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Chapter Title: Contractor Relations Book Title: Organizational Learning at NASA Book Subtitle: The Challenger and Columbia Accidents Book Author(s): JULIANNE G. MAHLER and Maureen Hogan Casamayou Published by: Georgetown University Press Stable URL: JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at University Press is collaborating with JSTOR to digitize, preserve and extend access to Organizational Learning at NASA This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to CHAPTER 4 Contractor Relations THE SHUTTLE PROGRAMis the result of the contributions of a large number of contractors who design, construct, and maintain its components.

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In this chapter we investigate what part the heavy reliance on contractors and the complexity of synchronizing and communicating with numerous contractors might have played in the accidents. More to the point, might the fact that so many portions of the shuttle project were in the hands of contractors, which are separate organizations with different pressures and motivations, have inhibited NASA’s capacity to monitor and correct the flaws that caused the accidents? Learning in this case would mean figuring out how to manage contracts to overcome problems with communication and coordination. The key questions here are these: Did lessons about how to manage contracts emerge from theChallengerinvestigations?

Were these lessons still in evidence at the time of theColumbia?

Various past incidents arising from contractor relationships provide some rea- son to suspect that NASA’s contract-management capacities may have played a role in the shuttle accidents. Flaws, for example, in one of the Hubble Space Tele- scope’s mirrors that diminished the clarity of its images and required a later, elabo- rate in-space fix, were directly linked to imperfect grinding by the contractor, Perkin-Elmer Corporation, and went undetected by NASA until after launch. It was unclear who was responsible for the prelaunch failure to test the assembly:

The university contractors who were in charge of the mirror assembly assumed that Marshall was overseeing testing of the primary mirror (Levine 1992).

More recently, in 1999, NASA lost the Mars climate orbiter, which was designed to scout the terrain and relay messages from the Mars polar lander to Earth. The orbiter crashed into Mars ‘‘because of poor management, inadequate staffing, and the failure of the prime contractor, Lockheed Martin Astronautics, to convert critical navigation data from English units into metric as specified in its contract’’ (Naeye 2000, 24). Three months later, the $165 million lander was due to touch down on Mars but was never heard from. The causes of the lander’s failure were investigated by an independent panel headed by Tom Young, a 78This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 79 former Lockheed Martin manager, who specifically targeted NASA’s ‘‘Jet Propul- sion Laboratory (JPL) in Pasadena for failing to manage the last two Mars mis- sions adequately, [and took] both NASA headquarters and Lockheed Martin to task for their respective roles in the botched orbiter and lander projects’’ (Lawler 2000a, 32). In 2001 the delicateGenesisspace probe designed to sample solar wind atoms crashed in the Utah desert (Malik 2004). The mishap investigation board inquiring into the crash traced it to a flaw in the deployment of parachutes and parafoils that might have been detected by the contractor. But Lockheed Martin skipped a preflight procedure, opting for a simpler test (Associated Press 2006). NASA’s own independent review of contractor relations, the Kraft Report released in February of 1995, was very critical of contract management: ‘‘Many inefficiencies and difficulties in the current shuttle program can be attributed to the diffuse and fragmented NASA and contractor structure’’ (NASA 1995, 8).

The GAO had also been critical of NASA’s systems for managing contracts and acquisitions at least since 1990. It noted, ‘‘there was little emphasis on end results, product performance, and cost control; the acquisition process itself was awkward and time-consuming; and NASA found itself procuring expensive hardware that did not work properly’’ (GAO 2001a, 7). In 2000 NASA imple- mented its third attempt at a new, integrated contract-management system.

But GAO found that serious problems with integrating contract requirements remained. The GAO report took care to point out that when ‘‘building a system from commercial components, it is essential to understand the characteristics and credentials of each component to select ones that are compatible and can be integrated without having to build and maintain expensive interfaces’’ (GAO 2003, 3). GAO also found that the new system for tracking the details of budgets and contractors’ actual cost data as implemented ignored the needs of NASA’s own program managers: Accordingto…programofficials,theychosetodefercertainsystemcapabili- ties and related user requirements in order to expedite implementation of the core financial module. As a result, program managers and cost estimators told us that they will not rely on the core financial module and instead will con- tinue to rely on other systems or use other labor-intensive means to capture the data they need to manage programs such as the International Space Sta- tion. (2003, 4) Students of public management have also been suspicious of problems with organizational feedback and learning in the current climate of outsourcing. Kettl (1994) argues that when services are contracted out, critical information about the workability of programs is imperfectly passed on to the contracting agency.This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 80 Analyzing the Causes of the Shuttle Accidents Public agencies are, in effect, cut off from direct experience with the programs, and the contractors who are experiencing program effects do not have the authority to make program or policy changes. In addition, there is the problem of perverse incentives. It may be too much to expect that a contractor, whose continued funding or profitability depends on successful service, will report problems at the level of detail or with the interest in longer-term outcomes that actors in the agency themselves might do.

So for both historical and theoretical reasons, we might expect that the reli- ance on contractors for many shuttle components and services might have both contributed to the loss of the shuttles and made learning more difficult. We first investigate theChallengercase to determine how poor contract management contributed to the accident and what changes were instituted afterward to deal with identified flaws. We then examine theColumbiacase to determine if the same problems with contract management appeared. NASA–CONTRACTOR RELATIONS NASA has always relied on contractors, early on for hardware and propulsion systems and more recently for operational services for the shuttle as well. Even before 1958, when NASA was created from the National Advisory Committee for Aeronautics, contract engineers and scientists in the aeronautics and aerospace industry have been essential to the agency’s workforce. Early administrators favored contracting as a conservative management strategy to avoid increasing the size of government and to create a viable space technology industry (Brom- berg 1999, 40). Contracting has also been a political resource for NASA, offering a way to garner congressional support when contracts are awarded to firms in key states. A map of NASA contracts in 2003, for example, shows that the agency boosts the economy in every state, from a low of $1.3 million in South Dakota and Montana to a high of $3.79 billion in Texas (Wikipedia, NASA budget). On occasion, the political ties between some firms, Congress, and NASA officials may have influenced the selection of one contractor over another. NASA admin- istrator James Fletcher from Utah was the center of controversy when NASA awarded the solid rocket booster contract to Thiokol, also from Utah (Dunar and Waring 1999, 219). These kinds of ties also made large contractors into stakeholders with influence and leverage in their own right. NASA and the mili- tary needed them. They could ‘‘push back.’’ The dependency of NASA on contractors has grown in recent decades so that by the time of theColumbiaaccident over 90 percent of the shuttle workforceThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 81 were contract employees (CAIB, 106). Contract personnel were directly involved in the events surrounding both accidents and were among the first to express concern about the shuttle program elements that destroyed both theChallenger and theColumbia. After theChallengerdisaster, the Rogers Commission uncov- ered disagreements between contractors and NASA officials over how informa- tion about the reliability of the seals in cold weather had been clearly conveyed from Thiokol, the contractors for solid booster rockets, to NASA managers. The Columbia Accident Investigation Board reports that warnings and concerns of lower-level contract engineers about the need for in-flight images to determine the damage from foam debris were not heeded.

By 1986, the Marshall Space Flight Center in Huntsville, Alabama, managed the contracts with Thiokol in Utah for the solid rocket boosters and solid rocket booster motors, and the contract with Martin Marietta Denver Aerospace in Michoud, Louisiana, for the external tank. The Kennedy Space Center in Florida managed the contracts for shuttle-launch processing, and the Johnson Space Center in Houston managed the contracts for the orbiter. The engineers and managers in the contracting organizations formed Level IV in the flight- readiness-review hierarchy described in the previous chapter.

Relations between Marshall’s managers and its contractors were often diffi- cult. In the 1960s and ’70s a number of episodes raised suspicions about contrac- tors. Since the early 1960s, NASA had practiced what is called ‘‘penetration,’’ whereby agency engineers were permanently stationed in contract facilities to monitor quality and costs. With increased downsizing and reductions in force in the late 1960s, however, NASA lost some of its capacity to oversee contractor performance. Nevertheless, by 1978 Marshall was still assigning three shifts of its own engineers to the Thiokol facility to monitor operations. The NASA engi- neers identified twenty-six incidents leading to damaged components and other problems with quality control in 1977 and ’78, and Marshall blamed Thiokol management for the problems. Marshall was also critical of work by Martin Marietta and McDonnell Douglass on account of work errors, cost overruns, and schedule delays (Dunar and Waring 1999, 311). For their part contractors viewed Marshall’s oversight stance as overly critical, leading managers at all of the con- tractor facilities to become reluctant to report problems to their overseers (311). CONTRACTOR RELATIONS IN THE CHALLENGER ACCIDENT Thiokol conducted the lowest-level flight-readiness review of the solid rocket booster for the fatalChallengerflight, making a presentation to NASA managersThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 82 Analyzing the Causes of the Shuttle Accidents at the Marshall center on December 11, 1985. They also participated in the pre- sentation to the next level of NASA managers at the Solid Rocket Motor Booster Project Office at Marshall a week later. After that, in the six-week run-up to the launch, six more reviews were conducted at successively higher levels in NASA, ending with the signing of the flight readiness certificate.

Long before this final review process, however, as early as 1977, test findings led a pair of NASA engineers to call for immediate attention to the potential for hot gas leaks between segments of the solid rocket boosters from the rotation or twisting of the joints. The engineers argued that Thiokol was lowering the techni- cal requirements for the seals, but managers at both NASA and Thiokol rejected these claims (Dunar and Waring 1999, 345), observing that Thiokol was the expert in solid-rocket technology while Marshall’s work had been almost exclu- sively with liquid propellants. By 1982, NASA managers came to agree with their own engineers about the need to redesign the seal, but as noted in chapter 3, still believed the joint to be safe (Dunar and Waring 1999, 352).

Thiokol first denied that the early tests had revealed inherent flaws that would oblige them to undertake a costly redesign of the seal (Dunar and Waring 1999, 344; Rogers Commission 1986, 84). NASA, however, insisted that they wanted further tests as more launch experience demonstrated O-ring charring and seal erosion. Roger Boisjoly, a Thiokol expert on the joint seal, wrote a memo also expressing concern about test results and predicted that ‘‘NASA might give the motor contract to a competitor or there might be a flight failure if Thiokol did not come up with a timely solution’’ (Rogers Commission 1986, 139). He con- vinced the firm to set up an O-ring task force to recommend short- and long- term solutions (139). But the team made little progress, and internal memos from Boisjoly complain about administrative delays and obstruction in getting cooperation with Thiokol divisions that had other priorities. NASA, too, com- plained about the slow pace (141).

Meanwhile, Thiokol engineers assembled more information about the O-ring erosion and charring. Their data were used to determine that the seal mecha- nisms were no longer officially considered redundant because the secondary seal was not reliable. Thiokol engineers had also assembled laboratory data on the relationship between cold temperatures and the resiliency of the seal, and it used these data to brief Marshall and Level III officials in February 1985. As noted in the previous chapter, in August 1985, the erosion problems with the seals were presented at a meeting of Level 1 and Level III shuttle managers by NASA offi- cials from the solid rocket booster program and the Thiokol seal experts. All of the later external investigators of the accident agree that this information wasThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 83 available across the organization (Rogers Commission 1986, 148; Dunar and Waring 1999, 349).

However, disagreement surfaced in testimony before the Rogers Commission about how clear Thiokol engineers had been about the connections between cold temperatures and the resiliency of the O-ring seal, and it does not appear that the laboratory data were included in the August 1985 briefing documents (Rogers Commission 1986, 158). Roger Boisjoly, the Thiokol engineer who made the presentation and who had been a member of the solid rocket booster seal task force, however, argued that in at least one of the charts he had prepared for the briefing, the connection was clearly made (Rogers Commission 1986, 88–89).

Perverse Incentives: The Eve of theChallengerLiftoff The case was certainly made in the teleconference with NASA managers from Marshall and Kennedy and the Thiokol engineers and managers on January 27, 1986, the day before theChallengerlaunch. Boisjoly and his colleague Arnie Thompson expressed serious reservations about the launch based on the contin- ued cold weather at the Cape. At past launches in cold weather, temperatures had moderated by launch time. Boisjoly reported that he and Thompson had been successful in convincing the other Thiokol engineers and managers of the problem. Bob Lund, who was a Thiokol vice president and director of engineer- ing, summarized the findings with a recommendation that theChallengernot launch the next day because the O-ring temperatures predicted at launch time would be lower than on previous launches, that is, below 53 degrees Fahrenheit (Rogers Commission 1986, 91). He said, ‘‘Gee, you know, we just don’t know how much further we can go below the 51 or 53 degrees or whatever it was. So we were concerned with the unknown’’ (94). No one at this Thiokol meeting recommended launch. Boisjoly later testified, ‘‘There was never one positive, pro-launch statement ever made by anybody’’ (90).

But as we saw in chapter 3, NASA managers resisted this conclusion. George Hardy, deputy director of science and engineering, the safety organization at Marshall, said he was ‘‘appalled’’ at Thiokol’s decision because it would cause delays (90), but he said he would not support a launch against Thiokol’s recom- mendations. Lawrence Mulloy, manager of the solid rocket booster project at Marshall, was at Kennedy Space Center for the launch. He was obviously unhappy, and said he feared Thiokol was trying to ‘‘generate a new Launch Commit Criteria on the eve of launch’’ (96).

The arguments that Marshall shuttle managers used to resist another shuttle- launch delay were that there were, in effect, margins of safety in the seals becauseThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 84 Analyzing the Causes of the Shuttle Accidents they had withstood erosion in the past. Mulloy later testified, ‘‘My assessment at that time was that we would have an effective simplex seal, based upon the engi- neering data that Thiokol had presented, and that none of those engineering data seemed to change that basic rationale’’ (Rogers Commission 1986, 91). In addi- tion, they had seen erosion in both cold and warm temperatures. Unnoted were the larger number of instances of warm-weather launches where no erosion was found. But all this ignored the fact, clearly articulated by Richard Feynman in an appendix to the Rogers Commission report, that there was no margin of safety.

‘‘O-rings of the Solid Rocket Boosters were not designed to erode. Erosion was a clue that something was wrong. Erosion was not something from which safety could be inferred’’ (Rogers Commission 1986, vol. 2, F-2, 2).

At this point, one of the Thiokol managers, Joe Kilminster, who was vice president for space booster programs at Wasatch, Utah, called for a caucus of Thiokol staff ‘‘off the loop’’ (Rogers Commission 1986, 93). It was after this meeting that Thiokol management changed its position.

The dynamics of the thirty-minute caucus are instructive. It opened with a statement by Jerald Mason, the senior vice president for Thiokol in Utah, who said that because the matter boiled down to a judgment call, a management decision was required (Rogers Commission 1986, 92). Bob Lund, who earlier supported a launch delay, testified that he was asked by Mason ‘‘to take off his engineering hat and put on his management hat’’ (94). But Roger Boisjoly and Arnie Thompson continued to argue for a delay: ‘‘I tried one more time with the photos,’’ Boisjoly recalled. ‘‘I grabbed the photos, and I went up and dis- cussed the photos once again and tried to make the point that . . . temperature was indeed a discriminator and we should not ignore the physical evidence’’ (92).

As the meeting progressed, however, the consensus shifted to support Mason and the other managers in recommending launch. None of the other Thiokol mana- gers maintained their support for delaying the launch.

The Rogers Commission reports, ‘‘At approximately 11 p.m. Eastern Standard Time, the Thiokol/NASA teleconference resumed, the Thiokol management stat- ing that they had reassessed the problem, that the temperature effects were a concern, but that the data were admittedly inconclusive’’ (Rogers Commission 1986, 96). Kilminster formally released the Thiokol recommendation to launch.

Thiokol engineers said afterward that the decision had already been made by management, and that the normal burden of proof to demonstrate safety was, in this case, reversed so that they were being asked to prove conclusively that the launch wasnotsafe. According to Lund, I guess I had never had those kinds of things come from the people at Marshall.

We had to prove to them that we weren’t ready, and so we got ourselves in theThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 85 thought process that we were trying to find some way to prove to them it wouldn’t work, and we were unable to do that. We couldn’t prove absolutely that that motor wouldn’t work.’’ (Rogers Commission 1986, 94) Boisjoly also testified: Mr. Mason said we have to make a management decision. . . . From this point on, management formulated the points to base their decision on. There was never one comment in favor, as I have said, of launching by any engineer or other non-management person in the room before or after the caucus. I was not even asked to participate in giving any input to the final decision charts.

(92–93) Lawrence Mulloy, who was NASA’s manager of the solid rocket booster at Marshall, insisted that there was no management pressure and Thiokol had just wanted time to discuss the comments he and Hardy had made earlier (95). SHORT-TERM LEARNING ABOUT CONTRACTOR MANAGEMENT Several questions arise at this point. Why did the Thiokol managers accede to NASA management’s urgings? And why did Thiokol not act sooner to investigate and resolve the seal-erosion issues? We must also ask why NASA managers resisted Thiokol’s original advice on the eve of the launch. It is puzzling that no indications of learning by the participants emerge from the early indications of problems with the seals.

First, Thiokol managers were clearly daunted by NASA management’s reac- tion to their cautions about the launch. Mulloy’s rejection of each of the argu- ments offered by the engineers about the dangers of the launch left Thiokol managers without a rationale NASA would accept for refusing to fulfill their contract. Only with heroic self-sacrifice could they be expected to face the conse- quences of refusing their employer’s requirements. The Rogers Commission, in fact, offers as its fourth conclusion about the contributing organizational causes of the accident this statement: ‘‘The Commission concluded that the Thiokol Management reversed its position and recommended the launch of 51-L, at the urging of Marshall and contrary to the views of its engineersin order to accommo- date a major customer’’(Rogers Commission 1986, 104, emphasis added).

However, there was also a reluctance on Thiokol’s part early on to make changes to the seal. A redesign would have taken time and could have led toThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 86 Analyzing the Causes of the Shuttle Accidents delays. Pertinently, the contract specifications under which Thiokol operated provided no incentives to fix problems that were unlikely to significantly affect the mission; at the same time, the contract rewarded on-time delivery with incentive fees worth up to 14 percent of the value of the contract (Dunar and Waring 1999, 365) so that delays for redesign were costly. The report of Thiokol’s seal task force still was not available at the time of the accident. Robert Ebeling, a Thiokol manager overseeing the project, said the seal task force was ‘‘constantly being delayed by every possible means’’ and ‘‘Marshall Space Flight Center is correct in stating that we do not know how to run a development program’’ (Rogers Commission 1986, 141). Being unresponsive to the seal issues could also be costly, however, as Boisjoly feared.

The next question is perhaps harder to answer. Why did NASA not make better use of its contractor’s expert information? Thiokol engineers were not in the chain of command, and if NASA chose to downplay their warnings, it could.

That the information needed to monitor performance depended on reporting from the contractor who had incentives to present positive results is one of the circumstances that makes learning through contractors particularly difficult. The more typical situation is that contractors are unwilling to provide performance information in order to maximize their autonomy as agents, and this may have been the case earlier as Thiokol chose not to redesign the seal. In the end, how- ever, the situation appears to have been reversed: The contractor had informa- tion that the principal appears to have been reluctant to accept.

Thiokol engineers had collected data on precisely the problem at hand, launch in cold temperature. A year before the accident, they had put together charts showing the relatively greater chance of serious erosion in cold temperatures, but this information, presented at reviews at every level in the months prior to the launch, was not factored into decisions about launch readiness.

Several factors appear to explain NASA’s, especially Marshall’s, decisions.

First, program managers believed that the seals, though flawed, were safe. While this assessment appears highly questionable in hindsight, it seems to have been the consensus at the time. As noted in chapter 3, NASA managers were encour- aged in this assessment by internal rivalries, defects in incident-tracking and safety systems, and external pressures to increase the rate of launch. We will examine NASA’s motivations in pushing the schedule ahead for launch in the chapters that follow, but it is clear that whatever the agency’s motives, warnings by contract engineers in the months and days before the launch were not given high priority.This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 87 All of this compromised short-term, single-loop learning. We saw in the last chapter that NASA’s own problem-tracking systems were flawed, but the depen- dent position of the contractors and their willingness to alter their recommenda- tions based on what NASA managers wanted to hear made it easier for these managers to ignore the early results about the charring and erosion of seals.

NASA management’s ability to control contractor recommendations allowed managers to insulate themselves from the results of bench tests and postflight reviews, making it less likely they would openly confront problems and seek solutions. They did not take these warnings seriously, did not acknowledge the gravity of the erosion problem, and did not make the analysis of how to prevent erosion a high priority. Neither the managers at Thiokol nor those at NASA were willing to openly acknowledge the problems and make the search for new solu- tions a high priority. AFTER THE CHALLENGER :LEARNING ABOUT CONTRACT MANAGEMENT The management reforms that followed theChallengeraccident, as noted in the last chapter, focused on restructuring the agency and establishing more indepen- dent and authoritative safety reviews. Other changes addressed the issue of con- tractor independence. Did NASA learn to insulate contractors from undue pressure and improve its willingness to hear contract-engineer concerns? If the front-line experience of agency members is not sought out (or, even worse, is actively repressed), the feedback that makes learning possible will be lost. Any attempt to learn from the past, compare results, and explore promising cause– effect inferences builds on just this kind of information.

The Rogers Commission concluded that the contractors were, in fact, reluc- tant to report problems that might delay the launch. Incentives built into con- tracts discouraged time-consuming data collection, analysis, and the kind of reflection upon which new inferences about cause and effect may arise. Motiva- tion problems judged to lie behind shoddy work and errors in shuttle prepara- tions were tracked in turn to other lapses, including the absence of an error- forgiveness policy that might have encouraged reports of problems. A 1988 report titledLessons Learned from Challenger, commissioned by the Office of Safety, Reliability, Maintainability and Quality Assurance, was very critical of the lack of protection for contractors from reprisals for reporting errors or safety violations (NASA 1988). The report further notes:This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 88 Analyzing the Causes of the Shuttle Accidents The fear that punishment will result from an employee reporting a problem, as well as all other obstacles to proper problem reporting, must be minimized.

NASA must encourage its contractors to devise effective policies for forgiving or mitigating truly accidental damage. All operations and assurance personnel must understand that their contributions are vital to a safe and successful pro- gram. Problem reporting and good procedural discipline must be rewarded.

(NASA 1988, 56) In response to the Rogers Commission report and theLessons Learnedreport, NASA adopted several changes that were designed to make contractors more willing to report problems and to improve the flow of information between the agency and its contractors. The mission management team responsible for the shuttle from just before launch to the end of mission would now include project managers from the major contractors. This team would have the power to stop the countdown (Dunar and Waring 1999, 418). New contracting rules included incentive and performance criteria for mission safety as well as on-time work.

Explicit attention was paid to designing a new safety- and quality-assurance pro- gram to include oversight into the safety practices of contractors. Additional staff were to be placed at large contractor facilities to monitor safety (Rogers Commission 1986, 48). The ‘‘penetration’’ system of earlier periods at Marshall gained staff, and a resident quality office was established at the Thiokol facility in Utah (Dunar and Waring 1999, 414). These changes show NASA looking back to earlier practices and forward to new techniques for improving the information flow with contractors.

Other changes were made to directly address the issues in the overall shuttle- program structure and in the procedures for safety reviews. As noted in the last chapter, safety offices were moved outside the offices of the program component they were to oversee. They were relocated as separate center organizations that gave them greater visibility and autonomy. For contractors, this change meant that their concerns would be heard by officials who were not their managers or supervisors in the contract relationship. Contractors were encouraged to enter information in a new agency-wide, standardized mishap-reporting and correc- tive-action system, but special provision was also made to insulate contractors from reprisals for reporting problems. In its implementation of actions after the Challenger, NASA described a supplemental safety-information channel created to allow contractors to communicate safety concerns to an independent agent when, in their opinions, standard reporting channels lack the proper degree of response to a criticalThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 89 problem. This system, patterned after the FAA’s aviation safety reporting sys- tem, is not intended to replace normal management channels for reporting hazards or safety concerns. (Rogers Commission 1986, 50) These changes should have given the contract firms more independence to report bad news on the safety front. Though the Rogers Commission did not make detailed recommendations for changes in contract managementper se,it did require NASA to create an independent safety program that would insulate con- tractors. These would seem to be reasonable solutions for at least some of the problems with contract management. They are based on an explicit analysis of the flaws of the previous management of contractor relations, and they appear to indicate that learning has occurred. They were built in part upon vicarious experience, a best practice developed at the FAA to cope with similar problems with error reporting by pilots.

Because of theColumbiaaccident, however, we must ask whether these rec- ommendations were in fact fully institutionalized and whether they were still in place at the time of theColumbia. CONTRACT MANAGEMENT BEFORE THE COLUMBIA ACCIDENT NASA’s reliance on contractors was even greater in 2003 than it had been in 1986. Yet both the number of civil service employees at NASA and the number of contract workers had shrunk under relentless budget pressures and downsizing strategies of Administrator Goldin, taken up in detail in the next chapter. Goldin used these budget constraints to undertake other major changes in program structures and to begin the development of long-term projects, including the replacement of the shuttle technology (Lambright 2001, 9). Under his policy of ‘‘faster, better, cheaper’’ and inspired by his past success with TQM and the government reinvention strategies supported by the Clinton–Gore administra- tion, NASA’s total workforce had gone from just over 30,000 in 1993 to 17,462 in 2002 (CAIB, 106). By 2002 only 1,718 members of the shuttle workforce were NASA civil service employees, and the proportion of the workforce that worked under contract rose from 87 percent to just over 90 percent.

Ten year s after th eChallengeraccident, critics inside and outside NASA were demanding cost containment and management streamlining. In 1995, NASA commissioned the Space Shuttle Independent Review Team, composed of aero- space executives, former astronauts, and former NASA executives, to examineThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 90 Analyzing the Causes of the Shuttle Accidents NASA’s management structure and, particularly, its relationships with its con- tractors. Most of the team’s conclusions, including a recommendation to assem- ble multiple contracts and subcontracts under one ‘‘business entity,’’ were adopted. The review team’s report, commonly referred to as the Kraft Report, viewed the increasing reliance on contractors as inevitable but not without pit- falls,amongthosethelossofinternalexpertiseandprestige.Accordingtothe team, ‘‘One highly regarded NASA scientist recently put it this way: ‘People used to come to NASA for information, now they come for a contract’ ’’ (NASA 1995, 10). The report did, however, also support the next major change in the contract environment at NASA: the consolidation of contracts and subcontracts to reduce the number of ‘‘NASA-contractor interfaces’’ and simplify program management (11).

In all, NASA moved from a series of eighty-six separate agreements with as many as fifty-six firms to one major contract with the United Space Alliance (USA), created by Boeing and Lockheed Martin (CAIB, 107). In 1996, USA was awarded a sole source agreement to conduct the day-to-day operation of the shuttle program (107–8). The contract gave USA responsibility for shuttle hard- ware, mission design and planning, crew training, software design, flight opera- tions, and facility maintenance (109). The contract was performance-based and offered incentives to USA for cost reductions. Performance was to be evaluated on ‘‘safety, launch readiness, on-time launch, solid rocket booster recovery, proper orbital insertion, and successful landing’’ (109). Renewed and revised many times, the original contract ran out in 2006. A new, final contract was implemented in October of that year to run through the planned retirement of the shuttle in 2010 and established ‘‘USA as NASA’s primary industry partner in human space operations, including the Space Shuttle and the International Space Station’’ (United Space Alliance 2006).

The contract also gave added responsibilities to USA for safety inspections, requiring the contractor to meet a ‘‘series of safety gates’’ (CAIB, 108). NASA retained ownership of the shuttles and their launch components and was still in charge of safety procedures, performance audits, and ‘‘commit to flight’’ deci- sions (109). But the change in contract responsibilities had the effect of distanc- ing NASA from safety information. NASA now had only ‘‘insight’’ into safety through a system of reviews and ‘‘metrics’’ provided by contractors (179).

According to the Columbia Accident Investigation Board, ‘‘Collectively, this eroded NASA’s in-house engineering and technical capabilities and increased the agency’s reliance on the United Space Alliance and its subcontractors to identify, track, and resolve problems’’ (CAIB, 179).This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 91 The object of consolidating contracts was to reduce overhead and inefficien- cies ‘‘attributed to the diffuse and fragmented NASA and contractor structure . . . [with] ambiguous lines of communication and diffused responsibilities’’ ( NASA 1995, 11). The same NASA-commissioned analysis criticized the existing safety system as ‘‘duplicative and expensive’’ (10). It claimed that the safety, reliability, and quality-assurance effort had become overgrown afterChallenger and now stifled innovation and decisions involving risk. ‘‘Indeed,’’ the report ran, ‘‘the system used today may make the vehicle less safe because of the lack of individual responsibility it brings about’’ (10). The Kraft Report recommended that safety monitoring be restructured ‘‘to minimize parallelism and delegate greater responsibility to the contractor . . . to establish clear lines of responsibility with only the necessary checks and balances in place’’ (NASA 1995, 18–19).

TheColumbiaaccident investigators later noted that these new contracting arrangements created structural constraints that ‘‘hindered effective communica- tion’’ (CAIB, 182) and created a complex system of joint review and oversight that complicated the task of supervising contractors. The new contract made NASA decision makers more dependent on contractors for technical expertise (179), and, as noted earlier, because of the rollback of many safety checkpoints, it made the safety system ‘‘simultaneously weaker and more complex’’ (179).

The contracts created a demand for ‘‘better communication practices’’ (179) that was not met. Best practices seen in other high-risk programs, such as the Navy’s nuclear submarine programs, require that contractor recommendations be inde- pendent and peer-reviewed, a pattern at odds with the way contractor reports were handled at NASA (182). In contrast, the shuttle program essentially bought the safety services under contracts with the centers, decentralizing the safety sys- tems and making the safety experts dependent on the continued viability and funding of the shuttle program (186). A study by the General Accounting Office, as it was then called, conducted in 1993 also characterized NASA management as decentralized, a reversal of the earlier lesson learned afterChallengerabout the value of centralization. It further noted that NASA’s centers had ‘‘considerable latitude in many areas, including the award and administration of almost all of the agency’s contracts. For this approach to be effective, headquarters must set clear expectations and carefully monitor and measure the centers’ management of their own activities, as well as those of NASA’s contractors’’ (GAO 1994, 14).

All of these changes reduced the level of contact and interface between NASA managers and contractors, further limiting their ability to communicate their concerns.

At the end of the Clinton administration, agency officials considered taking contracting further to privatize the shuttle operation entirely. Shuttle ProgramThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 92 Analyzing the Causes of the Shuttle Accidents Manager Dittemore argued for privatization, noting that merging the ‘‘skills bases’’ was necessary if the shuttle was to remain ‘‘safe and viable’’(CAIB, 109).

But some NASA personnel objected to the downsizing and shift of responsibility within the agency. A senior Kennedy center engineer wrote to the president in 1995 that the shrinking of the NASA civil service force threatened safety and that the long-standing use of two teams of engineers—NASA’s and contractors’—was necessary to ‘‘cross check each other and prevent catastrophic errors.’’ He also claimed that only a hidden agenda or fear of job loss deterred others from saying so, too (108). The director of the Kennedy Space Center threatened to resign over personnel cuts he considered too deep, and both internal and external stud- ies convinced top NASA officials to halt the cuts and hire several hundred more workers (110).

Some positive developments in creating richer communication pathways between NASA and its contract workers did, however, emerge. A GAO study of communications in the shuttle program in 1996, after the consolidation of the contracts, finds two important changes that derived directly from findings about the management of contractors before theChallengeraccident. Relying on focus groups, GAO researchers reported: ‘‘One manager noted that theChal- lengeraccident prompted a change in his contractor’s management approach.

Before the accident, company meetings were closed to the NASA site represen- tatives. Since the accident, NASA representatives attend all technical meetings’’ (GAO 1996, 20).

In addition, efforts were made to induce contractors to be more forthcoming about reporting safety issues on their own. The purpose was to address the con- cerns expressed in the 1988 report for the Office of Safety, Reliability, Maintain- ability and Quality Assurance (NASA 1988). These changes were also part of a larger attempt at culture change covered in chapter 6. Working engineers in contract organizations noted that they were encouraged to report problems: For example, at one contractor facility, program teams are structured so that minority opinions about the handling of safety problems can be elevated to a higher level board. At another contractor facility, the work environment was described as one that encourages debate, discussion, and never keeping a safety concern quiet. At the third contractor plant, the formal reporting process ensures that NASA and contractor managers are continually apprised of issues, review how issues are resolved, and can request more work if they do not agree with the resolution of a safety issue. (GAO 1996, 21) In sum, of the numerous post-Challengerchanges in the design and functioning of the safety system, many targeted relations with contractors, including changesThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 93 in flight-review procedures, monitoring of contractors, and contract cost provisions.

To implement one of the commission’s recommendations, an official from the new safety organization, the Office of Safety, Reliability, Maintainability and Quality Assurance, was detailed to participate in revising contractor fee incen- tives so that work to improve safety was given higher priority (Rogers Commis- sion 1987, 51; Dunar and Waring 1999, 410). To encourage contractors to report problems, they were given the option to report their concerns to safety offices outside the chain of command of the program offices whose decisions they were questioning (Rogers Commission 1987, 50). This last set of changes was not long-lived, however. By the mid-1990s, as noted in the previous chapter, under pressure for downsizing and streamlining, the real independence of the center- level safety offices had been eroded.

Other changes as well were designed to ensure more open and complete infor- mation sharing between contractors and NASA management. AfterChallenger, Marshall replaced site visits to contractor facilities with an on-site quality office at Thiokol’s Utah facility (Dunar and Waring 1999, 414–15), a system used also in the earlier years of Saturn rocket development when the center had higher levels of personnel and funding (Dunar and Waring 1999, 44). We will see how these changes affected the ability of contractors to voice their concerns in the run-up to theColumbiaaccident. The role of contractors in theColumbiaacci- dent suggests that these changes were in some respects durable and effective.

Contractor Concerns about the Foam Strike Contractors were important in the events that led to the loss of theColumbia.

The external tank was manufactured by Lockheed Martin Space Systems at the Michoud assembly facility outside New Orleans under contracts managed at the Marshall Space Flight Center, and the major part of the foam insulation was installed there. As noted in the previous chapter, problems with foam shedding were well-known and had been seen in sixty-five of seventy-nine previous launches, including many from the same area of the external tank (CAIB, 122).

In the flight prior to theColumbia, ST-112, particularly serious damage had been caused by foam debris. Though the formal shuttle specifications explicitly precluded debris shedding (122), the divots in the thermal tiles produced when foam pieces struck the shuttle had become so common that they were accepted by contractors and NASA engineers as problems of maintenance or ‘‘turnaround.’’ During the launch of theColumbia, the Intercenter Photo Working Group captured the blurred image of the foam strike and distributed it to a wide circleThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 94 Analyzing the Causes of the Shuttle Accidents of NASA and contract personnel. As noted in chapter 3, it was a USA engineering manager who, observing this largest yet debris strike, classified it as ‘‘out of fam- ily’’ (CAIB, 143, 171), that is, an event outside the known performance range and experience (122). According to the CAIB, ‘‘In the case of the foam strike on STS-107 (Columbia), which was classified as out-of-family, clearly defined writ- ten guidance led United Space Alliance technical managers to liaise with their NASA counterparts’’ (142). Under NASA procedures designed to ensure coordi- nation between NASA and its contractors, the classification of the foam strike event as out-of-family required NASA engineers to coordinate with contractors on the investigation, first as a debris assessment team, and then as a ‘‘tiger team’’ (142), cochaired by NASA and USA representatives. The assessment team was formed with members from both NASA and USA, but the group was never designated as a tiger team. The CAIB notes, ‘‘This left the debris assessment team in a kind of organizational limbo, with no guidance except the date by which Program managers expected to hear their results: January 24th’’ (142). In conse- quence, communication problems between this team, designated to pursue the problem, and the mission management team, which had the authority to order the necessary better imagery, plagued the rest of the flight, as noted in the previ- ous chapter.

We begin to see at this point in theColumbiacase the same kind of differences in level of concern between the managers and working engineers that had occurred in theChallengercase. Engineers from the Intercenter Photo Working Group thought the orbiter had sustained damage from the strike (CAIB, 142), while Ralph Roe, from NASA’s Shuttle Office of Vehicle Engineering, and Bill Reeves, the USA manager, thought it unlikely that the strike threatened the safety of the flight. They planned to reconvene for a review of the evidence after the Martin Luther King weekend. But USA/Boeing contract engineers, without even encouragement from higher-level management, much less orders, worked through the holiday weekend on the analysis of the strike with their computer model for predicting tile damage, Crater. Unfortunately, the team of contract engineers at Johnson Space Center who performed the analysis was relatively new to the task, because the Boeing contract had just been shifted from California to Houston, and the transition was incomplete. This was the first mission to be undertaken by the engineers at Houston without the guidance of the more expe- rienced analysts in the Huntington Beach facility (190). The CAIB said, ‘‘NASA failed to connect the dots: the engineers who misinterpreted Crater—a tool already unsuited to the task at hand—were the very ones the shuttle programThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 95 identified as engendering the most risk in their transition from Huntington Beach’’ (190).

The debris assessment team did meet informally on Monday, cochaired by Pam Madera from USA and Rodney Rocha, NASA’s designated engineer for the shuttle’s thermal tile system. This meeting included an expanded list of participants, including tile experts from NASA and Boeing, and a representative from the safety contractor, Science Applications International. The composi- tion of this group, particularly in its larger form, illustrates the efforts NASA made to foster communication and coordinated action between itself and its contractors. The meeting ended with an agreement that images of the wing were needed. As noted in the previous chapter, this and other requests were never granted. The formal and informal petitions from the group that had been assembled to look at the problem were dismissed for lack of concrete evidence of the severity of the strike damage. In examining the role of contractors, it is important to note that the requesters included, by design, both NASA and contractor employees.

The safety contractor Science Applications International agreed with the shut- tle program managers and introduced little into the electronic safety log over the duration of the flight (CAIB, 166). Safety personnel, including both contract and NASA staff, were present but passive in the meetings of the debris assessment team, the mission evaluation room, and the mission management team (170).

The safety contractors in the mission evaluation room ‘‘were only marginally aware of the debris strike analysis’’ (170). They deferred to shuttle program man- agers and failed to act as an ‘‘independent source of questions and challenges’’ (170). Having been told that the mission management team had classified the strike as an ‘‘in-family’’ event, they took their inquiries no further (153).

What we see in this summary of evidence about the role of contractors in the Columbiacase is that engineers at the lower levels of both NASA and contractor hierarchies were typically more worried about the effects of the strike, more apprehensive about the limitations of their models and projections, and more concerned about the need for imagery than most (but not all) of the higher-level NASA project managers. The classification of the strike as out-of-family was initially made by a USA manager, and that classification was resisted by the NASA managers in the mission evaluation room and the mission management team. After that, various requests for images by both lower-level NASA and USA engineers were miscommunicated or misrouted and eventually turned down. In contrast to what occurred in the case of theChallenger, however, the fault line for information was not usually between contractors and NASA personnel, butThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 96 Analyzing the Causes of the Shuttle Accidents between levels of NASA management. Resistance to investigating the size and location of the strike came from mission managers who were reluctant to ques- tion the rationale to launch and thus delay the next flight. CONTRACTOR RELATIONS AND ORGANIZATIONAL LEARNING The CAIB concluded that NASA was not a learning organization because of the similarities overall in the organizational patterns and management actions that led up to the two shuttle accidents. However, a comparison of the role of con- tractors and the course of contractor management in the accidents suggests that NASA did learn to avoid the agency–contractor communications and incentives problems that had emerged in theChallengercase. That is, there were some important similarities but also significant dissimilarities between the two cases in the relationship between contract engineers and managers. By 2003 better communication across NASA–contractor lines and written guidance for joint decision making in the case of an out-of-family event were in place. Not all of the guidance was followed, but the parts relating to the constitution of the debris assessment team did operate successfully.

The two accidents are similar, however, in that neither contractors nor NASA officials stopped the launches to remedy known problems that violated formal shuttle specifications. And in both cases, upper-level NASA managers disre- garded the sometimes diffidently expressed concerns of both contract and NASA engineers during the flight. In neither case was critical information about safety fully and unambiguously communicated. Questions remain about whether Thio- kol’s graph communicated the pattern of cold-weather failure of the O-rings adequately to NASA managers on the eve of theChallengerlaunch. Similarly, in theColumbiacase, the ‘‘viewgraph’’ slide meant to summarize the findings of the USA and Boeing engineers aboutColumbiatile damage failed to clearly con- vey the engineers’ real uncertainties.

But it is also true that the decision makers to whom the engineers’ reserva- tions were, perhaps imperfectly, conveyed were not actively looking for evidence that could challenge the conclusions they had already drawn. The Rogers Com- mission found fault with the insularity of the Level III NASA administrators at the Marshall Space Flight Center and their unwillingness to pass along critical information (Rogers Commission 1986, 200). Similarly, the CAIB report noted several times that theColumbiaproject managers ‘‘resisted new information’’ and had determined that the foam strike did not pose a safety issue long beforeThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 97 analysis began (CAIB, 181). It is also clear that oversight and support for the debris assessment team, which the mission management team should have pro- vided, was missing. The effect of this neglect was to allow requests for imaging to go astray. These lapses in communication, however self-inflicted, also reduced the ability of the mission management team to detect the debris assessment team’s real level of uncertainty. Furthermore, the contract organization assigned to monitor safety was largely absent from the scene. Only two comments on the foam strike situation, both minor, were lodged by this contractor (170).

Though the evidence seems to point to the contributory effects of poor con- tractor relations in theChallengercase, contractor management does not appear to have played a major role in theColumbiaaccident. Both USA and NASA engineers in the debris assessment team sought images, and both submitted to pressure to provide an estimate of damage that ignored uncertainties. Even if they had persisted in calling for images of the damaged wing, it is far from clear that upper-level program managers would have acceded to their request. Though the CAIB does not exonerate miscommunication across NASA–contractor lines in theColumbiaaccident, neither do they identify contractor relations effects as a significant cause. LEARNING, UNLEARNING, AND FORGETTING What does this tell us about whether NASA learned lessons from theChallenger accident about managing contractors? The answer, not surprisingly, varies depending on the lesson. First, some learning clearly did occur. Changes to coor- dinate contractor and agency crisis decision-making procedures and to share information more completely were made after theChallengeraccident, and they were largely in place at the time ofColumbia. These changes were invented and designed by NASA. They were not simply the recommendations of an outside body, and their institutionalization is reported in the post-Challengerimplemen- tation report issued in 1987. Furthermore, we see them in place during the Columbiacrisis. Thus they appear to meet the requirements for a learned response.

AfterChallenger, contractor incentives and communications issues had been addressed. NASA did change structures and procedures based on past events.

The debris assessment team and the mission evaluation room both were staffed by a combination of NASA and USA personnel. The debris assessment team was cochaired by Pam Madera from USA and Rodney Rocha from NASA. Though there were still incentives for cost-cutting and on-time performance in the newThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to 98 Analyzing the Causes of the Shuttle Accidents USA contract structure, we do not see the USA management resisting imaging in theColumbiacase. The communications problems that emerged during the Columbiaflight were not along NASA–contractor lines but between levels in NASA’s own management hierarchy. The impact of the organizational isolation of the Thiokol engineers in theChallengerhad been noted, and a remedy was designed and instituted, all of which constitute reasonable evidence of learning.

In addition, fear of reprisals for reporting problems had been addressed at least in part by creating separate safety offices that contractors could report to if they felt they were not being heard. Larger numbers of NASA liaisons were also installed at some contractor facilities. These actions provided communication channels outside of the chain of command, though as will be noted in chapter 6, they were not necessarily trusted. Nevertheless, the changes can reasonably be considered as lessons learned. The Rogers Commission had made a general recommendation about the independence of contractors, but NASA elaborated on this recommendation and charged its own Office of Safety, Reliability, Main- tainability and Quality Assurance to further investigate the problem.

Unfortunately, more sweeping changes to the design of the safety structures that were to have decentralized safety offices and made them more prominent and aggressive were ‘‘unlearned’’ in the streamlining and downsizing of the 1990s, as noted in chapter 3. There is no indication that these changes were based on a considered decision to reduce unnecessary levels of independence for contractors generally or safety contractors in particular. On the contrary, a GAO report noted the efforts NASA management was making to encourage indepen- dent voice. Rather it appears the lessons about contractor independence were dropped as a by-product of the other changes to cut costs, streamline the chain of command, and consolidate offices. The lessons about an independent safety organization were swept aside, justified by the logic articulated in the Kraft Report that a ‘‘diffuse and fragmented NASA and contractor structure’’ (NASA 1995, 8) did not provide accountability.

Some lessons learned afterChallengerappear also to have been unintentionally lost or forgotten. Despite the initial efforts to remedy contractor relations, the debris assessment team chaired by Madera from USA and Rocha from NASA was isolated at the time of theColumbiaaccident. Two reasons for this appear in the case. The cochairs persisted, but only up to a point, in pressing for images of the wing. In part, their lack of success was due to the fact that downsizing and multi- ple reorganizations had left the agency with few people who seemed to know the procedures for obtaining images. In addition, however, existing, known proce- dures were not being observed by program managers. The debris assessment team was isolated because the mission management team did not follow establishedThis content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to Contractor Relations 99 rules and did not pay attention to the team’s requests and analyses. Similarly, the mission evaluation room and the safety offices were not fully engaged. They were caught between the debris assessment team’s uncertainty about the severity of the damage and the mission management team’s determination to prevent foam strikes from becoming the kind of issue that would delay subsequent flights. The mission evaluation room did not pass along the debris assessment team’s actual degree of uncertainty or its desire for images. Later, Rocha said he regretted not having been more forceful in making the case for images to the mission manage- ment team (Wald and Schwartz, 2003). Why he did not is the subject of the next two chapters. But what this failure to follow the rules suggests is that, in practice, NASA’s upper management neglected the procedures and the lessons embodied in them. In the face of pressures to avoid delays in the long-term launch schedule and the structural streamlining and downsizing that were part of cost-reduction strategies favored by several administrations, they forgot lessons from theChal- lengerabout tracking engineers’ concerns.

Though the two shuttle accidents are similar in many respects, the contractor relations played out differently, at least in part because of the changes made between 1986 and 2003. Even though problems with communication remained, and some of them involved contract employees, NASA did learn some lessons about managing their complex contracting relationships after theChallenger accident. They learned how to create workable communication opportunities for NASA and contract engineers, though not, apparently, for the safety contractors.

We conclude that NASA did learn some important lessons about managing con- tractor communications, and it did institutionalize these lessons into new rules.

But at the critical time, some of these rules were forgotten or displaced by more pressing priorities.This content downloaded from on Fri, 15 Oct 2021 18:59:35 UTC All use subject to

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