NASA’s safety experts are working hard to build a culture of safety that prevents another disaster like the destruction of the space shuttle Columbia 20 years ago.
- On February 1, 2003, NASA faced its third major disaster when the space shuttle Columbia disintegrated as it entered the Earth’s atmosphere, killing seven astronauts and spreading debris across multiple states.
- Now 20 years later, the dangers of space flight haven’t gone away. NASA is preparing to launch four American astronauts aboard Artemis II to orbit the moon in late 2024.
- According to NASA’s Chief of Safety and Mission Assurance Russ Deloach and Safety Culture Manager Dr. Tracy Dillinger, the organization has seen a radical change in governance policy in the past two decades.
- Speaking with Leaders Media, both safety officials say NASA has wholly reworked how it approaches safety by creating new positions, increasing education requirements, and giving more power to safety managers to raise alarms for minor issues that could become deadly.
- The company is also working diligently with its partners at SpaceX and Boeing to maintain a strong safety culture, lest private space companies face a similar tragedy.
Why It’s Important
Historically, NASA has been trapped in a 20-year cycle of deadly tragedies caused by neglect or poor safety precautions. A fire aboard Apollo 1 killed three astronauts in 1967. The space shuttle Challenger exploded after takeoff in 1986, killing seven astronauts on live television. Finally, Columbia was destroyed in 2003. If the pattern holds, NASA appears to be overdue for a tragedy. The rapid expansion of space travel through the Artemis Program and private space launches are increasing new opportunities for failure.
In the case of the Columbia disaster, the burnup was caused by a small piece of tile breaking off the fuel tank during launch and striking the shuttle’s wing at high velocity. None of the engineers noticed it during launch or later imagined it was severe. An email to the crew even mentioned the damage, dismissing it as irrelevant. Recovered video footage of the cabin later showed the astronauts confident in their final minutes. However, the damage was severe enough it caused the shuttle to lose control and break up several minutes into reentry. The complacency of safety procedures killed seven men and women.
“I was hired in 1987, just after the Challenger accident, which created the office I now work at. I came to Kennedy Space Center in the safety organization after NASA realized they didn’t have enough of a safety culture to do the job they needed to do. Columbia was devastating. We all thought, ‘I was hired to stop that, and I let it happen again.’ There has been alot of change in safety culture since. Our new governance model gives authority to safety positions, allowing individual concerns to be elevated to the level of NASA’s administrator,” says Deloach.
Building a New Generation Of Safety Experts
The root of safety is a strong safety culture. Following the disaster, NASA asked itself hard questions about how it could move forward. The two significant changes it made have been in its educational programs and its governance structures. Every new generation of NASA employees is carefully trained with knowledge of past disasters.
“We developed a new online course for the 20th anniversary using case studies that we put into every employee’s annual training program. We updated the Columbia lesson and made it mandatory training for all employees. We are speaking to leadership and making sure the new generation feels this. It’s about personally connecting with the crew that died,” says Deloach.
The most significant change it made has been to perpetuate a culture of “healthy paranoia,” acknowledging that they work in a dangerous business where small mistakes get people killed.
“There’s a heightened sense of awareness. What causes that 20-year gap to happen? We don’t want it to happen again. Is it because we forget the lessons? Is it because we’re arrogant? What we do isn’t inherently safe, and we can’t let success lull us to complacency. When something goes wrong, you need to understand why. You even need to same rigor to understand why something went right,” he continues.
What Does It Take To Be A Safety Manager
Columbia University sociologist Diane Vaughan, in her 1996 book The Challenger Launch Decision, discusses a concept called “normalization of deviance.” Sometimes in life, things continue to go okay when underlying problems exist. As Deloach notes, it’s easy as humans to say, “The check engine light has been on for a month, but the car keeps driving.” All humans have that tendency, but a broken-down car differs from a rocket disaster.
As Dr. Dillinger says, it takes very qualified people to handle safety positions—those with technical knowledge, people skills, and communication skills to understand serious problems and communicate them appropriately, often under stress.
“People who represent safety have a higher role than they did in the past, with a more equal footing and more deeply embedded in these programs. Chief safety officers are selected for their technical background and ability to communicate and given the confidence to know that their concerns will be heeded because one person feels there is too much of a risk,” says Dillinger.
Sharing A Safety Culture With Private Space
The ongoing privatization of space and the race to get to the Moon and Mars creates new wrinkles in the safety process. Dozens of companies now have the capacity to launch vehicles into orbit, and thousands of companies contribute to the process. Building a safety culture with an umbrella that wide may become the most significant safety challenge of this generation for NASA and other space agencies.
At the moment, NASA has two commercial providers—SpaceX and Boeing—and it is working very closely with both companies to make sure their space vehicles are up to government standards. As Deloach says, both companies are very interested in safety, and neither wants to fail. Safety is even more critical for smaller startups that can’t afford to absorb significant losses.
Deloach points to this safety success with the recent successful launch of SpaceX Crew 6, which aborted its mission suddenly during the first launch attempt due to safety concerns. “Getting down to two minutes makes it tempting for engineers to say ‘let’s do this, let’s go,’ but no.” Learning to say no when safety conditions are not fully met is part of keeping astronauts alive, even if it is disappointing when the rocket is delayed.
“For the first crewed mission with SpaceX, NASA was concerned that they might not really get the dangers of what they’re doing. We want them to feel the same way we do about human space flight, so we had the astronauts go live at Hawthorn with the SpaceX folks, and it made a huge difference. The astronauts are people with families who are expected to get back alive. Their safety is in your hands—don’t take that lightly,” says Deloach.
Many space startups are not currently flying under NASA’s guidelines. Instead, they fly under the FAA’s commercial guidelines, which mainly regulate public safety while acknowledging the danger to the pilots. NASA’s safety personnel work with their counterparts in the Air Force and FAA to maintain common standards, often working directly with private companies like Blue Origin and SpaceX to teach them the lessons of Columbia and Challenger so they can avoid them.
However, none of these processes are perfect. As Dillinger notes, the greatest threat they face is likely “black swan” events, things NASA cannot conceive of before they happen. Mistakes will happen, and someday astronauts will die again on NASA or SpaceX’s watch. These are the sacrifices necessary for innovation to happen, and these are the sacrifices astronauts enter the cockpit entirely aware they may be forced to pay. What is essential is to continuously learn so that the same deadly mistake is never made twice.