping organizational changes to correct the problems.
As the report explained, the board chose to focus on a broad “expanded cause model (describing) NASA as an organizational whole.”
Such an approach might provide an excellent academic exercise for understanding the difference between organizations that fail and those that succeed. Whether it will succeed in changing NASA, however, remains debatable.
Put simply, organizations are made up of people, and if the people do not change, it is almost impossible to change the organization.
Without an aggressive housecleaning of the mid-level andupper-level NASA staffers who – as the CAIB remarked – spent “as much time making sure hierarchical rules and processes were followed as they did trying to establish why anyone would want a picture of the orbiter,” nothing significant is ever going to change.
Unfortunate, but such a housecleaning at NASA has not yet occurred. Most of the people in charge today at all levels also were in charge prior to the Columbia accident.
Therefore, it should not be surprising to see from NASA the same complex rules, the same excessive reporting requirements, the same dependence on burdensome hierarchical organization and the same lack of simple common sense.
Perhaps the arrival of Michael Griffin as NASA’s newly nominated administrator, someone who has multiple degrees in aerospace engineering and science, will bring a more open and straightforward management style, focusing on the technical work of engineers, rather than the Powerpoint presentations of managers.
Next week: How politicians drive NASA’s culture
Robert Zimmerman is an independent space historian. His most recent book, “Leaving Earth: Space Stations, Rival Superpowers, and the Quest for Interplanetary Travel,” was awarded the Eugene M. Emme Award by the American Astronautical Society for the best popular space history in 2003.