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Showing posts with label NASA. Show all posts
Showing posts with label NASA. Show all posts

Thursday, January 31, 2013

Lessons from the Columbia Accident

Posted on 4:24 PM by Unknown
10 years ago tomorrow (February 1st, 2003), the Columbia shuttle accident occurred.  After the tragedy occurred, my colleagues and I embarked upon a lengthy research project culminating in the creation of an award-winning multi-media case study, a book chapter, a Harvard Business Review article, and other materials.  What lessons did we derive from this tragedy?

1.   NASA had a culture in which many people did not feel safe speaking up.  As a result, people downplayed their concerns about the foam strike, rather than sharing them openly.   Leaders did not do enough to cultivate dialogue and dissent.  They tended to be very passive, assuming that bad news would surface on its own.  It rarely does.  Leaders need to draw out the bad news, as it does not usually rise to the top.  

2.  Framing the shuttle program, from the very beginning in the 1970s, as a routine, operational endeavor turned out to have long-lasting detrimental effects.   The shuttle program should have been framed as an experimental initiative.  Promising dozens of flights per year, naming the vehicle a "shuttle" and describing space travel as "routinized" pushed the organization away from its roots during Mercury and Apollo as a laboratory of exploration.   The adoption of the production/routine mindset contributed to an obsession with schedules and deadlines, the creation of rigid organizational processes and protocols, and an insufficient emphasis on the imperfect state of knowledge in the organization. In short, it meant that the organization did not have a sufficient learning orientation. 

3.  Managers at NASA exhibited what Rebecca Wohlstetter has described as a "stubborn attachment to existing beliefs."  They had become convinced that foam strikes could not damage the shuttle.   The confirmation bias exacerbated the problem.   They tended to look for data that confirmed this pre-existing belief, and they discounted signs that contradicted the conventional wisdom about foam. 
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Posted in Columbia, leadership, NASA | No comments

Tuesday, January 29, 2013

Lessons from the Challenger Accident

Posted on 5:41 PM by Unknown
Yesterday marked the 27th anniversary of the Challenger space shuttle accident.  Still today many leadership programs and business schools study this awful tragedy.   We analyze it because it offers profound lessons about leadership, risk management, and decision-making.  

Let me offer three points that we should take away from this tragedy as we reflect on it today:

1.  Normalization of deviance.    Diane Vaughan wrote the seminal book on the Challenger accident in 1996.  In that book, she explained how organizations gradually come to accept more and more risk.   She described this normalization process whereby the unexpected gradually becomes the expected and then becomes the accepted.   All organizations should be wary of moving down that slippery slope.

2.   Advocacy vs. Inquiry.    Many people initially described the eve-of-the-launch teleconference as an example of groupthink.   I don't think that's correct.   Engineers from Morton Thiokol clearly were arguing against the launch.  The meeting did not lack dissent and disagreement.   The real problem was that both sides (for and against launch) were operating purely in advocacy mode.  Each side was pushing its position.  Neither side did much to truly learn from the other.   The entire group did not move into collective inquiry mode, seeking to understand the problem of O-ring erosion more deeply or the reasons for each side believing what it did.   Instead, they argued their positions with regard to the next morning's launch and became more and more entrenched and polarized.   Effective teams balance advocacy with inquiry, so as to have a more constructive dialogue and debate.

3.  Learning from our failures.   During the Columbia shuttle accident investigation, astronaut Sally Ride said, ""I think I'm hearing an echo here."  She meant that NASA had repeated many of the failures of the past.  While they had fixed the technical errors after Challenger (no more o-ring erosion), NASA executives had not fixed the leadership and cultural problems that contributed to the tragedy.  Those problems continued and contributed to the Columbia disaster many years later.  Successful organizations take a hard look at their failures, and they examine the broad range of causes for those failures...not just the technical issues.   
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Posted in Challenger, learning, NASA | No comments
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