Case Study: The Cultural Tale of Two Shuttles

The first space shuttle flight occurred on February 18, 1977, with the launch of Enterprise. It was a proud day for NASA and the beginning of a new age in space exploration. Less than nine years later, on January 28, 1986, the nation was stunned when the space shuttle Challenger disintegrated seventy-three seconds after launch. All seven crew members perished. The technical explanation for this disaster was the "O-ring" problem-a crucial shuttle component was compromised by the cold weather on that launch day. Subsequently, it became clear that there were voices speaking against the launch because of worries about the O-ring problem. However, there were pressures to launch and a belief in the infallibility of the decision-making process. Thus, the voices speaking against launch were silenced.

During the late 1980s and 1990s, there were a plethora of studies considering the Challenger disaster, and many pointed to the organizational culture at NASA as a crucial contributing factor leading to the launch decision (McCurdy, 1992). For example, in 1990, the U.S. government issued the "Augustine Report" on the future of the U.S. space program (U.S. Advisory Committee, 1990). This report was built largely on the premise that organizational culture directly contributes to organizational performance. The report notes that "[t]he most fundamental ingredient of a successful space program ... is the culture or work environment in which it is conducted" (U.S. Advisory Committee, p. 16). This committee also worked from the assumption that the culture at an organization like NASA needs to be fundamentally different from that at many organizations. NASA works with the most complex of technologies, and the stakes are incredibly high. As McCurdy notes, "[e]rrors that might be forgotten in other government programs can produce in NASA a myopic space telescope or an exploding space shuttle" (McCurdy, 1992, p. 190). Given these assumptions, the report pointed to many specific aspects of organizational culture at NASA and made recommendations regarding cultural beliefs and assumptions that should characterize a successful space program. These include the beliefs that:

• The success of a mission should take precedence over cost and deadlines. Mission success is more important than the role of any individual or group.
• Space flight requires open communication in which individuals are encouraged to report on problems or anomalies. Issues need to be "put on the table" for consideration.
• The space program cannot succeed in an environment where "avoiding failure" is seen as an important goal. Instead, the risky nature of the operation must be acknowledged.
• The space program should not get "spread too thin" by working simultaneously on different projects, such as flight, research and development, and design. "Either operations dominates to the detriment of research and development, or employees working on new projects neglect operations" (McCurdy, 1992, p. 190).

NASA seemed to be following these "cultural guidelines" in the 1990s. The first "post-Challenger" mission occurred on September 29, 1988, with the launch of Discovery. The one hundredth shuttle mission occurred on October 11, 2000. However, as we all know, there was yet another tale of shuttle disaster to be written. On February 1, 2003, the space shuttle Columbia disintegrated during re-entry. Pieces of the shuttle fell over eastern Texas, and all seven crew members died. The sense of déjà vu was mournful and unavoidable. And the reports dissecting this disaster came quickly.

Of course, a different technical problem led to the Columbia disaster. In this case, a piece of foam fell off during launch and ripped a hole in the left wing. During re-entry, this allowed superheated gases to enter the wing interior, and the wing frame melted. But were the underlying cultural traits that led to the Columbia disaster similar to the ones that doomed Challenger? Sadly, the Columbia Accident Investigation Board concluded that the cultural themes of the two tales were much the same. Indeed, "[t]he board's final report said that NASA had done little to improve shuttle safety since it lost the shuttle Challenger in 1986" ("Concerns Raised That Changes in NASA Won't Last," 2003). This report listed specific cultural traits that contributed to the Columbia disaster, including:

• Reliance on past success as a substitute for sound engineering practices
• Organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion
• The evolution of an informal chain of command of decision making that operated outside the organization's rules

So, had NASA learned at all from the Challenger disaster? Had the organization learned and just fallen back into old bad cultural habits? The chairman of the investigation board, Harold Gehman Jr., thought that this was possible. He noted, "Over a period of a year or two, the natural tendency of all bureaucracy, not just NASA, to migrate away from that diligent attitude is a great concern to the board because the history of NASA indicates that they have done it before" ("Concerns Raised," 2003).

Perhaps the most poignant comment during this time period came from Jonathan Clark, a NASA flight surgeon whose wife, Laurel Clark, died in the Columbia disaster: "I wasn't here during the Challenger disaster but I certainly talked to a lot of people who were. And, yes, there were similarities, as Diane Vaughn pointed out earlier in her book [The Challenger Launch Decision, 1996]. You could almost erase the O-Ring problem and put in the tile shedding and put 'Columbia' instead of 'Challenger'" ("Columbia Spouse: Report a Prescription for Change," 2003).

Fourteen brave Americans lost. The separate tales of two destroyed space shuttles linked by one organizational culture. The first post-Columbia launch occurred on July 25, 2005, and the final shuttle launch is slated for around the time this book is published: February 2011. Let's hope that as NASA completes this important period of its history and moves forward that it heeds Jonathan Clark's advice: "I think we are really going to have to look very carefully at what lessons we didn't learn from Challenger and make sure we absolutely learn them this time" ("Columbia Spouse," 2003).

Case Analysis Questions

• What factors in NASA's culture contributed to the Challenger and Columbia shuttle disasters? Using Schein's "onion model" of culture, is it possible to identify specific cultural markers, performances, and values that were critical? Discuss your answers.
• Cultural change was obviously difficult at NASA. Can you think of specific things that could have been done to make cultural changes more lasting or more effective? Discuss your answers.
• How could Karl Weick's model of organizing be brought to bear on these disasters? Can you identify patterns of sensemaking that actors used in coping with equivocality? Did these sensemaking patterns contribute to what happened at NASA? Discuss your answers.