Lessons in Organizational Ethics from the Columbia Disaster: Can a Culture be Lethal?

On February 1, 2003, the Space Shuttle Columbia, on its way to its landing site in Florida, blew apart in the skies of East Texas. Its seven-member crew perished. The $2 billion ship was lost; some destruction occurred on the ground, and considerable cost was incurred to recover debris scattered over several states. The disaster sounded an eerie echo from the past. Seventeen years earlier the shuttle Challenger exploded 73 seconds into flight due to an O-ring malfunction. All seven crewmembers were also lost. And, about 11 years before that, the cabin of Apollo 1 burst into flames on its pad. Three crewmembers were killed. Within a day, as NASA policy requires, an internal investigation team of six ex officio members was formed. Harold Gehman Jr., a retired admiral who was NATO supreme allied commander in Europe, was appointed to chair it. A veteran of several military investigations, including the bombing of the U.S. Cole, Gehman, in an initially unpopular move, broadened the inquiry to include the agency’s organization, history and culture. Sean O’Keefe, NASA’s administrator, was incensed that the investigation would reach beyond the confines of the shuttle project alone, and his relations with Gehman became strained and stiff. Based on his experience, however, Gehman persisted. An Accident Investigation Board (hereafter referred to as the Board) was appointed with six additional members who represented a broader set of relevant constituencies. In addition to the chair, the 13 member Board included three other military aviation experts, a former astronaut (Sally Ride), a top NASA official, a retired corporate executive, several senior civil accident investigators and two distinguished engineering professors. The Board’s overarching questions were those inevitable ones: Why did the accident occur? Who (or what) is to blame? What is to be done? It was a mammoth task. During less than seven months, the Board’s staff of more than 120 worked with over 400 NASA engineers examining more that 30,000 documents, conducting over 200 formal interviews, hearing testimony from dozens of expert witnesses and receiving and reviewing thousands of inputs from the general public. On Tuesday, August 26, 2003, the 248-page report of the Columbia Accident Board (Board Report) was released. The Board’s report pointed the finger at NASA’s culture and its history. ‘‘The bitter bottom line,’’ lamented New York Times correspondent David Sanger, ‘‘. . . comes down to this: NASA never absorbed the lessons of the Challenger explosion in 1986, and four successive American presidents never Organizational Dynamics, Vol. 33, No. 2, pp. 128–142, 2004 ISSN 0090-2616/$ – see frontmatter 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.orgdyn.2004.01.002 www.organizational-dynamics.com