Mending A Cracked Safety Culture
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MENDING A CRACKED SAFETY CULTURE
A Google search using keywords "NASA safety culture" conducted on Labor Day turned up 1,370 news stories. Never has the notion of safety culture received such attention. But as usual when it comes to job safety, the headlines follow a tragedy, and the stories are uniformly negative.
The Washington Post: "Experts doubt fix for NASA safety culture."
FOX News: "NASA's safety culture may be too broken to fix."
The Associated Press: "The Columbia accident investigators are giving NASA months, if not years, to change the deeply rooted culture that led to the destruction of Columbia and the deaths of seven astronauts on Feb. 1."
Among the many options: A housecleaning at the top. Hauling back Apollo-era decision-makers. Perhaps even a new name for the agency.
In this edition of ISHN's e-newsletter, we look at how NASA got into this mess. Just how does a safety culture get fractured so badly for all the world to see?
It's a story with many parallels to workplaces in industry: Tight schedules. Resource constraints. Managers pressed to show results. Employees concerned but intimidated. Fluctuating priorities. Conflicting goals of cost, scheduling and safety. Mixed signals sent from on high. Near miss incidents ignored.
With one small difference. Your safety program will never be the subject of 1,370 news stories.
BORN BEHIND THE EIGHT BALL
Investigators claim the causes of NASA's cracked safety culture are rooted in history. So let's go back to the beginning.
On October 4, 1957, Sputnik I shot into Earth orbit shrouded in the usual Soviet secrecy. All we knew was that the mission was guided by The Chief Designer, a dark genius straight out of James Bond. In the U.S., panic set in immediately.
The country is in a race for survival, cried The New York Times. We face national extinction if we don't catch up, House Speaker John McCormack thundered. The Soviets could rain nuclear bombs on us from platforms built in space.
Gloom deepened two months later when the Navy tried launching the first American satellite with a Vanguard rocket. Before a national TV audience, the rocket shuddered six inches off the launch pad, exploded like a cigar, and sank ignobly into the sand amid billowing smoking and flames. On the other side of the world, Soviet kingpin Khrushchev flashed his mocking grin.
Government, military and aircraft industry officials hurriedly convened an emergency meeting in March, 1958 to figure out how to get a man in space before the Russians. There was no time to waste. The Air Force called it the "Man in Space Soonest," or MISS mission. It would become Project Mercury, and the job of outfoxing The Chief Designer would go to the newly formed National Aeronautics and Space Administration.
Into this pressure cooker environment NASA was born, with an initial payroll of 8,000 employees and a budget of $100. From the very start, the heat was turned way up. Tom Wolfe, in his book, "The Right Stuff," wrote that there was no time for orderly progress. A quick and dirty approach was seized on to save the free world.
What kind of safety culture - values, norms and employee attitudes - takes root in this type of do-or-die climate? And what happens to safety when there is no time for orderly progress, when the stakes are nothing less than extinction of the free world?
FEARLESS ROLE MODELS
In the race against the Russians, NASA needed the nation's best and brightest technical minds, and pilots - astronauts - willing to hang their hide out over the edge, as Wolfe described. And so the country was introduced to a team of fearless risk-takers, the original seven Mercury astronauts.
They were role models, heroes, furnished with new homes and an exclusive contract with Life magazine. The energy, confidence and ambition of these fighter jocks from the Navy, Air Force and Marines set the tone for NASA - and its fledgling culture. Supreme self-confidence was a prerequisite. As pilots of small, high-performance jets, the Mercury Seven lived on the edge: they faced a 23 percent probability of dying in an aircraft accident if they planned to fly for 20 years, according to Navy estimates. A 56 percent probability of being ejected from the cockpit like a cannonball at some point.
Today, General Electric has the reputation of a hard-charging, take-no-prisoners culture. But what GE exec ever faced one-in-four odds of violent death? NASA's high-risk, ride the envelope's edge culture was something entirely different, and an "It can't happen to me" mindset was part of the package.
Those highly publicized original seven Mercury astronauts epitomized NASA's can-do culture. Never succumb to psychological stress. Never challenge the confidence needed to stare down the odds. Support the mission or get out of the way.
Here's an example of that mindset. One of the seven, Deke Slayton, was furious when doctors grounded him for an irregular heartbeat. Wolfe described his anger in "The Right Stuff": Docs don't make operation decisions, fumed Slayton. There are too many goddamn docs in the way.
Close calls wouldn't get in the way, either. Gus Grissom nearly drowned when the hatch blew off his capsule and it sank in the Atlantic Ocean at the end of the second piloted Mercury flight. John Glenn flew parts of his last two orbits manually because of an autopilot failure. Scott Carpenter narrowly survived reentry after ignoring warnings about wasting fuel and splashed down 250 miles off target.
Mission control's reaction to Carpenter's near disaster reflected that determined mindset. The immediate thought was not about Carpenter, but that program would have been set back a year or worst had he died, wrote Wolfe. In NASA's culture, it was all about the program, the mission, success.
It had to be. President Kennedy had raised the bar for all to see in May, 1961. In a speech on "Urgent National Needs", Kennedy rallied Congress and the public, claiming the U.S. faced extraordinary challenges and needed to commit to putting a man on the moon by the end of the decade.
Kennedy's "stretch goal" compelled NASA to take more risks. In 1968, Apollo 8 took off on a historic mission to orbit the moon. That wasn't the original plan. The mission was initially set up to test Apollo hardware in the relatively safe confines of low Earth orbit. But a senior engineer and the Apollo program manager pressed for approval to make it a circumlunar flight. They got it. The program moved closer to Kennedy's goal. And NASA won more praise for its technical genius. To the gamblers went the plaudits.
REAP WHAT YOU SOW
Flash forward 35 years. The Columbia Accident Investigation Board concludes that a cluster of attitudes and behaviors rooted in NASA's history 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.
Nothing new there. NASA had been gung-ho since day one, when it was hatched in that emergency meeting in 1958, egged on by Khrushchev, urged on by Kennedy.
Too ambitious? Too arrogant? Too accepting of risks? No surprises there, either. From the beginning, managers were told that nothing less than the fate of the free world depended on their mission. Engineers and scientists had to close the technology gap, and fast. Brilliant technicians and charismatic risk-takers were recruited, and lauded in the press. Walter Cronkite became an admiring astro-buff. Ticker-tape showered down on the parading dare-devils
Goals, deadlines and marching orders have changed over the decades, but the pressure on NASA's culture has been 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 artifact?
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.
As you see, NASA managers weren't the only ones sending mixed signals. And for that reason, NASA alone can't fix its safety culture.
Sure, numerous steps can be taken from within. 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 administrator O'Keefe dispatched in April, 2002, when he told employees "it is a good time to recommit ourselves" to "our core value to 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 more steps need to be taken. Taken by the outside forces that give NASA's culture its cues, its goals, its budget, its rewards. Congress, the White House, the media and public opinion all have influential roles in any reform move.
The same holds true in the private sector. Want to mend a broken safety culture? It's not just a job for line employees, supervisors, and execs. Sure they have a role. But you can't ignore the influence of shareholders, customers, regulators, board directors, activists, agitators, image-makers and other outsiders in shaping cultural values and perceptions. If the culture has become a self-protective cocoon, as NASA's has been described, ask yourself: What are they afraid of?
Dave Johnson is the ISHN E-News editor. He can be reached at firstname.lastname@example.org, (610) 666-0261; fax (610) 666-1906.
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