UNINTENDED CONSEQUENCES

¶A number of changes to the Space Shuttle Program structure made in response to policy decisions had the unintended effect of perpetuating dangerous aspects of pre-Challenger culture and continued the pattern of normalizing things that were not supposed to happen. At the same time that NASA leaders were emphasizing the importance of safety, their personnel cutbacks sent other signals. Streamlining and downsizing, which scarcely go unnoticed by employees, convey a message that efficiency is an important goal. The Shuttle/Space Station partnership affected both programs. Working evenings and weekends just to meet the International Space Station Node 2 deadline sent a signal to employees that schedule is important. When paired with the "faster, better, cheaper" NASA motto of the 1990s and cuts that dramatically decreased safety personnel, efficiency becomes a strong signal and safety a weak one. This kind of doublespeak by top administrators affects peopleʼs decisions and actions without them even realizing it.26

¶Changes in Space Shuttle Program structure contributed to the accident in a second important way. Despite the constraints that the agency was under, prior to both accidents NASA appeared to be immersed in a culture of invincibility, in stark contradiction to post-accident reality. The Rogers Commission found a NASA blinded by its "Can-Do" attitude,27 a cultural artifact of the Apollo era that was inappropriate in a Space Shuttle Program so strapped by schedule pressures and shortages that spare parts had to be cannibal- ized from one vehicle to launch another.28 This can-do attitude bolstered administratorsʼ belief in an achievable launch rate, the belief that they had an operational system, and an unwillingness to listen to outside experts. The Aerospace Safety and Advisory Panel in a 1985 report told NASA that the vehicle was not operational and NASA should stop

¶treating it as if it were.29 The Board found that even after the loss of Challenger, NASA was guilty of treating an experimental vehicle as if it were operational and of not listening to outside experts. In a repeat of the pre-Challenger warning, the 1999 Shuttle Independent Assessment Team report reiterated that "the Shuttle was not an ʻoperationalʼ vehicle in the usual meaning of the term."30 Engineers and program planners were also affected by "Can-Do," which, when taken too far, can create a reluctance to say that something cannot be done.

¶How could the lessons of Challenger have been forgotten so quickly? Again, history was a factor. First, if success is measured by launches and landings,31 the machine appeared to be working successfully prior to both accidents. Challenger was the 25th launch. Seventeen years and 87 missions passed without major incident. Second, previous policy decisions again had an impact. NASAʼs Apollo-era research and development culture and its prized deference to the technical expertise of its working engineers was overridden in the Space Shuttle era by "bureaucratic accountability" – an allegiance to hierarchy, procedure, and following the chain of command.32 Prior to Challenger, the can-do culture was a result not just of years of apparently successful launches, but of the cultural belief that the Shuttle Programʼs many structures, rigorous procedures, and detailed system of rules were responsible for those successes.33 The Board noted that the pre-Challenger layers of processes, boards, and panels that had produced a false sense of confidence in the system and its level of safety returned in full force prior to Columbia. NASA made many changes to the Space Shuttle Program structure after Challenger. The fact that many changes had been made supported a belief in the safety of the system, the invincibility of organizational and technical systems, and ultimately, a sense that the foam problem was understood.