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NASA and the Columbia Disaster: Decision-making by Groupthink?

Claire Ferraris, Rodney Carveth

Western Oregon University/Rochester Institute of Technology

On Saturday February 1, !!", the s#ace shuttle Colu$bia e%#loded over Te%as u#on re&entering

'arth(s at$os#here) *ll seven $e$bers of the cre+ died) The accident forced $any #eo#le to

recall the Challenger s#ace shuttle disaster over fifteen years earlier) On the $orning of anuary

-, 1.-, the s#ace shuttle Challenger blasted off fro$ the 0ennedy S#ace Center in Florida

only to e%#lode " seconds later) The death of the seven $e$bers of the cre+, and #articularlyteacher Christa 2c*uliffe, shoc3ed the nation) Unfortunately, the nation learned in the

succeeding $onths that the tragedy could have been avoided)

*s infor$ation began to e$erge directly after the February 1, !!" Colu$bia s#ace shuttle

e%#losion, attention #ointed to the #ossibility that faulty decision&$a3ing +as ende$ic in the

culture of 4*S*) In a 4e+ 5or3 Ti$es article, ohn Sch+art6 and 2atthe+ Wald 72arch .,

!!"8 suggest that the grou#thin3 that #ervaded the decision&$a3ing at 4*S* in 1.- $ay still

be #resent in !!" +ith si$ilarly disastrous conse9uences)

This #a#er is an e%a$ination of the infor$ation as re#orted during the investigation of the

Colu$bia disaster) We address the 9uestion: ;oes the evidence de$onstrate decision&$a3ing by

grou#thin3< To begin, +e describe the $ethod for our e%a$ination and #rovide an overvie+ of

the characteristics of Irving anis( 71.8 grou#thin3 hy#othesis)

Method

=ased on an inter#retive #ers#ective, te%tual analysis is utili6ed to e%a$ine the re#orted

infor$ation $ade #ublicly available during the investigation of the e%#losion of 4*S*(s

Colu$bia shuttle) Te%tual analysis is a $ethod co$$unication researchers use to describe and

inter#ret the characteristics of a recorded $essage)

The co$$unication te%ts e%a$ined are articles re#orted and #ublished by the New York Times

fro$ February >, !!" ? *ugust -, !!") *s the ne+s#a#er of #ublic record, the 9uality and

relative ob@ectivity of the re#orting during the investigation is reliable) The re#orted infor$ation

is disclosed under the Freedo$ of Infor$ation *ct) Aarious other #ublications are used to

validate infor$ation and are referenced)


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Our $ethod involved e%a$ining the re#orts e$erging fro$ the investigation of the Colu$bia

shuttle e%#losion and organi6ing the re#orts in categories consistent +ith the characteristics of

grou#thin3 as outlined by Irving anis 71.8) S#ecifically, +e e%a$ined evidence of antecedent

conditions, grou#thin3 sy$#to$s, and decision&$a3ing defects) Follo+ing is an overvie+ of the

characteristics of grou#thin3 develo#ed by anis and utili6ed in this study)

Groupthink characteristics

Irving B) anis, #ioneer in the study of social dyna$ics, coined the ter$ grou#thin3D and

#ro#osed the hy#othesis after investigating the #roble$s that confor$ity #ressure brought to

$a@or *$erican #olitical and $ilitary decisions) Ee stated that grou#thin3 is the triu$#h of

concurrence over good sense, and authority over e%#ertise) rou#thin3, anis said, can be found

+henever institutions $a3e difficult decisions) For instance, anis 71., 1.8 cites the

escalation of the Aietna$ War and the 1.1 *$erican invasion of Cuba 7the =ay of Gigs8) In his1.- volu$e, anis adds an analysis of the Watergate cover&u# decision)

rou#thin3, anis 71.-8 +rites, is a 9uic3 and easy +ay to refer to a $ode of thin3ing that

#eo#le engage in +hen they are dee#ly involved in a cohesive in&grou#, +hen the $e$bers(

strivings for unani$ity override their $otivation to realistically a##raise alternative courses of

actionD 7#).8) Ee su##orts the grou#thin3 hy#othesis by analysis of the occurrence or non&

occurrence of antecedent conditions, grou#thin3 sy$#to$s, and decision&$a3ing defects#

Antecedent conditions

To begin, anis outlines three #ri$ary antecedent conditions for the develo#$ent of grou#thin3

to e$erge: 718 a highly cohesive grou#, 78 leader #reference for a certain decision, and 7"8

insulation of the grou# fro$ 9ualified outside o#inions)

$roupthink smptoms

anis discovered that grou#thin3 tends to occur +hen several factors are o#erating at the sa$e

ti$e) These factors he called the sy$#to$s of grou#thin3) anis 71.-8 develo#ed three

categories 7ty#es8 +ith eight s#ecific sy$#to$s)

Ty#e I: Overesti$ation of the grou#Hits #o+er and $orality1) *n illusion of invulnerability, shared by $ost or all of the $e$bers, +hich creates

e%cessive o#ti$is$ and encourages ta3ing e%tre$e ris3)

) *n un9uestioned belief in the grou#(s inherent $orality, inclining the $e$bers to

ignore the ethical or $oral conse9uences of their decisions)

Ty#e II: Closed&$indedness


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") Collective efforts to rationali6e in order to discount +arnings or other infor$ation

that $ight lead the $e$bers to reconsider their assu$#tions before they reco$$it

the$selves to their #ast #olicy decisions)

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) Stereoty#ed vie+s of ene$y leaders as too evil to +arrant genuine atte$#ts to

negotiate, or as too +ea3 and stu#id to counter +hatever ris3y atte$#ts are $ade to defeat

their #ur#oses)

Ty#e III: Gressures to+ard unifor$ity>) Self&censorshi# of deviations fro$ the a##arent grou# consensus, reflecting each

$e$ber(s inclination to $ini$i6e the i$#ortance of doubts and counterargu$ents)

) * shared illusion of unani$ity concerning @udg$ents confor$ing to the $a@orityvie+ 7#artly resulting fro$ self&censorshi# of deviations, aug$ented by the false

assu$#tion that silence $eans consent8)

) ;irect #ressure on any $e$ber +ho e%#resses strong argu$ents against any of thegrou#(s stereoty#es, illusions, or co$$it$ents, $a3ing clear that this ty#e of

dissent is contrary to +hat is e%#ected of all loyal $e$bers)

-) The e$ergence of self&a##ointed $indguardsH$e$bers +ho #rotect the grou#fro$ adverse infor$ation that $ight shatter their shared co$#lacency about the

effectiveness and $orality of their decisions 7##) 1&1>8)

%ecision&making defects

The result of the antecedent conditions and the sy$#to$s of grou#thin3 is a defective decision&

$a3ing #rocess) anis outlines several ty#es of defects in decision $a3ing that can result) For

instance:

1) Fe+ alternatives: The grou# considers only a fe+ alternatives, often only t+o)

) 4o re&e%a$ination of alternatives: The grou# fails to re&e%a$ine alternatives that $ay have

been initially discarded based on early unfavorable infor$ation)

") Re@ecting e%#ert o#inion: 2e$bers $a3e little or no atte$#t to see3 outside e%#ertso#inions)

) Re@ecting negative infor$ation: 2e$bers tend to focus on su##ortive infor$ation and

ignore any data or infor$ation that $ight cast a negative light on their #referred alternative)>) 4o contingency #lan: 2e$bers s#end little ti$e discussing the #ossible conse9uences of

the decision and, therefore, fail to develo# contingency #lans)

Findings: NASA and the Columbia Shuttle inestigation

4*S* ad$inistration e%ists at the discretion of #residential a##oint$ent +ith the inherent

#roble$s that co$e +ith leadershi# change and #olitical #arty agendas) In order to 3ee# the

s#ace #rogra$ funded 4*S* needs to 3ee# the #ublic interested) Shuttle flights and ris3s are

+eighed against #olitical and econo$ic ris3s to 3ee# the #rogra$ visible) In order to $eet

deadlines and 3ee# the shuttle launches fre9uent enough to hold the #ublic interest, 4*S*

#rovides bonuses to inde#endent contractors for on ti$e delivery) This re+ard syste$ adds to

the co$#le% co$$unication issues that arise and are evident in the +ay 4*S* co$$unicates

during decision&$a3ing) *s a result, there is an un+illingness to discuss a #roble$ and #eo#le


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are reluctant to raise flags that $ight slo+ a #ro@ect and therefore carry #olitical or econo$icconse9uences)

Antecedent conditions in the Colum'ia (huttle incident

*nalysis of the re#orts of the decision&$a3ing by the $anage$ent tea$ sho+s the tea$underesti$ated the da$age during the launch of the Colu$bia shuttle) The characteristics of the

4*S* culture a##eared to set the #recedents for disaster) The 4*S* Colu$bia $ission

$anage$ent tea$, chaired by Binda Ea$, de$onstrated an un+illingness to discuss anything

other than an o#ti$istic analysis of the shuttle $ission) The tea$ did not investigate seriously

any suggestions that the foa$ insulation 7#roving to be the #hysical cause of the accident8 could

cause serious da$age to the s#acecraft) The transcri#ts fro$ the ongoing investigation sho+ a

tea$ that +as both isolated and isolating)

For instance, Binda Ea$, des#ite being head of the $ission $anage$ent tea$, re#orted that she

+as never officially notified of re9uests co$ing fro$ other agencies, +hile Colu$bia +as still in

flight, to obtain satellite i$ages of the shuttle) These satellite i$ages 7or i$ages fro$ #o+erful

ground&based telesco#es8 could have hel#ed identify the e%tent of da$age to the shuttle +ing

$ade fro$ the foa$ debris during the $ission launch) Binda Ea$ re#orted that she had heard

infor$ally about a re9uest for i$ages, but she s#ent a day as3ing +ithin 4*S* and the United

S#ace *lliance 7the chief shuttle contractor8 and could not find out +ho had $ade the re9uests

7Wald J Sch+art6, uly ", !!", #) 8) In fact, 4*S* ad$inistrators had cancelled re9uests

that had co$e fro$ inde#endent contractors for the satellite i$ages)

Transcri#t re#orts also sho+ 4*S* $iddle $anagers in the 2ission 'valuation Roo$, +here

engineering issues during flight are resolved, reluctant to raise certain issues of i$#ortance) For

instance, the chief engineer of the shuttle(s structural engineering division, in an intervie+

broadcast on *=C, said that he regretted not having brought the issue of the foa$ debris u# at

the $ission $anage$ent tea$ $eeting at +hich Ea$ #resided) The engineer said, #art of the

#roble$ is that everybody assu$ed that so$eone else +ould do it, and the old a%io$ of business

is no one ever +anted to be firstDK in fact, the engineer said, The 4*S* culture does not acce#t

being +rongL the hu$iliation factor al+ays runs highD 7Wald J Sch+art6, *ugust , !!", #)

8)

;uring a briefing, Binda Ea$ had #raise for the tea$ and argued that to# $anagers had to rely

on the assess$ents of others) Ea$ shifted bla$e though by saying, I don(t have the

engineering e%#ertise, nor do I have the tools, to do that 3ind of analysisD 7Wald, J Sch+art6,

uly ", #) 8) * 4*S* engineer +ho +or3ed closely +ith the $ission $anage$ent tea$

refuted this defense) Ee said, It(s your @ob to 3no+ the #eo#le to as3 the 9uestions) Gart of it is

recogni6ing your li$itations and to #ush hard for detailed ans+ers to critical 9uestionsD 7Wald J

Sch+art6, uly ", !!", #) 8)


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When 9uestioned about the effects of the Colu$bia disaster, Binda Ea$ +ho is $arried to an

astronaut, said that the $e$bers of the Colu$bia cre+ are our friends) They(re our neighbors)

We run +ith the$, +or3 out in the gy$ +ith the$D 7Wald J Sch+art6, uly ", !!", #) 8)

5et, transcri#ts sho+ a $anage$ent tea$ that +as not attentive to the needs of the shuttle cre+)

;es#ite 4*S* rules that the $anage$ent tea$ $et daily during the $ission, this tea$ only held

five $eetings during the 1&day $ission and even too3 off a long +ee3end for the 2artin Buther

0ing r) holiday 7Wald J Sch+art6, uly ", !!", #) 8)

This is evidence of a highly cohesive in&grou#D +here dissenting o#inions are not +elco$ed

and infor$ation does not flo+ coherently +ithin or fro$ the outside of the grou#) The

antecedent conditions including a highly cohesive grou#, leader #reference for a s#ecific

decision, and isolation fro$ outside o#inions, a##ears to e%ist)

$roupthink smptomsUnfortunately, the co$bination of an aging shuttle fleet, evidence of accidentrone as#ects of

the technology of the shuttle, a #ressure to overesti$ate the success of the shuttles, and a culture

of $anage$ent that rationali6ed ris3s +eighed against #olitical and econo$ic $easures, suggest

that the disaster could have been #revented) 'ach of the three categories 7and eight sy$#to$s8,

as identified by anis 71.-8, is e%a$ined in the record of the $ission $anage$ent tea$(s

decision&$a3ing)

Overesti$ation of the grou#(s #o+er and sense of invulnerability:

;uring the investigation by the inde#endent Colu$bia investigation board 7board8, a significantshift occurred in +eighing the i$#ortance of factors that led to the Colu$bia disaster) Initially

the board thought that there +as a hierarchy of factors to investigate +ith the foa$ debris at the

to#) Over ti$e a ne+ a##roach surfaced, as the board chair *d$iral Earold W) eh$an r)

states, We have +hat +e(re no+ calling either the #hysical or $echanical failure, and then +e

have the syste$ic failures) *nd +e(re no+ #utting the$ at e9ual +eightD 7Wald J Sch+art6,

uly 1, !!", #) 18) eh$an(s state$ent suggests that 4*S* 3ne+ in advance that it had an

engineering #roble$ but did not a##reciate its significance) *ccording to the board, 4*S*

$anage$ent had a $indset that this +as an o#erational vehicle, on an o#erational $ission, and

you don(t have to +orry about itD 7 #) 8) *d$iral eh$an argued that 4*S* $ust sto#

treating the shuttles as o#erationalD and start considering the$ as develo#$entalD 7#) 8 This

$eans that each launch should be treated as a first launch, each orbit as a first orbit, and each re&

entry as the first re&entry) 4*S*, eh$an states, has beco$e less interested in details and has

allo+ed its ca#ability to ta3e #hotogra#hs of shuttles on launching to gracefully atro#hy over

the yearsD 7#) "8) This clearly suggests an attitude of invulnerability, +here s#ecific safety

#recautions are allo+ed to atro#hy)


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Other $anage$ent factors re#orted by the board su##ort this overesti$ation by 4*S*(s

$anage$entHa #erce#tion of invulnerability) For instance, 4*S* had sufficient evidence that

the shuttle +as vulnerable to debris stri3es) The flight in !!! of the shuttle *tlantis +ent into



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orbit +ith a 9uarter&inch breach in the +ing(s leading edge, allo+ing hot #las$a into the +ing on

re&entry) 'ngineers 3ne+ that the shuttle +as being hit by foa$ debris on nearly every flight, but

chose to leave the concern unresolved)

*nother $anage$ent factor is that during the 1&day flight of the Colu$bia, although scientists

reali6ed that foa$ had struc3 the shuttle on liftoff and several 4*S* engineers suggested that

the agency should get s#y satellite #hotogra#hs of the shuttle to loo3 for da$age, the 4*S*

$anagers decided against it, even canceling re9uests) The shuttle launch and flight a##ear to

have been #erceived as a routine o#eration +ith $ission $anagers not holding the daily $eetings

re9uired by 4*S* and s3i##ing days during the long +ee3end) 4*S* $anage$ent +as denying

e%isting #roble$s 7Wald J Sch+art6, uly 1, !!"8)

Closed&$indedness, rationali6ation, and stereoty#es:

;ocu$ents released by 4*S* on uly -, !!", #rovided evidence that the s#ace shuttleColu$bia +as not the first to have su#erheated gas invade its left +ing on re&entering 'arth(s

at$os#here) The docu$ents sho+ that the shuttle *tlantis also +ent into orbit +ith a breach in

the +ing(s leading edge, allo+ing hot #las$a into the +ing on re&entry) Res#onding to the

docu$ents, Gaul *) C6ys6, a longti$e consultant to 4*S*, stated that the *tlantis incident

should have #ut 4*S* on alert about +ing da$age 7Sch+art6 J Wald, uly ., !!"8) Ee argued

that 4*S* $anage$ent should have said, If that o#ened u# a crac3 any bigger than the one on

*tlantis, +e(re in dee# troubleD 7Sch+art6 J Wald, uly ., !!", #)1 8) 5et, an astronaut on the

2ay !!! $ission, 2ary 'llen Weber, de$onstrated the collective rationali6ation of the agency

and disagreed +ith C6ys6) She argued, *bsolutely, #eo#le 3ne+ if you have a breach in the+ing, bad things can ha##en) That isn(t ne+s) ) ) 0no+ing +hat I 3no+ no+ about gas entering

the shuttle(s +ing, do I believe the $ission I +as on +as any $ore ris3y than I thought it +as

+hen I too3 off< 4oD 7 #)8) Further, she states, every astronaut 3no+s the ris3s of s#ace

flight, +e $ay fi% this #articular #roble$ ? but I guarantee the ne%t ti$e astronauts get on that

shuttle there +ill be a thousand other things that can ha##enD 7 #) 8) This is an e%a$#le of the

collective rationali6ation to+ards the ris3s of s#ace flight and the +ay in +hich #roble$s are

overloo3ed in the race for s#ace)

*ccording to re#orts co$ing fro$ inde#endent investigations, 4*S*(s e%#ectations for the

shuttle fleet are unrealistic and lac3 in&de#th understanding of the #hysical conditions of the

shuttle 7Wald, uly 1>, !!"8) For instance, a study by the R*4; cor#oration states that given

uncertainties about the full set of causes for the loss of Colu$bia and given unforeseen and

un#lanned aging issues, it is not obvious that the shuttle syste$ +ill reach even a "!&year life of

useful serviceD 7Wald, uly 1>, !!", #)18 5et, 4*S* #lans to fly the shuttle for ! years) The

study suggests that 4*S* needs to get a better gri# on so$e of the #otential age&related

#roble$s) In addition, re#orts also say that 4*S* has deferred ins#ections for corrosion, even

though standing +ater had occasionally been found inside the *tlantis and the Colu$bia after


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rainstor$s) Corrosion had been found in both the Colu$bia and ;iscovery in s#ots hard to

ins#ect and even harder to re#air) *t one ti$e, the re#ort states, 4*S* has a corrosion control


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board,D but it no longer e%ists 7Wald, uly 1>, !!", #) 8) * s#o3es#erson for 4*S* re#lied that

the corrosion ins#ections and re#airs had been deferred, but only after engineers investigated the

corrosion) The engineers deter$ined that the corrosion +as $inor and not a safety issue for

continuing shuttle flight 7Wald, uly 1>, !!", #)8) This dialogue de$onstrates a #attern at

4*S* +here #roble$s are deferred and then collectively rationali6ed)

*s the Colu$bia investigation board is discovering and re#orting, 4*S* still does not

understand the o#eration of the shuttle fleet +ell enough to ensure that future flights +ould be

safe) 5et, Sean O(0eefe, 4*S* ad$inistrator 7and a #olitical a##ointee8, said that he ho#ed the

three surviving shuttles could resu$e flying by ;ece$ber !!" 7Wald J Sch+art6, une 1",

!!", #) 8)

*nother 9uestion, rationali6ed at 4*S*, is the cost of ris3s to hu$an lives) 2atthe+ 0oss, a

scientist +hose e%#eri$ents +ere carried out on three $issions of the Colu$bia, +rote in a 4e+5or3 Ti$es article, In&orbit e%#eri$ents li3e $ine have been used to @ustify $anned s#ace

#ro@ects li3e the shuttle for decades ) ) ) )The truth is that the vast $a@ority of scientific

e%#eri$ents conducted in orbit ? including $y o+n ? do not re9uire astronauts) ) )in fact,

e%#eri$ents li3e these are often $ore efficient and yield $ore fruitful results +hen done +ithout

the involve$ent of astronautsD 70oss, une ., !!", #)1 8) 0oss states that the #ublic i$age of

astronauts as laboratory scientists +or3ing on their o+n e%#eri$ents is $isleading) The astronaut

cor#s, he argues, has served one overriding #olitical and #ublic relations #ur#ose ? to sell the

s#ace #rogra$) In fact, he +rites, the International S#ace Station has been aggressively

$ar3eted as a science lab, but the station is seriously fla+ed in that too $uch cre+ ti$e needs to be co$$itted to station $aintenance) Further, 0oss +rites, because of cost overruns and budget

#roble$s, the station(s cre+ +as cut bac3 to three fro$ the #lanned seven) Originally, 1!

astronaut&hours #er +ee3 +ere to be devoted to scienceK this has been cut to ! hours #er +ee3)

0oss argues that scientific e%#eri$entation in s#ace can be safer and $ore cost effective using

long&duration re$ote controlled orbital s#acecraft) The overall cost +ould be significantly

reduced because 4*S* +ould not need to #rovide a safe and sustaining environ$ent for

astronauts) The #oint of 0oss(s article is to argue for the se#aration of the goal of scientific

e%#eri$entation fro$ the desire for s#ace e%#lorations) Ee states, *stronauts do not ris3 their

lives to #erfor$ scientific e%#eri$ents in s#ace) They fly to fulfill a $uch $ore basic and

hu$an desire ? to e%#erience the vastness of s#aceD 7#)"8) 0oss $a3es a convincing argu$ent

+hen he +rites, If 4*S* is not able to convince the #ublic of the i$#ortance of science in orbit

+ithout astronaut involve$ent, then so be it) *t least *$erica(s refusal to su##ort science +ould

be honest, +ould not needlessly endanger hu$an lives or co$#ro$ise the integrity of science

and scientistsD 7#) "8) In $any res#ects, this $ay be one of the #ri$e sources of #roble$s +ithin

4*S* ad$inistration) When is the cost too $uch in the aggressive effort to sell the s#ace

#rogra$ to the *$erican #ublic< This is a 9uestion that 4*S* does not address #ublicly)


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Gressures to+ard unifor$ity & self&censorshi#, unani$ity, discourage$ent of dissent, and $ind&guards: The re#ort by Rodney Rocha, a structural engineer at 4*S*, is a good e%a$#le of self&censorshi#) Rocha tells his story during an *=C )Primetime* (pecial +dition intervie+ on uly

th

7Sch+art6, uly , !!"8) Rocha states that on the second day of Colu$bia(s $ission he sa+a grainy video that sho+ed a chun3 of insulating foa$ hitting the left +ing of the shuttle -!

seconds after launch) *fter +atching it intensively for days he voiced urgent concerns to

colleagues about the need to e%a$ine the +ing using s#y satellites) *s this #a#er has #reviously

stated, Shuttle $anagers decided against as3ing for the #ictures) Rocha +rote $essages urging

4*S* to begD for #hotogra#hic assistance) 5et, during the $eeting #resided over by Binda

Ea$, +here $anage$ent dis$issed the #roble$ of the foa$, Rocha did not s#ea3 u# and

e%#ress his concerns 7Sch+art6, uly , !!", #)8) When 9uestioned about his reluctance to

s#ea3 at the $eeting he res#onded that he +as frightened for his @ob 7#)8) Flight director,

BeRoy Cain refutes this state$ent, 5ou are duty bound as a $e$ber of this tea$ to voice your

concerns ) ) ) in #articular as they relate to safety of flightD 7Sch+art6, uly , !!", #)8)

Su##orting Rocha(s state$ent, though, is *d$) Earold W) eh$an r), +ho is leading the

inde#endent investigation into the Colu$bia disaster) eh$an argues that 4*S*(s ability to

ensure safety is very, very shallo+D and adds that the syste$ for engineers to e%#ress safety

concerns is bro3eD 7Sch+art6, uly , !!", #) 8) Other $e$bers of the investigation board

also su##ort this clai$ and re#ort that by the ti$e of the Colu$bia $ission 4*S* $anagers had

beco$e co$#lacent about safety and lo+er&level engineers +ere reluctant to raise issues that

$ight interfere +ith a $ission)

%ecision&making defects

'vidence of both the antecedent conditions and grou#thin3 sy$#to$s hel# to identify the defectsin decision&$a3ing) '$#hasi6ing the defective decision&$a3ing by 4*S* $anage$ent is the

state$ent fro$ Walter Cantrell, a retired rear ad$iral recently na$ed by 4*S* to a tas3 force to

revie+ the agency(s return to flight #re#arations) Cantrell had +or3ed +ith 4*S* before +hen

he hel#ed to conduct a study of the nuclear 4avy and co$#ared its #rocesses +ith 4*S*(s)

Cantrell, at that ti$e of the 4avy study, identified significant #roble$s +ith 4*S*(s structure

and re#orted that at 4*S*, having no inde#endent revie+ of #roble$s allo+s the #ossibility of a

#rogra$ $anager tailoring safety technical re9uire$ents to $eet schedule and cost

re9uire$entsD 7Wald, uly 1, !!", #) 8) Further, Cantrell re#orted that the nature of 4*S*(s

$anage$ent structure conta$inated the goal of safety +ith the desire to fly its $issions ) ) )They e%ecuted their #rocesses conscientiously, and #rofessionally, but their #rocesses $ay not be

as good as the confidence they #laced in the$D 7Wald, une ., !!", #) "8)

In the re#ort to 4*S*, co$#aring the nuclear 4avy syste$ and 4*S*(s, the i$#ortance of an

inde#endent technical authority 7or revie+8 +as e$#hasi6ed) Cantrell states as an e%a$#le,

One could reasonably e%#ect that if this #roble$ 7the foa$8 had been given to an inde#endent

technical authority, they $ight not have #roceeded until they solved that technical #roble$D


16/26

7Wald, uly 1, !!", #) 8) *n inde#endent revie+, Cantrell argues 7#) 8, could have found

that #ieces of foa$ big enough to da$age tiles could do serious da$age) Cantrell states that it is


Communication


17/26

i$#ortant to be able to se#arate safety issues fro$ other issues) In this $atter, Cantrell suggests

that the #roble$ at 4*S* is that the ris3 of safety for the shuttles is +eighed against the #olitical

and econo$ical re9uire$ents) This is a significant decision&$a3ing factor contributing to a

defect +ithin 4*S*, the lac3 of outside e%#erts called in as resource #ersons and encouraged to

disagree +ith the grou#(s assu$#tions)

In res#onse to the reco$$endation for an inde#endent revie+, 4*S* re#orts that it +ill

establish an additional safety organi6ation +ithin 4*S*) Cantrell argues that this solution is not

as good as the closed loo#D syste$ of the nuclear 4avy #rogra$, in +hich any ti$e a #roble$

is identified corrective action $ust be found and ta3en 7Wald, uly 1, !!", #)8) 4*S*(s

solution $ight $ean another layer of ad$inistration +ithout the accountability of each #erson

and +ithout the encourage$ent to dissent)

The freedo$ to dissent is another #ri$ary ele$ent that is $issing in the decision&$a3ing cultureof 4*S*) *s the investigative board study has found, 4*S*(s flight readiness revie+ syste$

can be an inti$idating venue in +hich to raise a technical issue not fully su##orted +ith dataD

7Wald, uly 1, !!", #) 8) *lso, a $a@or obstacle for 4*S* is the lac3 of involve$ent of to#

$anage$ent in day&to&day decisions) The 4avy, to contrast 4*S*, conducts $ost

co$$unications by letter and co#ies of each letter go the ad$iral in charge of the #rogra$) That

officer has a tenure of eight years) *t 4*S* the to# ad$inistrator has a ty#ical length of tenure

of four or five years) The 4*S* ad$inistrator serves at the #leasure of the #resident and so the

@ob often changes +hen the White Eouse does) For e%a$#le, the current ad$inistrator, 2r)

O(0eefe, has sho+n hi$self in congressional testi$ony to be una+are of details of the shuttle #rogra$ 7Wald, uly 1,!!", #) "8) In addition, 4*S* offers bonuses for on&ti$e launches to

its inde#endent contractors, a factor that is critici6ed for raising the #ossibility of conflict of

interest for contractors +ho $ust decide +hich #otential #roble$s to bring to 4*S*(s attention)

In contrast, the 4aval Reactors #rogra$ has not such #rovisions for contractors 7Wald, uly 1,

!!"8)

*nother defect in the decision&$a3ing #rocess is re#orted in the bench$ar3ing studyD 7Wald,

uly 1, !!", #) 8) This study #ointed out that, 3no+ledge and o#erational s3ill degrade

+hen not #eriodically recalled or usedD 7#) 8) 4*S* technicians re#orted to investigators that

there +ere tas3s that they #erfor$ed only a fe+ ti$es a year and that they +ere concerned about

beco$ing rusty) 2aintaining 3no+ledgeable technicians, outside revie+, an e%#erienced staff

that can 9uestion ad$inistrators adds to the list of re9uire$ents needed to counteract defect

decision&$a3ing)

Conclusion: !s it groupthink?


18/26

*s the Colu$bia accident investigation board continued to collect data, analy6e, evaluate, and

re#ort its findings, infor$ation no+ in the #ublic record disclosed under the Freedo$ of

Infor$ation *ct reveals a critical brea3do+n in co$$unication in the Colu$bia $ission



Communication


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$anage$ent tea$ and 4*S* ad$inistration) Infor$ation $ade available through $edia re#orts

include $eeting transcri#ts, intervie+s +ith 4*S* engineers, and intervie+s +ith engineers and

ad$inistrative #ersonnel fro$ agency contractors) The re#orts describe a 4*S* culture that

does not acce#t being +rong and suggests a dysfunctional flo+ of infor$ation +ithin 4*S*)

The re#orts also describe 4*S*(s a##roach to #eer revie+ and accountability +here no one

+ants to be the first to as3 the difficult 9uestions and +here u##er $anage$ent does not +ant to

loo3 beneath the o#ti$istic surface of re#orts of their subordinates)

The evidence in re#orts of the 4*S* ad$inistration decision&$a3ing during the Colu$bia flight

indicate significant defects in the #rocess of co$$unication due to the nature of the $anage$ent

culture and the resulting decisions) ;oes the faulty decision&$a3ing de$onstrate the

characteristics of grou#thin3 as evident in the investigation of the accident< The first issue to

address is +hether there is sufficient evidence that the antecedent conditions e%ist for grou#thin3

to occur)

The #ublic re#orts clearly suggest that all the antecedent conditions for grou#thin3 are evident)

The Colu$bia $ission $anage$ent tea$ is described as a grou# dee#ly involved in a cohesive

in&grou#) This high level of cohesiveness is evident in the grou#(s adherence to the #olitical

#ressure) 4o one in the grou# +ould raise issues that +ould 9uestion the status 9uo) The

leadershi# had a #reference 7and #ressure8 for a certain decision) The #ressure to 3ee# the

$ission on ti$e/trac3 a##eared to +eigh $ore than the cost of as3ing the hard 9uestions that

$ight result in a delay in the launch) The #olitical and econo$ic ris3s out+eighed the ha6ards

for the shuttle) The $e$bers of the $anage$ent tea$ a##eared to be isolated fro$ infor$ationco$ing fro$ outside 4*S* or fro$ different sections of 4*S*) The tea$ also $ade it al$ost

i$#ossible for infor$ation that did not adhere to the #referred decision to be discussed) The

tea$ lac3ed a syste$ of chec3s and balances, isolated fro$ e%#erts +ho $ight 9uestion the

#referred decision) The $anage$ent tea$, also, created a cli$ate that $ade it nearly

i$#ossible for staff engineers to raise 9uestions regarding safety issues)

The second issue to address is the evidence of grou#thin3 sy$#to$s s#ecifically overesti$ation

of the grou#(s #o+er, closed $indedness, and #ressure to+ards unifor$ity) There is sufficient

evident that the $ission $anage$ent tea$ overesti$ated the shuttle successes and assu$ed a

#osition of invulnerability) 2anagers 3ne+ foa$ had struc3 the shuttle(s +ing, but refused to get

satellite i$ages of the shuttle for further investigation) The shuttle launch and flight a##ear to

have been #erceived as a routine o#eration) These e%a$#les #rovide evidence of closed

$indedness and rationali6ation in the investigation re#orts) In addition, sufficient evidence

e%ists to suggest that the $anage$ent tea$ created #ressure to+ards unifor$ity and discouraged

dissent a$ong the staff engineers)


20/26

The third issue, is the evidence of defective decision&$a3ing) The decision&$a3ing defects

during the Colu$bia flight beco$e a##arent after revie+ing the antecedent conditions and the

sy$#to$s) For instance, there is no evidence of a survey of all #ossible alternatives to consider



Communication


21/26

after the launch of Colu$bia) There +as no re&e%a$ination of alternatives after the shuttle

sustained da$age during the launch) Instead, there +as an acce#tance of the flight as a routine

o#eration) There +as a re@ection of e%#ert o#inions +ith 4*S* actually canceling re9uests for

satellite #hotogra#hs to vie+ the da$age to the shuttle after the launch) There +as a re@ection of

negative infor$ation and a rationali6ation that acce#ted the da$age as routine) 2ost i$#ortant,

there +as no docu$ented evidence fro$ the investigation of any discussion of the #ossible

conse9uences or for contingency #lans)

In conclusion, based on the re#orts to date, there is sufficient evidence to describe the faulty

decision&$a3ing during the tragic and final flight of 4*S*(s Colu$bia shuttle to be grou#thin3)

Richard Covey, a retired *ir Force colonel, astronaut, and co&chair$an of the inde#endent #anel

$onitoring the resu$#tion of the s#ace shuttle #rogra$ argues that 4*S*(s $anage$ent issues

are barriers to good decision&$a3ing D 7Wald, *ugust -, !!", #)8)

"e#erences

=road, W)), J Sanger, ;)') 7!!", February >8 4*S* +as told in 1..! about vulnerable #rotective tiles)

Retrieved on une -, !!" fro$ +++)nyti$es)co$/!!"/!/!>/national/!>FO*2)

;unn, 2) 7!!", uly 18) Investigator: Cuts hurt shuttle ins#ections) (tatesman ,ournal" p#-A#

'%cer#ts fro$ 4*S* $eeting on shuttle) Retrieved on uly >, !!" fro$

+++)nyti$es)co$/!!"/!/"/national/"ST'M)

lan6, ), J Wong, ') 7!!", February 8) 'ngineer(s (. re#ort +arned of da$age to tiles by foa$) Retrieved onune -, !!" fro$ +++)nyti$es)co$/!!"/!/!/national/!WRO4)

anis, I) 71.8) .ictims of groupthink# =oston: Eoughton 2ifflin)

anis, I) 71.-8) .ictims of $roupthink 7nd

ed)8) =oston: Eoughton 2ifflin)

anis, I) B), J 2ann, B) 71.8) %ecision making/ A pschological analsis of conflict" choice" and commitment#

4e+ 5or3: Free Gress)

0oss, 2)=) 7!!", une .8) Eo+ science brought do+n the shuttle) Retrieved on une ., !!" fro$

+++)nyti$es)co$/!!"/!/./o#inion/.0OSS)

)

Beary, W)') 7!!", 2ay 1!8) 4*S* a##oints ne+ chief for s#ace shuttle #rogra$) Retrieved on 2ay 1!, !!"

fro$ +++)nyti$es)co$/!!"/!>/1!/national/nationals#ecial/1!4*S*)

)

http://www.nytimes.com/2003/02/05/national/05FOAMhttp://www.nytimes.com/2003/02/05/national/05FOAMhttp://www.nytimes.com/2003/02/05/national/05FOAMhttp://www.nytimes.com/2003/07/23/national/23STEXhttp://www.nytimes.com/2003/02/04/national/04WRONhttp://www.nytimes.com/2003/02/04/national/04WRONhttp://www.nytimes.com/2003/06/29/opinion/29KOSShttp://www.nytimes.com/2003/06/29/opinion/29KOSShttp://www.nytimes.com/2003/05/10/national/nationalspecial/10NASAhttp://www.nytimes.com/2003/05/10/national/nationalspecial/10NASAhttp://www.nytimes.com/2003/07/23/national/23STEXhttp://www.nytimes.com/2003/02/04/national/04WRONhttp://www.nytimes.com/2003/06/29/opinion/29KOSShttp://www.nytimes.com/2003/05/10/national/nationalspecial/10NASAhttp://www.nytimes.com/2003/02/05/national/05FOAM


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Communication


23/26

Beary, W)') 7!!", uly 18) In res#onse to #anel, 4*S* #lans safety center) Retrieved on uly >, !!"

fro$ +++)nyti$es)co$/!!"/!/1/national/nationals#ecial/14*S*

)

Beary, W)'), J Wald, 2)B) 7!!", *#ril 8) Shuttle #rogra$ $anager resigns) Retrieved on *#ril , !!"

fro$ +++)nyti$es)co$/!!"/!//national/nationals#ecial/SEUT)

Sanger, ;)') 7!!", February "8) Bessons fro$ uneven Challenger investigation hel# create attitude change)

Retrieved on une ., !!" fro$ +++)nyti$es)co$/!!"/!/!"/national/!"CE*B))

Sch+art6, ) 7!!", 2ay 18) 4*S* re#ort says nothing could have saved shuttle) Retrieved

on 2ay , !!" fro$

+++)nyti$es)co$/!!"/!>/!1/national/nationals#ecial/!1SEUT)

Sch+art6, ) 7!!", 2ay "8) 2e$o na$ed over "! Nhigh ris3( concerns regarding tan3s and foa$)

Retrieved on 2ay , !!" fro$

+++)nyti$es)co$/!!"/!>/!"/national/nationals#ecial/!"SEUT

Sch+art6, ) 7!!", uly 8) Rodney Rocha +as +orried about the foa$) Retrieved on uly , !!" fro$+++)nyti$es)co$/!!"/!/!/arts/television/!SCEW)

Sch+art6, ) 7!!", uly 18) Shuttle investigator faults 4*S* for co$#lacency over safety) Retrieved

on uly >, !!" fro$ +++)nyti$es)co$/!!"/!/1/national/nationals#ecial/1SEUT)

Sch+art6, ), J Beary, W)') 7!!", uly "8) 4*S* announces s+ee#ing changes in shuttle $anage$ent)

Retrieved on uly ", !!" fro$

+++)nyti$es)co$/!!"/!/!"/national/nationals#ecial/!"4*S*)

Sch+art6, ), J Wald, 2)B) 7!!", 2arch .8) Nrou#thin3( is "! years old, and still going strong)

The New York Times, #) >)

Sch+art6, ), J Wald, 2)B) 7!!", uly .8) 'arlier shuttle flight had gas enter +ing on return) Retrieved onuly >, !!" fro$ +++)nyti$es)co$/!!"/!/!./national/nationals#ecial/!.SEUT)

Wald, 2)B) 7!!", February "8) With lessons fro$ Challenger, e%#ert #anels search for clues) Retrieved

on une ., !!" fro$ +++)nyti$es)co$/!!"/!/!"/national/!"GRO=)

Wald, 2)B) 7!!", 2ay 8) Investigatory board(s assign$ent: =alancing analysis and reassurance) Retrieved

on 2ay , !!" fro$ +++)nyti$es)co$/!!"/!>/!/national/!*CCI)

Wald, 2)B) 7!!", une -8) 4*S*(s ne+ charge: Shuttle re#air in s#ace) Retrieved on une -, !!" fro$

+++)nyti$es)co$/!!"/!/-/national/nationals#ecial/-SEUT

Wald, 2)B) 7!!", une .8) Re#ort on shuttle brea3u# fleshed out a theory for$ed early) Retrieved on

une ., !!" fro$ +++)nyti$es)co$/!!"/!/./national/nationals#ecial/.SEUT)

Wald, 2)B) 7!!", uly 1>8) Re#ort critici6es 4*S* and #redicts further fatal accidents) Retrieved on

uly !, !!" fro$ +++)nyti$es)co$/!!"/!/1>/national/nationals#ecial/1>SEUT)

Wald, 2)B) 7!!", uly 18) Study suggests 4*S* should consider 4avy(s safety techni9ues) Retrieved

on uly 1, !!" fro$ +++)nyti$es)co$/!!"/!/1/national/nationals#ecial/14*S*)

Wald, 2)B) 7!!", *ugust 8) 2anage$ent issues loo$ing in in9uiry on shuttle safety) Retrieved on

*ugust -, !!" fro$ +++)nyti$es)co$/!!"/!-/!/national/nationals#ecial/!SEUT)

http://www.nytimes.com/2003/07/16/national/nationalspecial/16NASAhttp://www.nytimes.com/2003/04/24/national/nationalspecial/24SHUThttp://www.nytimes.com/2003/04/24/national/nationalspecial/24SHUThttp://www.nytimes.com/2003/02/03/national/03CHALhttp://www.nytimes.com/2003/02/03/national/03CHALhttp://www.nytimes.com/2003/02/03/national/03CHALhttp://www.nytimes.com/2003/05/01/national/nationalspecial/01SHUThttp://www.nytimes.com/2003/05/01/national/nationalspecial/01SHUThttp://www.nytimes.com/2003/05/03/national/nationalspecial/03SHUThttp://www.nytimes.com/2003/07/07/arts/television/07SCHWhttp://www.nytimes.com/2003/07/07/arts/television/07SCHWhttp://www.nytimes.com/2003/07/17/national/nationalspecial/17SHUThttp://www.nytimes.com/2003/07/17/national/nationalspecial/17SHUThttp://www.nytimes.com/2003/07/03/national/nationalspecial/03NASAhttp://www.nytimes.com/2003/07/03/national/nationalspecial/03NASAhttp://www.nytimes.com/2003/07/09/national/nationalspecial/09SHUThttp://www.nytimes.com/2003/07/09/national/nationalspecial/09SHUThttp://www.nytimes.com/2003/07/09/national/nationalspecial/09SHUThttp://www.nytimes.com/2003/02/03/national/03PROBhttp://www.nytimes.com/2003/02/03/national/03PROBhttp://www.nytimes.com/2003/02/03/national/03PROBhttp://www.nytimes.com/2003/05/07/national/07ACCIhttp://www.nytimes.com/2003/05/07/national/07ACCIhttp://www.nytimes.com/2003/05/07/national/07ACCIhttp://www.nytimes.com/2003/06/28/national/nationalspecial/28SHUThttp://www.nytimes.com/2003/06/29/national/nationalspecial/29SHUThttp://www.nytimes.com/2003/06/29/national/nationalspecial/29SHUThttp://www.nytimes.com/2003/07/15/national/nationalspecial/15SHUThttp://www.nytimes.com/2003/07/15/national/nationalspecial/15SHUThttp://www.nytimes.com/2003/07/15/national/nationalspecial/15SHUThttp://www.nytimes.com/2003/07/21/national/nationalspecial/21NASAhttp://www.nytimes.com/2003/07/21/national/nationalspecial/21NASAhttp://www.nytimes.com/2003/08/06/national/nationalspecial/06SHUThttp://www.nytimes.com/2003/08/06/national/nationalspecial/06SHUThttp://www.nytimes.com/2003/08/06/national/nationalspecial/06SHUThttp://www.nytimes.com/2003/07/16/national/nationalspecial/16NASAhttp://www.nytimes.com/2003/04/24/national/nationalspecial/24SHUThttp://www.nytimes.com/2003/02/03/national/03CHALhttp://www.nytimes.com/2003/05/01/national/nationalspecial/01SHUThttp://www.nytimes.com/2003/05/03/national/nationalspecial/03SHUThttp://www.nytimes.com/2003/07/07/arts/television/07SCHWhttp://www.nytimes.com/2003/07/17/national/nationalspecial/17SHUThttp://www.nytimes.com/2003/07/03/national/nationalspecial/03NASAhttp://www.nytimes.com/2003/07/09/national/nationalspecial/09SHUThttp://www.nytimes.com/2003/02/03/national/03PROBhttp://www.nytimes.com/2003/05/07/national/07ACCIhttp://www.nytimes.com/2003/06/28/national/nationalspecial/28SHUThttp://www.nytimes.com/2003/06/29/national/nationalspecial/29SHUThttp://www.nytimes.com/2003/07/15/national/nationalspecial/15SHUThttp://www.nytimes.com/2003/07/21/national/nationalspecial/21NASAhttp://www.nytimes.com/2003/08/06/national/nationalspecial/06SHUT


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Communication


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Wald, 2)B) 7!!", *ugust -8) Shuttle flights $ay resu$e before 4*S* culture changes) Retrieved on

*ugust -, !!" fro$ +++)nyti$es)co$/!!"/!-/!-/national/nationals#ecial/!-SEUT)

Wald, 2)B), J Sch+art6, ) 7!!", une 1"8) Shuttle investigator calls theory on foa$ Nho3u$)( Retrieved

on uly , !!" fro$ +++)nyti$es)co$/!!"/!/1"/national/nationals#ecial/1"SEUT)

Wald, 2)B), J Sch+art6, ) 7!!", uly 18) 4*S* $anage$ent failings are lin3ed to shuttle de$ise)

Retrieved on uly 1, !!" fro$ +++)nyti$es)co$/!!"/!/1/national/1SEUT)

Wald, 2)B), J Sch+art6, ) 7!!", uly "8) *lerts +ere lac3ing, 4*S* shuttle $anager says) Retrieved on

uly >, !!" fro$ +++)nyti$es)co$/!!"/!/"/national/nationals#ecial/"SEUT)

Wald, 2)B), J Sch+art6, ) 7!!", *ugust 8) Shuttle in9uiry uncovers fla+s in co$$unication)

Retrieved on *ugust , !!" fro$ +++)nyti$es)co$/!!"/!-/!/science/!SEUT)

Wheeler, B) 7!!", uly "8) Shuttle decision is defended) (tatesman ,ournal , *)

Whyte, ) 71.-.8) rou#thin3 reconsidered) Academ of anagement 1eview, 718, ##) !&>)

CB*IR' F'RR*RIS, Gh);), University of Utah, is *ssistant Grofessor in the S#eech Co$$unication

de#art$ent, Western Oregon University)

RO;4'5 C*RA'TE, Gh);), University of 2assachusetts 7*$herst8, is *ssociate Grofessor in the ;e#art$ent

of Co$$unication, Rochester Institute of Technology)

http://www.nytimes.com/2003/08/08/national/nationalspecial/08SHUThttp://www.nytimes.com/2003/08/08/national/nationalspecial/08SHUThttp://www.nytimes.com/2003/08/08/national/nationalspecial/08SHUThttp://www.nytimes.com/2003/06/13/national/nationalspecial/13SHUThttp://www.nytimes.com/2003/06/13/national/nationalspecial/13SHUThttp://www.nytimes.com/2003/07/12/national/12SHUThttp://www.nytimes.com/2003/07/12/national/12SHUThttp://www.nytimes.com/2003/07/12/national/12SHUThttp://www.nytimes.com/2003/07/23/national/nationalspecial/23SHUThttp://www.nytimes.com/2003/07/23/national/nationalspecial/23SHUThttp://www.nytimes.com/2003/07/23/national/nationalspecial/23SHUThttp://www.nytimes.com/2003/08/04/science/04SHUThttp://www.nytimes.com/2003/08/04/science/04SHUThttp://www.nytimes.com/2003/08/04/science/04SHUThttp://www.nytimes.com/2003/08/08/national/nationalspecial/08SHUThttp://www.nytimes.com/2003/06/13/national/nationalspecial/13SHUThttp://www.nytimes.com/2003/07/12/national/12SHUThttp://www.nytimes.com/2003/07/23/national/nationalspecial/23SHUThttp://www.nytimes.com/2003/08/04/science/04SHUT


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Communication

672 ferraris & carveth

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