The Columbia Accident Investigation Board recently concluded that a cluster of attitudes and behaviors rooted in NASA's history - the organization's culture - is as much to blame for the second shuttle disaster as the suitcase-size piece of foam insulation that struck Columbia's wing.

NASA's managers are chided for thinking they are too smart for outside advice.

For being too ambitious. For believing they are bulletproof to failure.

For pushing to get on with the mission and accepting more and more risk to stay on schedule. For accepting near misses as the norm.

For inbred groupthink that squelched dissenting opinion.

For a safety program that was skimmed over and silent when it should have spoken up.

"We were too gung-ho about the schedule," admits NASA administrator Sean O'Keefe.

What goes around. . .

There's nothing new about that attitude. NASA has been gung-ho since 1958, when it was hatched in an emergency meeting following the Soviet Union's surprise launch of Sputnik I. From day one, NASA's culture has been fueled by competition and anxiety.

Are NASA's values too ambitious? From the beginning, NASA managers were told that nothing less than the fate of the free world depended on their mission.

Is its attitude too arrogant? Brilliant NASA scientists, engineers and charismatic astronauts have been lauded in the press for decades. Walter Cronkite became an admiring astro-buff early on. Life magazine had an exclusive contract with the original seven Mercury astronauts.

Is NASA's behavior too accepting of risks? Early on, engineers and scientists had to close the technology gap, and fast. And risk-taking has always had its definite rewards. Daredevil astronauts treated to ticker tape parades. Engineers and scientists heralded as geniuses after saving Apollo 13. John Glenn elected to the U.S. Senate.

Mixed messages

Goals, deadlines and marching orders have changed over the decades, but the pressure on NASA's culture has remained constant. At a Congressional hearing in the summer of 2002, NASA officials were told by lawmakers (who control their funding) that "it is critical to be bold and innovative." You are the "intellectual pioneers" of the country. It is essential to remain "the jewel of the federal government."

But by the way, we can't tolerate your delays and cost over-runs.

And you are getting smaller and smaller, older and older, with no sign of rejuvenation, said one congresswoman. What are you going to do to avoid becoming a museum exhibit?

Think about it. What happens to safety in private industry when managers are scolded for delays, cost over-runs, and threatened with extinction - shuttering the plant or maybe moving it to Mexico?

What happens when the message is mixed? Be bold, but be safe. Do it faster, cheaper, better, and oh yes, safer. Be the best and brightest, but be open to others' advice. Honor your tradition, but don't be held hostage by it.

You see, NASA managers weren't the only ones sending mixed signals. They were on the receiving end, too. And for that reason, NASA alone can't patch up its broken safety culture.

More than memos & mirrors

Sure, numerous steps must be taken from within. Many options have been bantered about. Bring in new managers. Clean house. Eliminate communication barriers. Set new policies. Train and retrain on safety procedures.

Send out more safety memos, like the one NASA administrator O'Keefe dispatched in April 2002. Months before Columbia disintegrated over Texas, he told employees, "It is a good time to recommit ourselves" to "our core value of safety."

Look in the mirror, as O'Keefe says he will. Admit to blind spots and concede, "We are the cause," as O'Keefe has done. Set up independent safety boards. Hire quality assurance gurus.

But obviously, memos and mirrors won't permanently fix a cracked culture. Follow the money, the saying goes. The outside forces that give NASA's culture its cues, its goals, its budget, its rewards must be accountable, too. Congress and the White House must make decisions and commitments about NASA's future.

The same holds true in the private sector. Want to mend a broken safety culture? It's not just an assignment for line employees, supervisors and execs. Sure they have much to contribute. But you can't ignore the influence of shareholders, customers, competitors, regulators, board directors, activists, agitators, image-makers and other outsiders. They help shape the goals, deadlines and objectives that go into the making of cultural values and the shaping of employee perceptions and assumptions.

If a culture cracks, ask yourself, "Who held the hammer?"

- Dave Johnson, Editor