THE WELCH COMPANY
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S U M M A R Y
DIARY: August 26, 2003 04:23 PM Tuesday;
NASA culture of denial contributed to loss of Columbia Space Shuttle.
.....Attitudes on Vigilance Slips Away Because Success Imparts Security
.....Success Imparts False Sense of Security Causing Vigilance to Slip
.....Vigilance Slips with Success that Imparts False Sense of Security
.....Race to the Bottom Denial Eviscerates Good Management
.....Denial Evolves Cultural Transformation in Race to the Bottom
.....Innoculated Against Requirements by Success Status Bureaucracy
.....Requirements Become Suggestions Guidelines Goals for Upper Limits
.....Tragedy Loss Bring Vigilance Until Success Creates Atrophy Entropy
2...Tragedy Focuses Attention on Blueprint Road Map to Improve
3...Attitudes Change Tragedy Focuses Attention on Road Map to Improve
4...Canary in Mine NASA Presages Critical Mass of Bumbling will Explode
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Columbia Shuttle Exploded ISS International Space Station
Columbia Shuttle Review Board Reports NASA Management Culture of Deni
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Management Culture of Denial Contributed to Loss of Columbia Space Sh
Lessons Learned Review Board Columbia Shuttle Reports NASA Management
Improvement Unnecessary Overkill Culture of Denial NASA Management Co
Good Management Unnecessary Overkill Culture of Denial NASA Managemen
Yuen, Jason SFIA Attitudes Must Change to Enable Better Management by
Denial Ignorance Fear Intelligence New Way of Working Funny Foriegn A
Improve Loathe Frustrating Learning New Way Working Change Hand Eye M
Culture of Denial NASA Management Contributed to Loss of Columbia Spa
NASA Management Culture of Denial Contributed to Loss of Columbia Spa
AC14 - ..
AC15 - Summary/Objective
AC1601 - Follow up ref SDS 17 0000, ref SDS 16 0000.
AC1603 - Article published by Reuters today reports on findings in a report by
AC1604 - the Board of Review commissioned to determined the cause of failure
AC1605 - when the Columbia Space Shuttle exploded during re-entry on 030201.
AC1606 - ref SDS 13 0001
AC1608 - ..
AC1609 - Reuter's article says...
AC1611 - WASHINGTON (Reuters) - NASA needs to change how it monitors safety
AC1612 - if the grounded space shuttle fleet is to fly again, and cannot
AC1613 - fall into the complacency that led to the Columbia disaster,
AC1614 - investigators reported on Tuesday. ref OF 1 0001
AC1616 - ..
AC1617 - Board Chairman Harold Gehman stressed at a briefing that the space
AC1618 - shuttle fleet is not inherently unsafe, and praised NASA as an
AC1619 - "outstanding organization." ref OF 1 LC6I
AC1623 - ..
AC1624 - Attitudes on Vigilance Slips Away Because Success Imparts Security
AC1625 - Success Imparts False Sense of Security Causing Vigilance to Slip
AC1626 - Vigilance Slips with Success that Imparts False Sense of Security
AC1628 - ...NASA's management and culture have led to slipping safety
AC1629 - standards that doomed Columbia's crew. Budget and schedule
AC1630 - constraints and the quick construction tempo of the International
AC1631 - Space Station added to the pressure, the board found. ref OF 1
AC1632 - 6F6N
AC1634 - [On 050315 Boston tunnel has safety concerns, and billions in
AC1635 - cost overruns attributed to culture of coverup. ref SDS 27
AC1636 - 6R9R
AC1640 - ..
AC1641 - Race to the Bottom Denial Eviscerates Good Management
AC1642 - Denial Evolves Cultural Transformation in Race to the Bottom
AC1643 - Innoculated Against Requirements by Success Status Bureaucracy
AC1644 - Requirements Become Suggestions Guidelines Goals for Upper Limits
AC1647 - ..
AC1648 - In a television broadcast of congressional hearings on loss of the
AC1649 - space shuttle Columbia reported on 030204, ref SDS 13 0001, Sean
AC1650 - O'Keefe, NASA Chief Administrator, explained how a "culture of denial"
AC1651 - forms from pressure to show progress within approved budgets that are
AC1652 - unrealistic using approved tools and methods people like. People
AC1653 - gradually begin ignoring requirements as mere guidelines, because
AC1654 - managers are driven to cut corners to show the illusion of progress in
AC1655 - order to maintain program funding. Specified requirements that
AC1656 - cannot be met using approved tools and skills people already have are
AC1657 - applied as upper limits, goals and suggestions that people strive to
AC1658 - reach, but not criteria for measuring performance that supports
AC1659 - payment and ultimate "go" or "no go" on flight status.
AC1661 - ..
AC1662 - O'Keefe's testimony conflicts with the report on 030624 that NASA is
AC1663 - leading progress to implement Knowledge Management. ref SDS 18 X142
AC1665 - ..
AC1666 - Accurate communications that take extra time to avoid mistakes seem
AC1667 - annoying, reported on 020820. ref SDS 11 V66I
AC1669 - [On 080708 accurate communications seem annoying to health care
AC1670 - professionals, ref SDS 31 O65F; complex case management and
AC1671 - referral coordination make accurate communication essential to
AC1672 - avoid mistake, but annoying to busy practitioners. ref SDS 31 OK8M
AC1674 - ..
AC1675 - On 020504 study shows professional standards for communication
AC1676 - practices and requirements on good management specified in FAR, ISO,
AC1677 - Health Care, Covey, Drucker, law, contract notice provisions, and
AC1678 - 2,000 years of literacy for contemporaneous documentation of alignment
AC1679 - and feedback to work intelligently, quickly, and accurately are
AC1680 - ignored in government, business, health care, every sector.
AC1681 - ref SDS 9 NS6F
AC1683 - [On 040116 example corporate culture resists good management using
AC1684 - feedback to verify accuracy understandings. ref SDS 21 4L5J
AC1686 - ..
AC1687 - [On 040117 Gary explains in his SDS record importance of synergy
AC1688 - that is hard to achieve in organizational management practice,
AC1689 - illustrated by failure of Columbia space shuttle, following
AC1690 - Challenger disaster both related to culture of denial; where
AC1691 - O'Keefe proposes cosmetic changes, rather than institute
AC1692 - accountablity for alignement with requirements. ref SDS 22 WX9T
AC1694 - ..
AC1695 - [On 040203 bureaucracy resists speaking truth to power, causing
AC1696 - continual bumbling, mistakes, conflict, crisis, and calamity.
AC1697 - ref SDS 23 E44K
AC1699 - ..
AC1700 - [On 040421 Aerospace company "mandatory" requirements for conducting
AC1701 - productive meetings, similar to Intel procedures, and ISO criteria
AC1702 - that are specified but not followed. ref SDS 24 S66N
AC1704 - ..
AC1705 - [On 041012 medical management exasperating because staff fail to
AC1706 - invest time for organizing the record, causing mistakes, delay and
AC1707 - cost escalation. ref SDS 25 NV49
AC1709 - ..
AC1710 - [On 041110 Stanford Medical Center people giving up, fear of
AC1711 - accountability prevents timely, accurate communication; stifle,
AC1712 - proactive management, taking initiative to enable effective care.
AC1713 - ref SDS 26 2J42
AC1715 - ..
AC1716 - [On 050315 Boston tunnel has safety concerns, and billions in cost
AC1717 - overruns attributed to culture of coverup. ref SDS 27 6R9R
AC1719 - ..
AC1720 - [On 050824 Advice Nurse being persistant reminding the surgeon to
AC1721 - implement requirements in Kaiser's Healthwise Handbook on
AC1722 - following up patient calls to collaborate and coordinate via email
AC1723 - for accurate communications and patient medical history.
AC1724 - ref SDS 28 4M7N
AC1726 - ..
AC1727 - [On 051006 example medical practice communication, collaboration,
AC1728 - team care staff fears speaking truth to power, risks patient to
AC1729 - avoid risking personal reprisals. ref SDS 29 6H8M
AC1731 - ..
AC1732 - [On 080404 UCSF medical professionals feel conversation is fast
AC1733 - and easy, so there is not enough time to submit feedback that
AC1734 - verifies accuracy of understandings, ref SDS 30 YO6G; writing to
AC1735 - authenticate conversation seems like unnecessary overkill.
AC1736 - ref SDS 30 O166
AC1738 - ..
AC1739 - Denial transforms culture. Standards eviscerate performance toward
AC1740 - entropy, reported on 970707, ref SDS 4 0108, devolving into a race to
AC1741 - the bottom greased by the simple expedient of defining good practices,
AC1742 - that cannot be accomplished using approved tools and skills people
AC1743 - already have, as "unnecessary overkill," reported on 890325,
AC1744 - ref SDS 1 8R97, because ignoring requirements is faster and easier
AC1745 - than making extra effort to retool skills and to get approval for
AC1746 - tools to meet requirements, when many must say yes to experiment for
AC1747 - saving time and money, and only one person need say no to prevent
AC1748 - improvement -- most everybody just gives up. These dark forces came
AC1749 - into alignment in 1986 with loss of the Challenger, reported on
AC1750 - 921021. ref SDS 3 4499 NASA hit bottom again on 030201 with loss of
AC1751 - the Columbia. ref SDS 13 0001
AC1753 - ..
AC1754 - Denial is pervasive everywhere, not just NASA...
AC1756 - 1. On 891027 common example of coprporate culture denies feedback
AC1757 - needed to verify accuracy of understandings from communication
AC1758 - on the job; management wants to wait for mistakes performing
AC1759 - the work that demonstrate misunderstanding, rather than be
AC1760 - proactive to use concurrent discovery for preventing mistakes.
AC1761 - ref SDS 2 9M6G
AC1763 - ..
AC1764 - 2. On 020820 people working to develop "knowledge management" set
AC1765 - linking in email as a threshold requirement; when experience
AC1766 - showed this could not be accomplished using tools and skills
AC1767 - everybody has, but requires learning to retool basic skills to
AC1768 - use tools that save time and money, people suddenly deny that
AC1769 - links in email to provide connections of cause and effect and
AC1770 - verify accuracy to avoid mistakes that kill people, waste time
AC1771 - and lose money, are a requirement after all for improving
AC1772 - productivity, earnings and stock prices. ref SDS 10 KY4I
AC1774 - ..
AC1775 - 3. On 020905 DCMA requires everyone to use popular technology from
AC1776 - Microsoft that is fast and easy to learn and use for
AC1777 - information management, but prevents complying with regulations
AC1778 - for good management to save lives, time and money, so, like
AC1779 - NASA, it is easier to ignore regulations than to use tools and
AC1780 - methods for performing good management. ref SDS 12 QU9K
AC1782 - ..
AC1783 - [On 040116 example corporate culture resists good management
AC1784 - using feedback to verify accuracy understandings. ref SDS 21
AC1785 - 4L5J
AC1787 - ..
AC1788 - [On 040203 research shows bureaucracy descends into rote
AC1789 - command and control of people that prevents experimenting to
AC1790 - discover technology and methods that save lives, time and
AC1791 - money by improving command and control of the work.
AC1792 - ref SDS 23 E44K and ref SDS 23 V178
AC1794 - ..
AC1795 - [On 040421 Aerospace company "mandatory" requirements for conducting
AC1796 - productive meetings, similar to Intel procedures, and ISO
AC1797 - criteria that are specified but not followed. ref SDS 24 S66N
AC1801 - ..
AC1802 - Tragedy Loss Bring Vigilance Until Success Creates Atrophy Entropy
AC1804 - "There will be so much vigilance and so much zeal and attention to
AC1805 - detail for the next half-dozen flights," Gehman said. "The natural
AC1806 - tendency of all bureaucracies to morph and migrate away from that
AC1807 - diligent attitude is a great concern to the board, because the
AC1808 - history of NASA indicates that they've done it before."
AC1809 - ref OF 1 OG7N
AC1811 - [On 030830 progress reported on changing the culture at Aerospace company
AC1812 - by empowering people to experience benefits of a new culture
AC1813 - without making any effort. ref SDS 20 PPWS
AC1815 - ..
AC1816 - The board errs in ascribing loss of vigilance to NASA rather than
AC1817 - being endemic to human nature that is manifested in all organizations,
AC1818 - which is somewhat recognized by the board's reference to a "natural
AC1819 - tendency of all bureaucracies" to migrate away from a diligent
AC1820 - attitude. Success commonly sows the seeds of sloth and failure where
AC1821 - there is significant disjunction between effort and results, which is
AC1822 - common in any large enterprise.
AC1824 - On 990505 Jason Yuen noted that better management requires a
AC1825 - change in attitude. ref SDS 5 4732 On 990817 Morris related
AC1826 - need for a commitment to diligence is a predicate to improving
AC1827 - management. ref SDS 6 6829
AC1829 - [On 030830 progress reported on changing the culture at
AC1830 - Aerospace company by empowering people to experience benefits of a new
AC1831 - culture without making any effort. ref SDS 20 PPWS
AC1833 - ..
AC1834 - SDS routinizes good management, called out by Drucker on
AC1835 - 991025. ref SDS 7 0785 Using eight (8) steps of Communication
AC1836 - Metrics, listed on 001219, ref SDS 8 4W4L, solves the problem
AC1837 - of limited span of attention by routinely capturing the record
AC1838 - and checking alignment to give early notice of issues
AC1839 - requiring attention. This makes "debugging" daily management
AC1840 - to avoid problems a routine part of daily work, explained in
AC1841 - POIMS, ref OF 6 5795, rather than ad hoc after-the-fact
AC1842 - reporting on the cause of disasters.
AC1844 - ..
AC1845 - Reuters' article continues...
AC1847 - President Bush said NASA's next steps would be determined by a
AC1848 - close reading of the report. ref OF 1 LO9H "Our journey in space
AC1849 - will go on," Bush said in a statement. "The work of the crew of
AC1850 - the Columbia and the heroic explorers who traveled before them
AC1851 - will continue." ref OF 1 RO9O
AC1855 - ..
AC1856 - Tragedy Focuses Attention on Blueprint Road Map to Improve
AC1857 - Attitudes Change Tragedy Focuses Attention on Road Map to Improve
AC1859 - Reuters' article continues...
AC1861 - NASA chief Sean O'Keefe said the board's report would be "a
AC1862 - blueprint ... a road map" for change at the U.S. space agency.
AC1863 - "It's going to be a long road in that task," he told staff members
AC1864 - at a briefing at NASA Washington headquarters. ref OF 1 QO8L
AC1866 - [On 030828 O'Keefe" proclaims that "NASA "gets it" and so will
AC1867 - change the culture which did not occur following the loss of
AC1868 - the Challenger in 1986. ref SDS 19 OA8I
AC1870 - ..
AC1871 - The board said NASA engineers raised questions soon after
AC1872 - Columbia's launch on Jan. 16 about a piece of foam insulation that
AC1873 - was seen falling from the ship's massive external tank about 81
AC1874 - seconds after liftoff. ref OF 1 8P4J
AC1876 - ..
AC1877 - Engineers asked three times during the 16-day mission for
AC1878 - satellite images of Columbia in orbit to see if the foam struck
AC1879 - and damaged the ship, but such images were never obtained.
AC1880 - ref OF 1 HP5F
AC1882 - ..
AC1883 - The board's report said NASA officials missed eight opportunities
AC1884 - to address concerns about the falling foam, which was ultimately
AC1885 - found to be the accident's immediate cause. ref OF 1 ZP5K
AC1887 - [On 030828 O'Keefe" proclaims that "NASA "gets it" and so will
AC1888 - change the culture which did not occur following the loss of
AC1889 - the Challenger in 1986. ref SDS 19 OA8I
AC1891 - ..
AC1892 - [On 030830 progress reported on changing the culture at Aerospace company
AC1893 - by empowering people to experience benefits of a new culture
AC1894 - without making any effort. ref SDS 20 PPWS
AC1897 - ..
AC1898 - This finding aligns with reporting on 030304. ref SDS 15 KV6K
AC1901 - ..
AC1902 - LACK OF CONCERN AT NASA
AC1904 - ..
AC1905 - "From the beginning, the board witnessed a consistent lack of
AC1906 - concern about the debris strike on Columbia," the report said.
AC1907 - "NASA managers told the board 'there was no safety-of-flight
AC1908 - issue' and 'we couldn't have done anything about it anyway."',
AC1909 - ref OF 1 936F
AC1911 - ..
AC1912 - The report drew parallels between NASA management problems now and
AC1913 - at the time of the 1986 Challenger disaster, which also killed
AC1914 - seven astronauts. ref OF 1 D36O
AC1916 - [On 030828 O'Keefe" proclaims that "NASA "gets it" and so will
AC1917 - change the culture which did not occur following the loss of
AC1918 - the Challenger in 1986. ref SDS 19 OA8I
AC1920 - ..
AC1921 - Board members agreed early on that the foam hit the heat-shielding
AC1922 - leading edge of the left wing, causing a breach that allowed
AC1923 - superheated gas to invade the ship on re-entry and led to its
AC1924 - disintegration over Texas. ref OF 1 L43J
AC1926 - ..
AC1927 - This issue was raised by engineers at NASA, reported on 030304.
AC1928 - ref SDS 15 0001
AC1930 - ..
AC1931 - After seven months of work at a cost of about $20 million, the
AC1932 - 248-page report recommended wholesale changes in how the National
AC1933 - Aeronautics and Space Administration does business, including the
AC1934 - creation of a Technical Engineering Authority funded directly from
AC1935 - NASA headquarters to monitor safety outside the constraints of
AC1936 - individual program pressures. ref OF 1 1A4F
AC1938 - ..
AC1939 - The other three shuttles in the U.S. fleet were grounded after
AC1940 - Columbia disintegrated, and NASA chief Sean O'Keefe and others at
AC1941 - the U.S. space agency have estimated that next March or April is
AC1942 - the soonest that the fleet can return to flight. ref OF 1 6A4N
AC1944 - ..
AC1945 - No shuttles flew for 32 months after the 1986 shuttle Challenger
AC1946 - disaster, in which seven astronauts died. ref OF 1 DA5J
AC1948 - ..
AC1949 - But now, the shuttles are an integral part of the construction of
AC1950 - the International Space Station, an orbiting outpost involving 16
AC1951 - nations. The Columbia accident led to reducing the three-person
AC1952 - station crews to two, with Russia providing transport aboard Soyuz
AC1953 - space taxis. ref OF 1 LA5N
AC1955 - ..
AC1956 - The Columbia board also urged NASA to take high-resolution
AC1957 - pictures of the external fuel tank after it separates from the
AC1958 - shuttle and determine the structural integrity of the
AC1959 - heat-shielding material damaged by the foam strike before shuttles
AC1960 - fly again. ref OF 1 JA6K
Canary in Mine NASA Presages Critical Mass of Bumbling Will Explode
Murphy's Law, Avoiding Mistakes Requires More than Luck
NASA Canary in Mine Presages Critical Mass of Bumbling Will Explode
AN0601 - ..
AN0602 - Canary in Mine NASA Presages Critical Mass of Bumbling will Explode
AN0604 - Submitted a letter to Gary explaining opportunity presented by the
AN0605 - glare of NASA's troubles with the Space Shuttle program...
AN0607 - 1. Subject: SDS Action Item Review at Aerospace company
AN0608 - Date: Wed, 27 Aug 2003 00:02:38 -0700
AN0609 - From: Rod Welch
AN0610 - To: "Johnson, Garold L." company.com>
AN0619 - ..
AN0620 - 2. Gary,
AN0622 - ..
AN0643 - ..
AN0644 - 6. I caught a little of the Lehrer News Hour this evening
AN0645 - interviewing "experts" on why NASA crashed the Columbia Space
AN0646 - shuttle for generally the same management flaws that crashed
AN0647 - the Challenger in 1986. There was discussion that NASA
AN0648 - management was in denial about the need for improvement
AN0649 - following the 1989 incident with the result that
AN0650 - recommendations in the Roger's (former Secretary of State under
AN0651 - Reagan) report were not implemented. Both the management
AN0652 - "experts" being interviewed and the expert interviewer
AN0653 - addressed the matter with some incredulity that NASA could be
AN0654 - recalcitrant on a matter of such crucial importance,
AN0655 - overlooking Steven Pinker's point in his book on "How the Mind
AN0656 - Works" that error is a feature not a bug of human cognition.
AN0658 - ..
AN0659 - 7. Accordingly, my sense is that NASA is the "canary in the mine."
AN0661 - ..
AN0662 - 8. Recall that early in the game, miners adopted a practice of
AN0663 - taking canary birds into the deep mines because it these birds
AN0664 - were more sensitive to the presence of poisonous gas than are
AN0665 - people. For one thing, a canary is much smaller, so when a
AN0666 - small amount of gas that could not be noticed by people caused
AN0667 - the canaries to stop singing, or actually die, this was an
AN0668 - early warning that breathing conditions were deteriorating, and
AN0669 - the miners still had time to evacuate before ingesting a lethal
AN0670 - dosage of poison gas.
AN0672 - ..
AN0673 - 9. Same with NASA.
AN0675 - ..
AN0676 - 10. NASA's work is highly visible and risky. Bad management is
AN0677 - relatively more visible at NASA because the impact explodes in
AN0678 - everyone's face on television. This makes NASA the "canary in
AN0679 - the mine" that alerts the rest of us that current practice of
AN0680 - working by conversation, and derivatives in high tech using
AN0681 - email, Powerpoint and the cell phone, because spontaneous,
AN0682 - stream-of-conscious reaction that seems fast and easy and fun
AN0683 - in the moment is more and more overwhelmed by new realities of
AN0684 - a faster paced world, causing continual bumbling, noted by
AN0685 - Kissinger and reviewed on 940609. NASA shows that bad
AN0686 - management eventually reaches critical mass.
AN0688 - ..
AN0689 - 11. Turning back to the new broadcast, what the experts failed to
AN0690 - observe is that the problem is chronic and pandemic, i.e., it
AN0691 - is not limited to NASA, just as the death of a canary in the
AN0692 - mine was not chalked up to a bird with poor breathing skills.
AN0693 - One "expert" hinted at a solution in noting that NASA
AN0694 - management used shortcuts to determine credibility of problem
AN0695 - reports rather than investigate and analyze to make a reasoned
AN0696 - determination.
AN0698 - ..
AN0699 - 12. That is part of what I had in mind today, in noting that your
AN0700 - excellent analysis on 030812 showing opportunities and
AN0701 - challenges of transformation to a culture of knowledge by
AN0702 - expanding use of SDS. "Analysis" must reconcile current
AN0703 - perspective with prior related work, looking for both alignment
AN0704 - and conflict. Where there is conflict this becomes a point of
AN0705 - further inquiry and deeper analysis. The "Expert" on the
AN0706 - Lehrer News Hour program noted that NASA management fell into a
AN0707 - trap of ignoring conflict, and this became a convenient habit,
AN0708 - because analysis is hard work, noted by Drucker on 931130. The
AN0709 - example was given that if someone in the Johnson space center
AN0710 - got information from the folks at the Kennedy Space Center, it
AN0711 - was ignored and denied out of hand. This simple shortcut on
AN0712 - good management saved a lot of time so everyone could expedite,
AN0713 - but has a dangerous, noxious odor at NASA, and everywhere...
AN0714 - It turns out that on 030201 people discovered once again (see
AN0715 - previously on 001207 and 010911) that shortcuts on good
AN0716 - management don't save any time, rather time and cost are
AN0717 - greatly increased along with loss of life, as seen by the
AN0718 - canary in the mine.
AN0720 - ..
AN0721 - 13. On 921021 a program manager with JPL related that following
AN0722 - loss of the Challenger in 1986, NASA management came under
AN0723 - review and procedures were put in place to improve so that
AN0724 - failure would not be repeated. At that time, the same manager
AN0725 - related that communication was a sore subject at NASA, because
AN0726 - keeping track of daily working information was too difficult.
AN0727 - So, in fact today the new report confirmed what was known on
AN0728 - 921021, that NASA did not put in place improvements, because
AN0729 - the task is too difficult using IT tools and methods everybody
AN0730 - likes.
AN0732 - ..
AN0733 - 14. Nominally, this set of conditions should increase demand for
AN0734 - tools and practices that make good management fast and easy.
AN0736 - ..
AN0737 - 15. You seem to be showing at Aerospace company, that given the chance, people
AN0738 - are willing to improve, provided the effort is not too great.
AN0740 - ..
AN0741 - 16. Just hoping you don't keel over like the canary in the mine.
AN0743 - ..
AN0744 - 17. Rod