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S U M M A R Y
DIARY: March 4, 2003 11:38 AM Tuesday;
Columbia space shuttle failed; unable to analyse email in context.
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Columbia Space Shuttle Breaks Apart During Approach to Land Loss of 7
Columbia Explodes During Re-entry on Approach to Landing After Comple
Management Failures Reported Lack Documented Surveillance Contract Pe
Contract Requirements for Reporting Production Progress and Performan
Surveillance Shall Avoid Action Inconsistent with Contract Requiremen
Alignment Showing Audit Trail Traceability to Original Sources Docume
Intelligence Proactive Management Only SDS and Com Metrics Support In
Bumbling Small Details Later Cause Major Problems Need Proactive Disc
Bumbling Complex Information Communication Need Alignment on Challeng
Columbia Space Shuttle Explodes On Returning to Base in Florida
Management Failure Columbia Space Shuttle Explodes On Returning to Ba
Management Ignores Warnings Columbia Space Shuttle Explodes On Return
Bumbling Not Enough Time to Think Analyse Understand Context of Email
Email Overwhelmed NASA Management Not Enough Time to Analyse Context
NASA Columbia Space Shuttle Exploded Management Overwhelmed by Email
6917 - ..
6918 - Summary/Objective
691901 - Follow up ref SDS 29 0000. ref SDS 28 0000.
691903 - Article published by Reuters today indicates NASA management failed to
691904 - act on warnings in email correspondence among project engineers that
691905 - the Columbia Space Shuttle could explode during re-entry, reported on
691906 - 030201. ref SDS 27 0001, and later on 030222, ref SDS 29 0001, because
691907 - there was not enough time for analysis of email, and not because of
691908 - malice or complacency or indifference.
691910 - ..
691911 - Reuters reports.....
691913 - 1. WASHINGTON (Reuters) - NASA's chief bridled at criticism of
691914 - e-mail within the space agency that raised concerns over a
691915 - possible loss of Columbia's crew, saying on Tuesday that
691916 - whatever caused the tragedy was not the result of "malice or
691917 - complacency or indifference." ref OF 4 0001
691919 - ..
691920 - This quotes O'Keefe's remarks further in the article. ref SDS 0 VP3L
691922 - ..
691923 - 2. Internal e-mails released last week showed NASA engineers
691924 - worried about what would happen if super-hot gas got under
691925 - shuttle Columbia's aluminum skin during reentry, with one memo
691926 - concluding, "Our recommendation in that case is going to be to
691927 - set up for a bailout (assuming the wing doesn't burn off before
691928 - we can get the crew out)." ref OF 4 IK6F
691930 - ..
691931 - On 030222 reports email was ignored that cited launch issues that can
691932 - cause damage to the shuttle. ref SDS 29 0001
691934 - ..
691935 - 3. At NASA headquarters, administrator Sean O'Keefe said e-mail
691936 - could be more informal and more "emotional" than other
691937 - communications, and could easily be taken out of context.
691938 - ref OF 4 RL7L
691940 - [On 030826 NASA chief Sean O'Keefe said a culture of denial
691941 - forms when people cannot perform requirements for good
691942 - management using popular tools and methods approved by the
691943 - bureaucracy; people ignore requirements as mere suggestions
691944 - and guidelines, rather than experiment to discover tools
691945 - and methods for meeting requirements in less time and for
691946 - less cost, because people are afraid to notify management
691947 - that requirements are not being met; when procedures for
691948 - improvement require many to say yes, and only one person
691949 - can say no, most everybody gives up. ref SDS 33 8K4G
691951 - ..
691952 - 4. "Look at your own e-mail commentary in the last week -- just at
691953 - random, OK? -- and determine whether you think the phrase you
691954 - used ... today, a week later, looks different to you," O'Keefe
691955 - said. "If it doesn't, then you're a far better, more
691956 - disciplined person in writing your commentary than most folks
691957 - are." ref OF 4 SM8G
691959 - ..
691960 - [On 030826 review board found that NASA missed eight (8)
691961 - opportunities to avoid loss of Columbia. ref SDS 33 8R4F
691963 - ..
691964 - [On 030826 NASA chief Sean O'Keefe said the board's report
691965 - would be "a blueprint ... a road map" for change at the
691966 - U.S. space agency. ref SDS 33 1W6K
691968 - ..
691969 - 5. NASA has said the voluminous exchange of e-mail during
691970 - Columbia's voyage was a normal "what-if" discussion that
691971 - included extreme worst-case scenarios, and that the e-mail
691972 - concerns raised were determined not to threaten the shuttle or
691973 - its crew. ref OF 4 SL8N
691975 - ..
691976 - NASA's chief is correct saying that email can be taken out of context,
691977 - ref SDS 0 UL44, since, in fact, anything can be taken out of context.
691978 - Constructing the right context is hard work -- it takes time, skill
691979 - and tools to dig out of the record relevant history and make the
691980 - connections that impart cause and effect. What effort was made in
691981 - this case to organize communication into a causal context for reasoned
691982 - analysis? This is the same problem the national security folks at
691983 - CIA, the FBI, et al, faced leading up to events on 010911. ref SDS 16
691984 - YNGH
691986 - ..
691987 - On 020504 study shows professional standards for communication
691988 - practices and requirements on good management specified in FAR, ISO,
691989 - Health Care, Covey, Drucker, law, contract notice provisions, and
691990 - 2,000 years of literacy for contemporaneous documentation for
691991 - alignment and feedback to work intelligently, quickly, and accurately
691992 - are ignored in government, business, health care, every sector.
691993 - ref SDS 21 NS6F
691995 - ..
691996 - [On 030410 report that executives revert to "risk management"
691997 - by covering up rather than improve analysis to avoid mistakes.
691998 - ref SDS 30 BF4G
692000 - ..
692001 - [On 030428 IT was easy to use in email, but was not convincing
692002 - for transformation to KM. ref SDS 31 3K7N
692004 - ..
692005 - [On 030617 problems finding information are pandemic.
692006 - ref SDS 32 154H
692008 - ..
692009 - [On 030826 Review Board found NASA missed eight (8)
692010 - opportunities to avoid loss of Columbia. ref SDS 33 US4J
692012 - ..
692013 - [On 080404 UCSF medical professionals feel conversation is fast
692014 - and easy, so there is not enough time to submit feedback that
692015 - verifies accuracy of understandings, ref SDS 34 YO6G; writing
692016 - to authenticate conversation seems like unnecessary overkill.
692017 - ref SDS 34 O166
692019 - ..
692020 - O'Keefe is, also, correct that email is informal and often emotional.
692021 - ref SDS 0 DM4F
692023 - ..
692024 - Where then is the formal, unemotional analysis to address issues
692025 - raised in the informal, emotional email? Issues always start out
692026 - informally and often with emotion, for example talking in a meeting,
692027 - chatting in the hallway, on the telephone, driving home with a
692028 - colleague, or flying with the team to visit a customer. It is no
692029 - excuse that an issue is raised informally and with emotion in an email
692030 - in a boardroom or anywhere in between. When there is a lot at stake,
692031 - emotions flare up to encourage attention. What's important is how an
692032 - issue, once raised, travels the path to careful analysis for timely
692033 - action, which is the constant challenge every organization faces,
692034 - shown by the record on 921021 discussing improvements NASA made to
692035 - avert future disasters after the Challenger Space Shuttle was lost in
692036 - 1986. ref SDS 1 4489
692038 - ..
692039 - An example of "analysing" email is shown in the record on 020924.
692040 - ref SDS 26 0001 What comparable "analysis" did NASA make of the email
692041 - in this case?
692043 - Nobody is accusing NASA of malice or indifference; O'Keefe
692044 - misses the key issue. ref SDS 0 VP3L Tragedy strikes when a
692045 - roomful of competent people fall prey to bumbling because
692046 - nobody wants to invest more than 20 minutes to work
692047 - intelligently by clicking a few links, as reviewed on 020924.
692048 - ref SDS 26 KT3H
692050 - ..
692051 - The core question to be answered by investigation is what analysis was
692052 - made to "connect the dots" of email traffic that constructed a context
692053 - which justified ignoring warnings of failure and the consequent need
692054 - for alternate return scenarios to save the Space Shuttle or determine
692055 - feasibility of a bailout to save the crew?
692057 - a. How many days was the mission underway relative to the date
692058 - warnings of problems were first issued?
692060 - ..
692061 - b. Who was assigned responsibility for managing the problem?
692063 - ..
692064 - c. When was the asisgnment made?
692066 - ..
692067 - d. Where are the records showing analysis of warnings?
692069 - ..
692070 - e. What analysis placed what email warnings into what context
692071 - that justified ignoring persistant warnings of a big
692072 - problem, as "unnecessary overkill"?
692074 - ..
692075 - f. We have names of people who put pen to paper producing
692076 - analysis that indicated a problem, and we have been told
692077 - that the top people were not informed of these warnings.
692078 - Where are the names of the people who withheld the warnings
692079 - from uppoer management, if that really occurred, and where
692080 - is their analysis that supports the conclusion? Was it all
692081 - done with a shrug of the shoulders?
692083 - ..
692084 - In sum, so far, only emails have been released showing there was worry
692085 - about a problem. NASA says these email were reviewed and overruled
692086 - based on "analysis" that showed warnings were not supported. Where is
692087 - this analysis showing calculations and reasoning that justified
692088 - overruling warnings of a big problem?
692090 - ..
692091 - 6. O'Keefe has said he did not see the e-mails until after the
692092 - disaster, but noted he is not an aeronautics expert and others
692093 - at the agency are better qualified. ref OF 4 OM9L
692095 - ..
692096 - 7. "There's fine line between oversight and micromanagement,"
692097 - O'Keefe said. ref OF 4 SN4I
692099 - ..
692100 - 8. He stressed the independent investigation into the tragedy was
692101 - proceeding, and that until its conclusion, "we're speculating
692102 - based on bits, parts and individual pieces of a process."
692103 - ref OF 4 ON4M
692105 - ..
692106 - 9. Whatever the Columbia Accident Investigation Board concludes,
692107 - O'Keefe said, "There wasn't anything that I've seen or that
692108 - anybody else has hinted at that would suggest malice or
692109 - complacency or indifference. If anything, this (e-mail) appears
692110 - to be a spirited exchange that we want to encourage."
692111 - ref OF 4 2O5I
692113 - ..
692114 - The challenge NASA faces is to use the current crisis as justification
692115 - for improving capability to add intelligence for placing information
692116 - into a context that creates useful knowledge in time to make effective
692117 - decisions, rather than go the other way to "kill the messanger," by
692118 - suppressing communication through email in hopes of avoiding
692119 - accountability, as reported on 991021. ref SDS 12 2695
692122 - ..
692123 - 10. Bill Readdy, a former shuttle astronaut who now heads
692124 - spaceflight operations at NASA, said Columbia's crew had been
692125 - fully trained is such maneuvers as bailing out or a belly
692126 - landing. ref OF 4 YO6F
692128 - ..
692129 - 11. Asked why crew-members were not involved in discussions over
692130 - the e-mail concerns, Readdy replied, "That was not something
692131 - that you would then have burdened the crew with." ref OF 4 EP6L
692133 - ..
692134 - 12. The National Aeronautics and Space Administration has stressed
692135 - the independent nature of the investigative panel, known as the
692136 - Gehman board because it is led by Harold Gehman. ref OF 4 JQ3G
692138 - ..
692139 - 13. But last week, O'Keefe turned down a Feb. 25 request from
692140 - Gehman to remove NASA shuttle managers from the independent
692141 - investigation team, saying such a move would be viewed as
692142 - "prejudging the facts before the investigation is complete."
692143 - ref OF 4 ZQ3L