nasa learns to avoid its worst

NASA learns to avoid its worst practices in safety

The New York Times today includes an article on how the NASA culture

has changed since the Columbia disaster of 2003. By dissecting how the

agency has approached the tile-damage problem with the Endeavor

shuttle, reporter Kenneth Chang shows how thoroughly studying and

understanding what went wrong with Columbia has led to better

practices and, more profoundly, an improved "safety culture." An

excerpt:

For both the Columbia and the Endeavour, the falling foam did not

initially worry mission managers. The day after the Endeavour's

liftoff, John Shannon, chairman of the mission management team,

said that three small pieces of foam might have hit, but "nothing

significant."

What changed in the last four years is how NASA managers handle an

event they do not consider serious. Michael D. Griffin, the NASA

administrator, said he and managers listened to all of the data

before making decisions.

In order to get at that data, mission engineers took many steps to

examine the damage, including having the shuttle perform a back flip

to get a good photograph of the damaged area. Maybe most importantly,

the NASA culture had begun to change since Columbia, with one shift

being that "senior managers began to make sure that dissenting voices

could be heard." Writes Chang in the Times article:

John Allmen, program manager for shuttle support at the NASA Ames

Research Center, said the pre-Columbia culture of NASA was

sometimes intimidating for an engineer to bring up a concern. "The

general culture was that, `What are you talking about? Prove to me

it will fail,' " he said.

Arrogance and confidence in one's own abilities must take a back seat

to humility and openness to the opinions of others, especially when

people's lives are on the line. It's probably not unexpected that

NASA, the product of the "Right Stuff" test pilot and Mercury program

culture, would be late to the game when it comes to carefully

examining its own mistakes and addressing the root causes. But at

least they appear to have made that change now.

UPDATE 21 August 2007: The shuttle lands safely.

learning worst practice New York Times