Culture Change at NASA

According to the creation myth, in the beginning, NASA was full of young, cocky, innovative, hard charging folks who got us to the Gene Kranz's School for Young Gentlemen circa 1967moon inside a decade.  They were brash, confident, and did not suffer fools gladly.  If they were worried, they didn’t show it.  Stories abound of 100+ hour work weeks end to end, almost impossible to believe.  Their theme -as posted on the factory walls – was ‘waste anything but time’.  Going to the moon was the cliché for doing the impossible and they were going to be the ones to do it.  They were the epitome of risk-taking, innovative, creative, flexible, nimble, achievers.

 

 

 

 

 

 

 

On the way to the moon, the Apollo 1 fire happened.  It was a tragedy.  It was beyond awful.  With 20-20 hindsight, the root cause of the fire was obviously sheer stupidity.  There were investigations and panels and recommendations.  As in every accident investigation, the investigation board found that communications between people and organizations were faulty.  Management culture was poor.  And the safety organization was strangely silent on dangerous situations which they had been warned about.  So the recommendations, in additional to technical things, included improving communications, changing management culture, and reinvigorating the safety organization.  And even though everybody at NASA believed the fire was a one-time thing, NASA tried to improve.  Some bureaucratic checks took a little of the nimbleness out of the system in the name of safety, but mostly NASA got a pass because we had to beat the Russians.  The Eagle landed, the mission was accomplished, and time passed.

One the way to exploiting the space frontier with our new space shuttle, 19 years and one day after the Apollo 1 fire, the Challenger and her crew were lost during launch.  It was a tragedy.  It was beyond awful.  With 20-20 hindsight, the root cause of the accident was obviously sheer stupidity.  There were investigations and panels and recommendations.  As in every accident investigation, the investigation board found that communications between people and organizations were faulty.  Management culture was poor.  And the safety organization was strangely silent on dangerous situations which they had been warned about.  So the recommendations, in addition to technical things, included improving communications, changing management culture, and reinvigorating the safety organization.  And even though everybody believed that the accident was a one-time thing, NASA tried to improve.  More methods to communicate were added, more bureaucratic checks were added, the system slowed down and became more costly in the name of safety, but mostly NASA got a pass because we still had to beat the Russians, this time to build a permanent space station, and they were ahead of us.  The Hubble was launched, the assembly of the Space Station started, and time passed.

17 years and three days after the loss of Challenger, Columbia disintegrated during reentry and her crew was lost.  With 20-20 hindsight, the root cause of the accident was obviously sheer stupidity.  There were investigations and panels and recommendations.  As in every accident investigation, the investigation board found that communications between people and organizations were faulty.  Management culture was poor.  And the safety organization was strangely silent on dangerous situations which they had been warned about.  So the recommendations, in addition to technical things, included improving communications, changing management culture, and reinvigorating the safety organization. 

This time, nobody inside or outside of NASA believed that the Columbia accident was a one-time thing.  So we tried to change the very root culture at NASA.  Strangely, I found myself at the epicenter of the culture change; one of the least likely managers ever to participate in touchy-feely human relations changes.  We got trained by professional councilors on how to play nice and communicate affirmingly. At the end of seven years, some change is evident.  Safety is reinvigorated; the management culture has bent toward more safety; and  communications, well, need more work and probably always will.  Dissenters must be heard and understood, and mostly placated; much more bureaucracy has been added in the name of safety, and everybody now has a “stop work” card to play if they have a concern.  NASA did not get a pass, the Russians are no longer our competition but our partners, and the debate intensifies as to whether America should send humans into space.  Meanwhile, the Space Station has nearly been completed, the shuttle is about to be retired, its mission accomplished, and time has passed.

Now conventional wisdom says NASA is risk averse.  Afraid of failure, afraid to take risks, requiring draconian and expensive safety insight for even mundane tasks.  They say that NASA depends too much on extensive testing and expensive analysis to prove that every operation is as safe as humanly possible before undertaking it.  That is the conventional wisdom proffered by the media, the pundits, and those who want to be in the space business. To be successful in space, we hear, risks must be taken, fear must not inhibit innovation.  The possibility of failure must be deeply discounted and the consequences of failure should not be contemplated very hard lest we waiver from our goals.  We need organizations that are nimble, flexible, innovative, and risk taking to be successful in space. 

In short, NASA should turn to private enterprise for a ride to space.

So how can a staid, grey, old, inflexible bureaucracy approve flying its people on somebody else’s rocket?  Experience has been a hard teacher; everybody at NASA has been instilled with a great personal responsibility for safety; the knowledge that if the widget that they are responsible to monitor causes failure it will be their own personal fault.  Do you untrain the culture of the last seven, no –  forty, years as drilled into every NASA engineer and manager?  Probably not.  But if American astronauts are to ride to the international space station on a rocketship that NASA did not build, there will have to be a tectonic shift in NASA culture.  Regardless of who builds the ship or operates it or what shape it takes, one thing is certain; NASA’s role will have be different.  That will take a tremendous amount of energy, and time must pass.

In the middle of the last culture change I sent the following paragraph to the shuttle troops.  I still stand by it and it rings strangely true for the future, too.

Life is full of gray choices.  Deciding the work completed is good enough because more will not make it perfect.  Ten thousand gray choices; doing what we must do, and not a bit more because that would take away from other work that is absolutely critical to be done right.  When we have done what we can do, when we have driven the risk to the lowest practical level where it can be driven, then we have to accept the fact that it is time to make a decision and move on.  Because history is waiting for us.  But history will not wait forever, and it will judge us mercilessly if we fail to face tough choices and move ahead.