From: NASA HQ
Posted: Monday, January 28, 2008
The last week of January brings, every year, a confluence of sobering anniversaries that we honor this Thursday with our Day of Remembrance. On Jan. 27, we marked 41 years since the loss of the crew of Apollo 1, and with it NASA's loss of innocence. The Apollo fire made it clear that we bring to spaceflight the same human flaws as our forebears who first sailed the ocean or went aloft in stick-and-wire contraptions. Successive generations have known the same harsh truth; the crew of Challenger was lost to us on Jan. 28, 22 years ago, and on Feb. 1 we mark five years since the loss of Columbia.
These losses carry an inevitable and awful guilt for those of us who have spent our professional lives on the edge of the possible in aviation and space. We know that what we do carries risk to ourselves or those who depend upon us, risk beyond what is customary in most other walks of life. This risk is endemic to flight in all its forms; it cannot be set aside. And yet, anyone who has ever sat on a failure board or read its report knows that there are no smart accidents. Every one is the result of human frailty, of things done or not done that are, in retrospect, obviously wrong. When this is seen in the harsh light of yet another accident report, it eats at us in a way that leaves no escape and never goes away. How could we have been so blind? Yet we were, and there is no going back, there is only forward, forward with the knowledge that we missed something crucial, forward with the resolve not to make the same mistake again.
When it comes to engineering and operations, we don't. We won't again put a crew in a cabin with high-pressure oxygen and no escape route. We won't again accept a joint design that is somehow "OK" because, even though its primary o-ring fails routinely, its secondary o-ring remains mostly intact. And we will never again believe that foam moving at high speed is, after all, just foam.
But as tempting as it is for us who are engineers and managers to take comfort in finding and fixing the root causes of these accidents and other near misses, I think we do ourselves a disservice thereby. For when we investigate, we always find that there were people who did see the flaw, who had concerns which, had they been heard and heeded, could have averted tragedy. But in each case the necessary communication -- hearing and heeding -- failed to take place. It is this failure of communication, and maybe the failure of trust that open communication requires, that are the true root causes we seek. These are the real reasons we have a Day of Remembrance, and need one.
I was reminded of this the other day when an old NASA friend sent me a congratulatory e-mail on the success, so far, of the Messenger mission to Mercury, and acknowledging my (small) role in it from an earlier professional incarnation. My friend started his note by saying that because his message was in connection with my prior role, he felt that he was not violating "protocol" or jumping the chain of command. And of course he was not.
But I worry whenever someone brings up a concern about communicating between different levels in the "chain of command." Whenever it arises, my own worry is that the free and necessary flow of information is inhibited.
We employ the organizational hierarchy and its accompanying flow of authority and responsibility to serve us, not to tie our hands. A healthy organization allows information to move up, down, and sideways, and pushes decisions, and trust in those decisions, down to the place where they can best be made. An unhealthy organization prevents needed information from flowing to those who must determine where that place is.
But no amorphous "organization" does these things. For good or ill, it is the people in NASA who do, or do not do, what is needed. So, if you find yourself with a concern that you are reluctant to speak about to your supervisor, or to have a conversation about outside your "chain of command," think about what that can cost. If you're the one hearing a concern, think about whether you're really listening, or just waiting politely until the speaker is done talking, and think about what that can cost. In either case, think about whether you're working in the right kind of organization to meet the exacting demands of what it is that we do. Don't leave for a better organization -- that's not the right answer. Help us make NASA what it needs to be.
The authority to provide direction lies in the chain of command, and belongs there. But to require the "chain of command" to be coincident with the "chain of communication" produces only dysfunction. The information that provides the situational awareness to allow good leadership, and good followership, belongs to us all.
Remember that the next time you are reluctant to speak, or impatient with listening, and remember the real reasons that we have a Day of Remembrance. The more we remember those real reasons, the longer it will be before we have another cause for mourning.
Michael D. Griffin
National Aeronautics and Space Administration
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