alt Hacker NewsI'm literally guest lecturing at a Harvard class tomorrow on systemic failures in decision making, using the Columbia and Challenger disasters as case studies, and changed my slides last night to include Artemis II because it could literally happen again.
This broken safety culture has been around since the beginning of the Shuttle program.
In 1980, Gregg Easterbrook published "Goodbye, Columbia" in The Washington Monthly [1], warning that NASA's "success-oriented planning" and political pressure were creating the conditions for catastrophe. He essentially predicted Columbia's heat shield failures in the article 1 year before the first flight.
Challenger in 1986, and the Rogers Commission identified hierarchy, communication failures, and management overriding engineering judgment.
Then Columbia happened in 2003. The CAIB found NASA had not implemented the 1986 recommendations [2].
Now Charles Camarda (who flew the first shuttle mission after Columbia and is literally a heat shield expert!) is saying it's happening again.
[1] https://www.iasa-intl.com/folders/shuttle/GoodbyeColumbia.ht...
[2] Columbia Accident Investigation Board Report, Chapter 8: https://www.nasa.gov/columbia/caib/html/start.html
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May as well link the full report too. IMO, this is a bit easier to read.
https://ehss.energy.gov/deprep/archive/documents/0308_caib_r...
But in the 80s I guess there was the pressure to one-up the Soviets, so everything had to be done yesterday, but Artemis has existed most of my adult life at various levels of maturity (Orion and its predecessors certainly did), and considering its been more time spent between that famous Kennedy speech and the actual Moon landing (where there was apparently no issue with safety culture).
Considering how much humanity has allegedly advanced since then, I don't understand what are we gaining thats caused us to have to abandon safety.
The most frustrating part of the whole thing is that when you read Charles Camarda’s thoughts after his meeting with NASA in January, it could have been written in 1986 or in 2003.
https://docs.google.com/document/u/1/d/1ddi792xdfNXcBwF8qpDU...
It’s pretty clear at this point that the shuttle was already broken at design. But seeing the same powder keg of safety/budget/immovable time constraints applied to a totally different platform decades in the future feels like sitting through a bad movie for the third time.
What strikes is not the systemic failures. But the intense culture of secrecy.
Reports are heavily redacted. They aren't shared. Failures aren't acknowledged. Engineering models aren't released. That secrecy eventually causes what we see today.
As an aside, do you have any suggestions for "state of the art" reading on safety culture?
It’s fundamentally a human coordination problem that cannot be solved
The more populated and complex an organization gets it becomes impossible to maintain a singular value vector (get these people around the moon safely)
Everyone finds meta vectors (keep my job, reduce my own accountability) that maintain their own individual stability, such that if the whole thing fails they won’t feel liable
``It is difficult to get a man to understand something, when his salary depends on his not understanding it.''
It is bound to happen again and again considering humans are so oblivious to safety.
> This broken safety culture has been around since the beginning of the Shuttle program.
It's broken everywhere. I have worked in some dysfunctional shops and the problem I see time and time again is the people who make it into management are often egoists who don't care about anything other than the financial compensation and clout the job titles bestows upon them. That or they think management is the same as being a shotgun toting sheriff overseeing a chain gang working in the summer heat in the deep south.
I've worked with managers who would argue with you even if they knew they were wrong because they were incapable of accepting humiliation. I worked with managers who were wall flowers so afraid of confrontation or negative emotions that they covered up every issue they could in order to avoid any potential negative interaction with their superiors. That manager was also bullied by other managers and even some employees.
A lot of it is ego along with a heavy dose of machismo depending. I've seen managers let safety go right down the tubes because "don't be a such a pussy." It's a bad culture that has to go away.