Organizational Learning at NASA: The Challenger and Columbia Accidents

Organizational Learning at NASA: The Challenger and Columbia Accidents

Organizational Learning at NASA: The Challenger and Columbia Accidents

Organizational Learning at NASA: The Challenger and Columbia Accidents

Synopsis

Just after 9:00 a.m. on February 1, 2003, the space shuttle Columbia broke apart and was lost over Texas. This tragic event led, as the Challenger accident had 17 years earlier, to an intensive government investigation of the technological and organizational causes of the accident. The investigation found chilling similarities between the two accidents, leading the Columbia Accident Investigation Board to conclude that NASA failed to learn from its earlier tragedy.

Despite the frequency with which organizations are encouraged to adopt learning practices, organizational learning -- especially in public organizations -- is not well understood and deserves to be studied in more detail. This book fills that gap with a thorough examination of NASA's loss of the two shuttles. After offering an account of the processes that constitute organizational learning, Julianne G. Mahler focuses on what NASA did to address problems revealed by Challenger and its uneven efforts to institutionalize its own findings. She also suggests factors overlooked by both accident commissions and proposes broadly applicable hypotheses about learning in public organizations.

Excerpt

Just after 9 A.M. on February 1, 2003, the shuttle Columbia broke apart and was lost over Texas. This tragic event led, as had another catastrophic shuttle accident seventeen years earlier, to an intensive government investigation into the technological and organizational causes of the accident. Chilling similarities appeared. The shuttle elements that caused both accidents had failed on numerous previous flights. Erosion of the seals between the joints in the shuttle's solid rocket boosters and tile damage to the orbiter from foam debris from the external tank had been recognized as undesirable but “acceptable” conditions despite the fact that each violated specifications. In both accidents, investigators found that decision makers were isolated and failed to listen to either in-house or contract engineers who expressed concern about the problem elements. Before both accidents, flight managers had been under extreme pressure from Congress and the public to maintain launch schedules, and they had not followed established procedures for clearing unresolved problems. Based on these and other observations, the Columbia Accident Investigation Board concluded that NASA was not a learning organization.

Organizational learning, especially in public organizations, is an idea that is often promoted but seldom studied in any particular detail. This book hopes to remedy that deficiency by examining a case in which it is charged that learning did not occur. Using a detailed operational definition of organizational learning and its component processes, this book looks closely at the conditions and actions that did lead to learning and the circumstances that blocked learning or led to the loss of earlier lessons. The book also assembles evidence about the learning process at NASA to refine the general theory of organizational learning to account for the pressures and constraints of learning in public organizations.

Organizational learning is not one but several processes by which organizations seek to improve their performance by searching out the causes behind what they judge to be unacceptable results. What counts as unacceptable is . . .

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