**Read the NASA Case study below and answer the 3 questions highlighted. Create 3 PowerPoint slides with bullet points, 1 slide for each question below, with notes:

Questions:

1. To many, culture seems to be an abstract concept and difficult to observe in action. However, in both post-mortem studies of the disasters, cultural problems are identified as critical causal factors. Culture has many definitions, but here we think of it as ways in which a group of people believe, think, and behave. It is, we might say, learned behavior. Perhaps it is slightly more precise to say it is a pattern of learned behavior as well as a product of that learned behavior. The product is our attitudes, values, and knowledge, of course, but also including music, art, language, and othermeans of communication. And it is important to add that it must bemore or lessshared by the entire group, however, defined.

Given this imagery, what does it mean to say that "cultural problems" were very much at the heart of NASA's two catastrophes? It is notable that organizational cultures are more mutable than social/national cultures, and this suggests that change, modification, and adaptation can beperhapsmore quickly and dramatically achieved in organizations. So, beyond acknowledging the influences of culture in these disasters, what specifically might we imagine doing to remedy the problem?

2. The risk analysis "journey" from proximate cause to root cause is a particularly interesting aspect of the Challenger and Columbia stories. And it seems to be interesting that though the proximate causes were technically distinct and different, the analysis led to a similar conclusion about root causesserving as a modest validation of the analytical processes employed.

Is it possible to develop a general description of the process of risk analysis? This question seeks to encourage a principles-based, rather than technical reflection. How does a risk leader think about "getting to the bottom" of a risk issueespecially something as complicated as an institutional failure?

3. Institutional memory/institutional learninghow is it inculcated into an organization? Remembering and adapting are presented in this book as fundamental risk management/leadership tools. They are, to employ another concept,dynamic capabilitiesthat contribute to sustainably resilient organizations.

Beyond introducing or developing the ideas, how are they managed and maintained, and how do we know when they are working?

Case Study:

How do organizations and leaders learn? The shuttles Challenger and Columbia

Case overview

While the majority of case studies covering NASA's two most notable disasters tend to focus on one or the other, the story of the relationship of the two events has emerged as a distinctly specific category of examination. Is there a story that directly connects the two events? Of course, it is possible to suspect a connection without examining thedetails. Both disasters befell space shuttles, both were NASA endeavors, and superficially both were failures of engineering. But in attempting to dig more deeply, the question becomes, not "what" happened, but "why." And how does this help us learn?

However, begin with the "what."

Space shuttle Challenger

On January 28, 1986, the space shuttle Challenger disintegrated 73 seconds after launch, killing its entire crew of seven. The flight was the tenth for the Challenger itself. The technical explanation of the event is summarized as follows:

Shortly after launch, a joint in its right solid rocket booster failed. This failure was attributed to the specific inability of an O-ring (a seal for the joint) to respond to the unusually cold weather conditions at launch. In simplest terms, the cold temperatures did not allow the O-ring to expand and seal the joint. This allowed pressurized burning gas within the booster to escape and damage hardware attached to an external fuel tank. This led to a structural failure of that tank, which in turn influenced specific aerodynamic forces that broke apart the shuttle.

A number of features of the Challenger disaster added a particular poignancy to the events that day. One feature of note is that the launch was witnessed in classrooms around the United States. The crew included a teacher, and this flight was intended in part to promote science education and include live "lessons from space." Thusthough far from the worst aspect of the incidentthe launch was watched by many, many more people than would ordinarily have done so at this stage of the shuttle program's life.

Space shuttle Columbia

The Columbia incident occurred on February 1, 2003, just over 17 years after the Challenger disaster. In this case, the accident occurred at the end of the shuttle's voyage (however, events were set in motion by an incident at launch), with the orbiter disintegrating as it reentered the atmosphere. Again, all seven crew members were killed. The technical description of the event is summarized as follows:

During launch, a piece of foam insulation broke off an external tank and struck the orbiter's left wing. The damage sustained at that time was to the protective tiles allowing super-heated atmospheric gases to penetrate the shuttle's heat shield. Consequently, the orbiter suffered significant damage with the internal wing structure, which in turn led to the shuttle becoming unstable and breaking apart.

To the general public, the loss of the Columbia appeared to be quite similar to the Challenger disaster. Both events could be traced to a specific engineering failure. However, in addition to the subsequent discovery of deeper "root cause" factors, the story of the Columbia was significantly influenced by the fact that this was the second of two disasters to befall NASA, which introduced a new dimension of analysis. How did this happenagain?

The search for root causes

Risk analysis may involve a wide-ranging number of methodologies and structural approaches. Beyond the surface issues of likelihood and potential impacts, most analysis endeavors to address underlying factors with the rarely attained Holy Grail being the ultimateroot cause. It is rarely attained not because analysis methods are not powerful or useful, but rather because complexity is present. Complexity suggests many things, but the key here is the absolute difficulty (impossibility) of having complete confidence in our perceptions and evidence. Even when the outcome is known with certainty, the ability to retrofit a story that explains the causes of that outcome we discover that complexity exists in the past too and the ability to make absolute pronouncements is difficult-to-impossible.

Such is the case with the stories of Challenger and Columbia. We do know a lot, and we do have a persuasive grasp of the factors leading to both disasters, but we have also lost what might be called the "emotional essence" of the story. That is, at any given moment where key decisions were made or not made, or actions were or were not taken, can we fully capture the mind of the decision-maker at those moments? We can imagine bureaucratic, political, even scientific pressures that affect the decision-maker at that moment, but it is just beyond our grasp to say, "This is exactly how a manager saw the situation, saw the choices, managed the emotional dimension, and processed the many considerations that would go into a decision."

So, risk analysis starts with an awareness that there are things we cannot, will not, are unable to know about a given situation. And this happens with assessments of past events as well as the future. So, it must be with the story of the Challenger and Columbia disasters. And yetthere is much that can be gained from what we can find. In brief here is what we can understand about the two stories that may help clarify why a disaster happenedagain.

The analysis of the Challenger disaster was conducted through a formally authorized inquiry, what came to be called the Rogers Commission. In the initial phases, the commission focused on theimmediate proximate cause, the O-ring failure. Here the science was found to be clear. O-rings harden in cold temperatures preventing a full seal of the joints. Temperatures on the day of the launch were in the range where hardening would occur. Therefore, the question arose, was the decision to launch the trueimmediate proximate cause? A telling quote within the Commission's report contains the essence of that moment. The report indicates that the decision to launch was the product of:

a conflict between engineering data and management judgments, and a NASA management structure that permitted internal flight safety problems to bypass key Shuttle managers.

Here risk analysis methods turn to consider the "causes of causes." What had produced the conflict that led to the decision to launch? The Commission broadened the scope of its inquiry to examine, yes, the engineering data in more detail, but also managerial judgments and the management structureand to understand the longer story that leads to the disasters.

For purposes of brevity here, the story of both the shuttle program disasters might be said to begin with the triumph of the moon landings. In very short order, NASA had achieved its strategic purposeto put a man on the moon by the end of the 1960s. While President Kennedy's directive stands as an example of how a clear, direct, and simpleobjective canin itselfserve to propel the work necessary to achieve that goal, in this story it also meant that the achievement of that goal left NASA, and indeed, the United States as a whole, bereft of a clear vision for the future. Political will and commitments of resources began to diminish, and NASA found itself in a position of having to discover a new or longer-term ambition to justify its existence. In some senses NASA never did. What it did do narrows the narrative leading to the disasters.

The response to changes in the political and public support was to conceive of an initiative that was based on routine and economic ventures in space. Certainly, understandable as a choice, but also nowhere as clear as the "any cost, any burden" ethos of Kennedy's vision. The manifestation of this new directionit is difficult to call it a strategywas the introduction of the Space Shuttle program. The language of this new direction was built around the number of missions per year (24 was the goal), seeking greater economies, and reducing average costs through repeated use of hardware. Tellingly, the design of the shuttle itself revealed this language in action. Some basic safety features were excluded (a launch escape tower, ejection seats). Further, the funding process quickly devolved into a yearly hat-in-hand exercise thatowing to the emphasis on economics and the routinizing of a heretofore glamorous and heroic ventureled to ongoing underfunding, at least in the judgment of the Rogers Commission.

Beyond these underlying factors, issues pertaining to managerial structure and performance, and individual leadership emerged. The Commission sought to recommend a number of measures to improve lines of communicationinteractions between the engineers and scientists and managers. Career management issues were discussed. The Commission's essential takeaway was an organizational structure adrift with a lack of clarity in terms of understanding mission, purpose, lines of authority, decision rules, and more. Indeed, the organizational culture of NASA came into focus as an issue influencing almost all aspects of management and leadership.

The Commission's report was released with great fanfare in 1989 and this led to a resumption of the shuttle program, whichto the general publicwas interpreted as evidence that the causes of the disaster had been fully identified and, if not fully addressed, were on their way to being addressed. In fact, that general sensibility of "problems solved" remained up to at least 2002. In an interview with NASA's then-Chief Administrator, Sean O'Keefe, he indicated that the safety culture was strong and that NASA managers kept a copy of the Rogers Report in their desks. This view, seemingly, was offered in response to criticisms at the time that echoed the concerns raised in that Rogers report.

Thus, when the Columbia accident took place in 2003, the investigative body (the Columbia Accident Investigation BoardCAIB), followed the pathway set out by the Rogers Commission 16 years earlier, which is to say, the search for proximate, systematic, and root causes commenced again. As noted, the proximate causes were vaguely similar though quite different in technical substance. However, when attention turned to management, leadership, culture, funding, and governance, the story was horrifyingly in line with the Rogers' findings. Such was the consistency in the CAIB findings that it chose to include special analysis on similarities of the two disasters.

Notable in CAIB's assessment of the common features of Challenger and Columbia were three key observations. First, despite numerous technical changes made after Challenger, there was little evidence of institutional change. This was interpreted as meaning that the organization's structure, systems and processes, and management (and leadership) had not been changed in any fundamental ways since Challenger. Second, if institutional change did not take place, accidents like Challenger and Columbia willcontinue to occur. And third, individual responsibility and accountability are not exempt from the concerns about institutional defects. This was meant to suggest that the personal qualities of managers, engineers, and others were key factors in both accidents. Embedded in that third point was a concern about the institutionalculture.

Postscript

As just a point of reference, the post-Columbia story for NASA has provided evidence of a significantly different look for the organization; a change characterized by, initially, the Constellation Program, which set goals for the future (including decommissioning the shuttle program, which was completed in 2011). Since 2010, a Commercial Crew Program introduced many features involving human space travel, but significantlyand expresslyinvolved partnerships with private organizations (Boeing, SpaceX), and international collaborations (Soyuz).

Various initiatives have been proposed, even initiated since Columbia. These includein no particular ordertravel to Mars, a permanent Moon base, a Space Force (part of the US Armed Forces), a Lunar Gateway (a permanent base orbiting the Moon), and a number of commercial collaborations. All in all, while initiatives have been greatly influenced by the political leadership changes since 2003, some general themes seem to have emerged and continued to persist. These include a vision of NASA as an initiator of or catalyst for collaborative ventures, a leader in the identification of new space-related projects, and NASA seems to have recognized that it is a repository of a wide range of knowledge, skill, and experience that may be applied in new wayseducation being an obvious examplebut also using those assets to collaborate with researchers to test new theories and insights. It is, in fact, a portfolio approach to its mission.

Does this represent "learning from the past," and an adaptive response?

Reflections

In this concluding chapter, an effort is made to consider the implications of the views we set out in the preceding six chapters (and, indeed, in our previous book). We have attempted to apply these views to real uses, but it is nevertheless true that many of our ideas are intended just to prompt thoughtthat is, thought about the real nature, purpose, and value of risk management and leadership. In the case of Challenger and Columbia, we see a large number of things to reflect on, and a number of things that might be done to bring value to an organization or in other settings. The following sets out three prominent issues deserving reflection, but it is hoped that readers will be able to identify other ideas from this short story. For example, the "Postscript" suggests a story where bothadaptationshave occurred, and where NASA has recognizedcollaborationas a model for future growth.