I read all the warnings before you. It's crazy," congressman Anthony Weiner raged at NASA chief Sean O'Keefe at a congressional hearing after the disaster . From the book The Crash by Avi Blizovsky and Yefa Shir-Raz
"I read all the warnings before you. It's crazy," Congressman Anthony Weiner raged at NASA chief Sean O'Keefe at a congressional hearing after the disaster. Wiener read the emails and warning documents written by NASA's safety engineers and was amazed. He demanded to know why the serious concerns had not reached O'Keefe while the shuttle Columbia was still in space.
"Does every argument in the agency have to come to my desk?" O'Keeffe defended himself.
"I can't think of anything more important on your agenda than the functioning of the shuttle," Viner snapped.
Beyond the specific technical problems that caused the Columbia disaster, from the many documents collected after the crash, as well as from the interviews we held with NASA personnel, it appears that NASA's organizational culture played a crucial part in the disaster.
It turns out that somewhere, on the way to becoming one of the most prestigious bodies in the world, NASA also suffered from fossilization, routine and mental stagnation, which are the sick evils of bureaucracy. All the emails, memoranda and documents that were exchanged after the Columbia launch between the safety engineers and the supervisors, and that warned of a disaster that could occur if the shuttle was not photographed by satellites to assess the damage caused, remained in the middle ranks of NASA. They never reached top management. The communication possibilities of the engineers who requested the photos to the decision makers at the top of the agency were blocked.
"They had good reasons for asking for the photos," said Sally Reid, a former astronaut and member of the congressional investigation team. "The question is why they did not request this from the program managers and the heads of NASA."
But the bureaucratic thinking didn't start after the Columbia launch. Years before, many experts, inside and outside of NASA, had already warned that a disaster like that of the Challenger could happen again if NASA continued to adopt the same policy. Diane Hardison, a former NASA engineer who worked for 17 years at the Kennedy Space Center and was fired two years ago, according to her, after warning of such a disaster, says in an exclusive interview that she gave us, that the organizational culture at NASA is the decisive factor behind the disaster. "I told them that the engineers and technicians were working too much," she accuses. "I told them that the seniors were playing games and spending their time planning how to give each other a raise, leaving the people in the field to struggle day after day with outdated, overpriced and inappropriate equipment, and I promised that the result would be a second Challenger."
Hardison, who was a member of the shuttle project's recovery team after the Challenger disaster, agreed to come forward because, she said, it was important to her that the world know the true cause of the disaster. "After the disaster in 86, the supervision of quality control was indeed tightened and most of the things that required correction were corrected," she said. "But little by little the supervision began to loosen again. In 88′-89′, a year or two after the shuttles started flying, there were 16 quality control inspectors at the Kennedy Space Center. Four or five years later, their number was reduced to a quarter. When old workers retired, they did not hire new workers, and those who were hired were not skilled enough."
According to Radisson, since the disaster, NASA has been trying to advance the theory that it was the falling of the insulation tiles that caused the disaster, and not by accident. Because while there was nothing to be done against the falling of the tiles, the technical failures that caused the disaster could have been prevented if NASA had taken sufficient supervision and control measures.
Hardison wasn't the only one trying to fight the system. Other experts also warned against the fixation of the concept under which the space agency has operated until today, according to which in order to return the astronauts home safe and sound, it is necessary to return the spacecraft itself safely. Some of them tried, unsuccessfully, to promote the idea of installing an escape system in the ferry. For example, Don Nelson, the same retired engineer whose warning letter he wrote to President Bush months before the disaster was published in the press after the crash, corresponded for several years with NASA on the subject, begging the agency to consider installing ejection seats on the shuttles. In the kind reply letter he received from NASA, the bottom line is: "The cost-benefit considerations have been made, and the matter is not profitable."
4 תגובות
It is true that it is easiest to be wise in hindsight.
But in the result test they failed
NASA's failure is far from unique to them
I would risk saying that it exists in every organization, especially in those that have dynamic elements of development.
In most organizations this ends in a financial loss, but in an organization like NASA the core of its activity
It is at the limits of the life-safety envelope with insane complexity
Any little thing can lead to immediate loss of life.
A good organization needs the ability to collect the relevant alerts from the multitude of alerts running through the system.
In many organizations there is an administrative disconnect to the point of a built-in disdain for the people in the field,
And in the case of NASA, the field personnel are the best engineers there are,
It means that that person has a very defined area where he is expected to stay
And any attempt by him to "enlarge his head" will be perceived by the management as a form of abnormality, even a threat.
This problem is even stronger in organizations whose core is linked to creating,
That's where the elements of marketing and finance and public relations and manpower are connected to management by an umbilical cord
And the technological system is seen as a kind of necessary excess fern somewhere down in the halls of production,
In addition, when there is a failure, their low position in the organizational hierarchy is who decides in the end
Who is responsible for the failure of this organization, the administrative system, certainly not the field, so that's the problem
which actually crosses an organization which in many cases stems from a lack of resources or
A broken organizational culture is thrown down on the people in the field because in the solution of a problem in an organizational system
Everyone has to take responsibility not only authority, but the management people have the strongest element
of escaping responsibility for failures because it projects from their point of view on their progress which is dynamic
Futuristic Today they are here tomorrow they are there, in front of the field people who are more static professionals,
In many cases, the knowledge found in the field personnel is directly related to managerial decisions about the future of the organization
But he fails to float to the top because in the organizational culture the decisions are made
At the level of assumptions from the management down without any dialogue, it's a kind of monologue, not a dialogue.
All closures are at the management level even though the subject is completely outside the management's area of expertise
There is not even an attempt to sit down with the people in the field, some of whom are experts at an international level
To get information for a decision that is based on data and the effects of the decision at the organizational level
The management considers it a nuisance that interferes with decision-making, perhaps a loss of dignity,
Then the data channel that should transmit information from the ground up and allow the decision makers
To make correct decisions based on real data is degenerate,
And maybe the decision-making in advance should have been more related to teamwork and not one person at the top.
More than that, the people in the field don't even feel that their area of responsibility is important
raise an alert because the times they did it they got a cold shower
The so-called sit on the sidelines and don't interfere or exceed your authority,
Because in most cases everything works properly even if an alert pops up so it confirms
The feeling of the administrative echelon raised by the alert is a systematic harassment that goes beyond its authority
And this is the transmission that the agent in the field receives and in the end assimilates it,
In addition, a good organizational system needs a culture of transparency where the ability of each part
In the organization to put on the record various problems and mistakes also of the one who raised the alert,
It is enough that once there was improper use of the data as an indictment against the one who raised the alarm
And you will never get it
A comprehensive and in-depth analysis of these organizations will give you a well-reasoned political manifesto,
And this cold shower will radiate not only on that factor but on the entire organization,
Thus the entire organizational system is anesthetized and degenerates,
that in its daily activity there are a host of failures that do not lead to a bad result
But every now and then a combination of several factors is created and the same failure leads to severe results.
It is easiest to be wise in hindsight.
In an organization like NASA, at any given moment there are many who warn, and there are many who are disgruntled, and the fact that after one time something happens everyone raises their voice to say "we told you so", there is nothing in it.