Even in the Shadow of Failure
Public Management 610
Looking at how two different organizations, NASA and the Kansas Cosmosphere and Space Center dealt with large problems and why there seems to be a lack of change within these types of organizations even after large scale failures. The author looks at research done surrounding the Space Shuttle Columbia and Challenger accidents and firsthand knowledge of how a small nonprofit space museum handle the institutional change needed after public failures. From how an emergency room doctor looks at critical thinking to the inside knowledge of a huge breach of public trust the paper looks at organizational culture and the problems it breeds. At the end of it all this culture is only fixable by the individuals that make up the organizations.
Organizations both large and small have throughout history shown an inability to make meaningful changes in procedures following large scale failures. The National Aeronautics and Space Administration had major space transportation system disasters in 1986 and 2003. In each of these instances the agency was under pressure from inside and outside the agency to launch. In each case the agency made changes but did not see the larger picture to change basic managerial actions that would enable for future accidents to be avoided. In 2005 Max Ary, the former President/CEO of the Kansas Cosmosphere and Space Center was convicted in a case that found him guilty of stealing federal property from the museum that he helped to create. Since that time the Cosmosphere has yet to put in place significant measures to keep this type of activity from happening again. What causes organizations both large and small to not make organizational changes that would enable them to avoid future failures?
In 1986 space shuttle Challenger was launched despite record freezing temperatures in Florida. Decisions were made by both shuttle program leaders and management within contractor agencies to allow the launch to go forward. Contractors felt that they were unable to make the decision to tell NASA that their components might fail in cold temperatures. This pressure led to NASA management making the decision to launch despite the possibility of failure in the Solid Rocket Boosters. (Boin and Schulman 2008)
The Solid Rocket Boosters provided the main percentage of thrust during ascent of the shuttle. They were constructed by the Thiokol Corporation. They were made of several sections that were assembled in Florida after being shipped from Utah. Each section had O-rings that were susceptible to cold temperature failure. In the past the O-rings had shown slight failures called blow by, where hot gasses escaped past the rings but in each instance before no catastrophic failure had occurred.
Following the accident, President Reagan ordered a committee be formed to investigate the cause of the accident and point to ways to keep it from happening again. While the Rogers Commission came back with one certain technical cause for the accident. They also pointed to managerial and cultural issues within NASA that were underlying reasons for the accident. They stated that the decision to launch was flawed and that management responsible for the launch decision were unaware of the past failures of the O-rings. They concluded that if the managers had been aware of the whole story the decision to launch would have been different. (Romzek and Dubnick 1987)
New launch parameters were initiated so that weather conditions could dictate the cancelation of launches. These launch conditions have caused numerous delays in the years since the Challenger accident. In addition the crew photo and patch image are located throughout NASA facilities where launch and mission decisions were made. This focus on the crew safety changed certain procedures but findings by the Columbia Accident Investigation Board