11 years since the disaster: The Columbia disaster could almost certainly have been prevented if NASA had investigated 'near-disaster' events

A study by researchers at NASA and abroad, published this week in a management journal, provides insights into the need to document events in which luck played a role in order to prevent them, and in particular, the managers must emphasize the importance of the issue among their employees

Peter Madsen, a professor of business administration at Beringham-Young University has been researching the safety atmosphere at NASA since the disaster of the Columbia shuttle crash when it entered the atmosphere on February 1, 2003. As you may remember, Col. Ilan Ramon, the first Israeli astronaut, was also killed in the crash.

Specifically, Madsen investigates how it is possible to identify 'near-accident' events, events in which failures were narrowly avoided and apparently the mission was successful. A new study of NASA's safety climate in collaboration with Prof. Madsen reveals that recognition of these 'near misses' increases when the significance of the project is emphasized, and when organizational leaders prioritize safety over other goals (such as efficiency).

In other words, if you want to prevent disasters, your employees need to feel that their work has greater meaning, and they need to know that safety is an important value for their managers. "This feeling challenges people to see something that had no visible negative consequence in a near-disaster situation," Madsen said. "It's part of human nature: we mainly tend to consider what happened instead of what could have happened. But this perception can be changed through effective leadership."
Using a database of in-flight anomalies over two decades (1989-2010) in unmanned NASA missions, the researchers discovered that when NASA leadership emphasized the importance of projects and in particular the importance of safety, the organization recognized and investigated near-disaster events, instead of dismissing the missions as successful.

The findings, which appear in the Journal of Management, can be applied by company leaders in several industries where safety is of utmost importance, including transportation, power generation, rescue and health.

"If you are in an industry where safety is important and you really want your employees to take it to heart, it is not enough to talk loudly, but also to back up the statement with actions." He said, "Employees are very good at receiving the signals that the managers send to them regarding the order of priorities."
The same was true at NASA over the years, Madsen found that when leaders created a climate of safety and emphasized the importance of project investigation of near misses, employees cataloged the events and could be used to improve mission operations. Unfortunately, Columbia took off at a time when the reported rate of near misses Malfunctions at NASA was one of the lowest
The investigation into the crash revealed that the failure that caused the disaster (the spectacular foam fall) happened in at least seven previous launches. In each of them, luck intervened, and the near misses turned into successes.
The Commission of Inquiry into the Columbia disaster found that NASA's poor safety climate was the main cause of its people's inability to recognize the falling of the foam as a near-disaster, and that in the collision between the goals of cost, schedule, and safety, safety lost.

"A lot of safety improvements happened after a disaster and they shed light on the deficiencies in the system," Madsen said. "If you can pick up on these deficiencies before something happens, that's the gold standard."
Madsen's ties to NASA go back to the time of Columbia's loss, when he was in graduate school at the University of California, Berkeley. His research advisor was a well-known expert in safety organizations, which led to Madsen and other doctoral students being assigned to work with NASA to research safety procedures.

He has continued his ties to NASA since Edward Rogers, Chief Knowledge Officer at NASA's Goddard Space Flight Center, is a co-author of this study. Robin Dillon of Georgetown University's School of Business Administration.

"Many safety improvements occurred after the disaster and they shed light on the deficiencies in the system," Madsen said. "If these deficiencies could be overcome before something happens, it should be the gold standard."

Madsen's ties to NASA date back to the days after the disaster, when he was doing his PhD at Berkeley. His supervisor was a well-known safety consultant, which led Madsen and another PhD student to work with NASA to investigate safety procedures. He continued his contacts with NASA and Edward Rogers, the Chief Science Officer at NASA's Goddard Space Flight Center, also participated in the research. The third partner was Robin Dillon from the Georgetown University School of Business.

Ham wrote together with Yaffe Shir-Raz the book "The Crash" which documented the Columbia disaster and the conclusions that were formed even then.

Chapter: Was NASA's corporate culture at fault for the shuttle Columbia? (from "The Crash")

The good ones for the pilot - a chapter about the late Ilan Ramon from the book The Crash