哈佛商學院羅伯托邁克爾A教授《如何設計和管理團隊》

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LectureText

ProfessorsAmyC.Edmondson,MichaelA.Roberto,andRichardM.J.Bohmer

OrganizationalLearningintheFaceofAmbiguousThreats

Introduction

(editedforclarity)

PROFESSORMICHAELROBERTO:WelcomebacktoHBS.It’sgoodtoseeyouherethismorning.ThefirstthingI’dliketodoisintroducetwocolleagueswhoarealsogoingtopresentwithmethismorning.ThefirstisAmyEdmondson,andthesecondisRichardBohmer.Overthepastyear,wehavebeenstudyingtheColumbiaspaceshuttledisaster,whichtookplaceinearly2003.ThisdisasterhasbeenparticularlyinterestingtousbecauseofmanyoftheorganizationaldynamicsthatweregoingonwithinNASAthatcontributedtothedisaster.Andthat’swhatwe’dliketotalktoyouabouttoday.

Aftertheaccident,therewasaninvestigationboardnamed,calledtheColumbiaAccidentInvestigationBoard(CAIB),andtheyreallydidanoutstandingjobofanalyzingthisincident—oneofthebestinvestigationreportsthatI’veeverseen.BrigadierGeneralDuaneDealwasamemberofthatboard,andhesummarizedtheirfindingsinthissimplephrase:“Thefoamdidit;theinstitutionallowedit.”

Thefoamdiditbecausethereasonthespaceshuttlecrashedwasthatfoamdislodgedfromtheshuttleduringlaunchandstrucktheleadingedgeofthewing.Andthatfoamstrikepuncturedaholeintheleadingedgeofthewing.Anduponreentryintotheearth’satmosphere,hotgaseswereabletogetinsidetheinternalstructureoftheshuttle,andcauseitto,essentially,disintegrate,comingbackintotheearth’satmosphere.

Sothefoamwasthetechnicalcauseoftheaccident.But,infact,whenthesekindsofthingshappen,wereallywanttopushbeyondthat—beyondthewidget,thetechnicalthingthatcausedtheproblem—andlooktotheorganizationalcauses.Whatallowedthemnottounderstandandfixthisproblem,eventhough,itturnsout,foamhadbeenstrikingeveryshuttle,nearlyeveryshuttle,sincethebeginningoftheprogramintheearly1980s?Sowhyisitthat—knowingthatfoamhadcontinuedtostriketheshuttle—forsomereason,theyhadnotbeenabletopreventorfixthisproblem,andtheyhadn’treactedinadifferentwayduringthisshuttlemissionwhentheydiscovered,onDayTwo,infact,thatfoamhadstruckonceagainduringlaunch?

Sowhatisitabouttheorganizationthatcontributedtothis?Howdidtheinstitutionallowthisaccidenttooccur?Andthat’swhatwe’dliketotalktoyouaboutthismorning.

LessonsLearnedFromColumbia

Letme,beforewediveintoallthedetails,giveyouabroadoverviewofwhatthelessonsarefromthisincidentandhowtheyapplytomanagementinalltypesoforganizations.

Ambiguousthreats

First,wewanttopointoutthatallorganizationsfaceambiguousthreats,attimes.Thefoamstrikingtheshuttleissomewhatofanambiguousthreat.Whyisthat?It’sbecausewedon’tknow,whenweseethefoamstrike,whetheritactuallypuncturedaholeornot;whether

AmyC.Edmondson,MichaelA.Roberto,RichardM.J.BohmerOrganizationalLearningintheFaceofAmbiguousThreats

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that’sathreattotheintegrityofthevehicleornot;whetheritwillcauseanaccident.It’sanambiguoussignal,anambiguousthreat.

Andallorganizationsfacethoseattimes:Firestone,severalyearsago;Johnson&Johnson,theTylenolincident,ofcourse,reactinginadifferentway,twentyyearsago,whenthatincidenthappened—moreaggressively,morevigorouslyaddressingtheambiguousthreat.

Therecoverywindow

Theideaisthatwiththosethreatscomesafiniteopportunityforrecovery,beforeamajorfailureoraccidentoccurs.Thisissomethingwecalltherecoverywindow:somefiniteperiodoftimeinwhichyouseeanambiguousthreat,andyouhavesometimebeforethatthreatturnsintoamajoraccident.

Organizationsunderreact

Unfortunately,ourhypothesis,ourtheorywewanttoputforththismorning,isthatorganizationsofallkindsarepredisposedtounderreacttoambiguousthreats,asNASAdidinthiscase.Andso,wehavetwoquestions.Oneis,whydoorganizationsdownplaythesethreats?Andtwo,howcanorganizationsrespondandrecovermoreeffectively?

AndI’vegivenyousomeexamplesofsafetyincidents—Merck,Firestone,Johnson&Johnson,NASA.Butthisalsopertainstocompetitivethreats,ifyouthinkbacktotheearly1970s,andhowthebigthreeautomakersreactedtoearlysignsoftheJapaneseimportsmakinginroadsintheUSmarket.Andthereareampleexamplesofhowtheydownplayedthatsomewhatambiguousthreattotheircompetitivepositionnumeroustimesthroughoutthe‘70s,andintothe‘80s,infact.

Andso,whyisitthatorganizationsseemtonaturallydothat,andhowcouldtheyresponddifferently?

Sotheconcept,then,isthatthereisthisperiodoftimebetweenanambiguousthreatandanaccident,orpreventedaccident,duringwhichpreventiveactionisfeasible.We’velabeledthattherecoverywindow.Andwe’regoingtospendourtimenow,inthenexthour,lookingattherecoverywindowatNASA,fromthetimethefoamstrucktheshuttle,ortheydiscoveredthatfoamhadstruckit,totheaccidentthatoccurredabouttwoweekslater.AndwewanttounderstandwhatwasgoingonatNASAinthosetwoweeks.Andthenwe’lltalklaterabouthowtheymighthavebehaveddifferently.

Columbia’sRecoveryWindow

Let’sjustgothroughthetimeline.

Launchday

January16,2003:Foamstrikestheshuttleduringlaunch.Adaylater,agroupthatlookedatphotosofthelaunchdiscoversthefoamstrike.Theyseeitdislodgingonthephoto.It’saveryhazy,difficult-to-discernphoto,buttheycanseethatsomethingdislodges,lookslikefoam.It’sfoaminsulationthat’susedonthetanks.Andthat,infact,itisstrikingsomewhereonthewing,althoughthey’renotexactlyclearifit’stheleadingedge,orifitstrucksomeofthetilesthatareunderneaththewing.That’shardtodiscern.

Sothisistheambiguousthreatthatoccurs.And,ofcourse,twoweekslater,onFebruary1,theshuttletriestoreentertheearth’satmospheretolandinFlorida,anditbreaksupuponreentry.That’sthemajoraccident.Soit’stheperiodbetweendiscoveringtheambiguous

threatandtheaccidentthatwe’relabelingtherecoverywindow.Letmegiveyouabitmoredetailaboutwhathappenedduringthatrecoverywindow.Solaunch.Thefoamstrikeactuallyhappenseighty-twosecondsintoascent—very,veryearlyonduringthelaunch.

FlightDayOne

AndonFlightDayOne,whichisthedayafterlaunch,theMissionManagementTeamlearnsaboutthefoamstrike.TheMissionManagementTeamisthegroupresponsiblefor,essentially,runningthismission.Itisleadbyamiddlemanager,inthiscase,namedLindaHamm.Youmayhaveheardofher.Shewasresponsibleforoverseeingthisgroupofothermanagers,andengineers,andtechnicians,whoweregoingtomonitorthismission.

Andtheywereresponsibleifanyanomalies,anyissuesarosetoresolvethoseduringtheflight.Theylearnaboutitveryearlyon.Butseniormanagers,bothontheteamandoutsideoftheteam,affirmalongstandingbeliefwithinNASAthatisthatfoamstrikesare,infact,notdangerous:Theyarenotasafety-of-flightrisk.

ThisisalongstandingbeliefwithinNASA.Remember,foamhasbeenhittingtheshuttlefor,atthispoint,twentyyears.And,infact,notonlythat,theyknowthatit’sdoingdamagetotheshuttle.Becausewhenitreturns—theyofcourseinspecttheoutside,andtheyseedamagetothetiles,damagetothewings,damagetheydon’tconsiderseriousenoughtoimperilthevehicle.But,infact,they’veseenthedamage.Theyknowithappensovertime.

Andpartofthestoryhereisthat,overtime,thiswentfrombeingunexpected,toexpected,toaccepted.That’sthewaysociologistDianeVaughan,whostudiedNASAfortwodecades,describeswhathappeninghere.We’regoingfromtheunexpected,totheexpected,totheaccepted.Andthat’swhat’sgoingon.Thislongstandingbeliefhasmadethisaveryacceptedthingbynow.Sotheyconsideritnotdangerous,andtheyreaffirmthatbeliefveryearlyonafterhearingaboutit.

Concernedengineers,however,formsomethingcalledtheDebrisAssessmentTeam(DAT).Theyareabitmoreconcernedthantheseniormanagers,andtheydecidetoformagroup,anadhocgroup,andtoinvestigateabit.Andtheyandothersbegintomakerequestsforadditionalimagery:“Weneedbetterphotostounderstandhowbigwasthispieceoffoam,howmuchofanimpactdidithaveand,veryimportantly,wheredidithittheshuttle?”Wherematters.Ifithitsthetilesthatareunderneaththewing,that’smuchlessdangerousthanifithitstheleadingedge,whichisadifferentkindofmaterialandamuchmoreperilouspointontheshuttleatwhichdamagecouldoccur.

Andsotheyaskformoreimagery.Infact,manypeopledo.Therearethreerequestsforadditionalimagerythathappen,thefirstofwhichhappensonDayOne.

FlightDayFive

OnDayFive,theMissionManagementTeamhasanimportantmeetingatwhichitsleader,LindaHamm,says,“Thefoamstrikeisnotreallyafactorbecausethere’snotmuchwecandoaboutit.”Meaning,evenif,infact,itdidpuncturetheleadingedgeandcreateasizeablehole,wecan’thelpthesepeople.Andthisisn’tjustherview,thisisactuallyaviewthat’sfairlyprevalentamongpeopleatNASA.Itturnsoutitisratherdifficulttogosavethesefolks,althoughnotimpossible.

FlightDaySix

FlightDaySix:Theimageryrequestsarecancelled.Theynevereventookadditionalphotostoinvestigate.Nevermindtryingtosavetheastronauts.Theydidn’teventakeadditionalphotos.What’sgoingon?We’regoingtotrytoexplainthattoday.

FlightDayEight

FlightDayEight.Withoutimagery,theDebrisAssessmentTeam—theseengineerswhoare,bytheway,bothfromNASAandBoeing,who’sjustoneofthecontractors—theyrelyoncomputermodelsforanalysis;veryimperfectcomputermodels,bytheway.Andtheyunderstandthatbut,withoutimages,that’salltheycando.Well,theycan’tprovethestrikeisunsafe.Andwe’lltalkmoreaboutwhytheburdenofproofwas:“Proveit’sunsafe,”asopposedto“Proveit’ssafe.”

Theycouldn’tproveitwasunsafe,andsotheyhadtoconcludethattherewasnosafety-of-flightrisk.Now,importantly,there’salotofuncertaintyinthatconclusion.Buttheirfindingsweresummarizedbyamidlevelmanagerwhowasnotamemberoftheirteam,whowenttotheveryseniorMissionManagementTeamandtoldthem,“Hey,theengineersanalyzedthis.Nosafety-of-flightrisk.”

Nodiscussionof,“Well,whatweretheirassumptionsintheanalysis?Howgoodarethosecomputermodels?Whatuncertaintyisthereinthatanalysis?”Theydon’treallydigtothatlevelofdetailinthediscussionduringthemeeting.

FlightDaySixteen

And,ofcourse,eightdayslater,Columbiaburnsupuponreentry.Andwe’regoingtotalkaboutwhat’sgoingoninthischainofevents:Whynoimagery?Whydoestheteamhandlethisdiscussionastheydo?What’sgoingonhere?

DownplayingAmbiguousThreats

OK.Downplayingambiguousthreats.Thekeyideahereisthatwe’resayingthatorganizationsarepredisposedtounderrespond.Whatdoesthatmean?Whatdowemean,“Underrespondtoambiguousthreats?”

Characteristicsofunderresponsiveness

Well,thatistosay,there’sactivediscountingofrisk,andwesawthatatNASA.It’snotjustthattheychosenottopursuemoreanalysis.Theywereactivelydiscountingtheriskanddiscouragingpeoplefromdoingmoreanalysis.

Thereisafragmented,largelydiscipline-basedanalysis.Whatdowemeanbythat?Wemeanthereisn'tacoherent,centralized,coordinatedefforttogolookintothefoamstrike.Instead,wehavevariousgroups,adhoc,indifferentpartsoftheorganization,indifferentpartsofthecountry,lookingatthisintheirsparetime,onaninformalbasis.

Andthey’rediscipline-basedgroups.It’snotacross-functional,cross-disciplinaryteam.It’sasetofengineers,whoallhavesimilartechnologicalexperience,whohappentobedrawninbecauseoftheirinterestinfoamasanissue.Pamela?

:CanIaskaquestion?Wasthistheonlythingthatwentwrong?

PROFESSORROBERTO:Duringthemission?

:Duringthemission.

PROFESSORROBERTO:No,ofcoursenot.Thingsdogowrong.

:Sothisistheonethatgotthem.

PROFESSORROBERTO:Thisistheonethatgotthem.Itturnsout,interestingly,thatthisisnotthefirsttimethatalongstandingambiguousthreatthathadbeenaroundawhilecausedashuttletodisintegrate,ortoencounteraproblem.Challenger,infact,followsthisexactsamepattern.Thatistosay,theO-ringproblemwasknownforsometime,andhadbeenhappening,anditwasdownplayed.And,ofcourse,itledtotheChallengerexplosion.

Sohereonthismission,thereareotherthingsthathappened.Theinterestingthingaboutfoamis,it’snotjustaproblemthataroseonJanuary17,2003.It,liketheO-rings,happenstobeaparticularkindofambiguousthreat,onethathadbeenaroundawhile.Andthat’swhatmakesitsointeresting.Ifitwasjustasignalthatallofasuddenarose,wemighthaveadifferenttakeonit.

Thelastpieceisthis“wait-and-see”orientationtoaction,whichistosay,therewasnotanactiveattempttogooutanddosomethingstoactuallyinvestigate—runsomeexperiments,andthelike.Instead,therewassortof“waitandsee.”Itwas,“Let’swaitfortheshuttletoreturn.Thenwe’lltakeitanddolotsofanalysisbasedontheamountofdamageweassessedwhenitreturns—thiswait-and-seeorientation.

Sothesearethecharacteristicsofwhatwecallunderresponsetoanambiguousthreat.Andwe’lltalkaboutwhatthealternativetothatwouldbeinabit.

Now,there’sonetakeonthisthatsaid,“Look,thatunderresponseisirresponsibleandincompetentmanagement.It’sjustincompetence.Youknewaboutthefoamstrikesfortwentyyears,andyoutotallydiscountthem.Youdon’tdoanyanalysis,youdenyimageryrequests.Thisisjustincompetentmanagementthatshouldbefired.”

We’renottakingapositiononthat.We’renotabsolvingthesepeopleofindividualaccountability.We’renotcondoningtheirbehavior,norarewecondemningtheirbehavior.We’rejustsayingthere’smoretoitthanindividualmalfeasance.Wethinkthere’smoretoit.Wethinkthere’sanorganizationalpredispositiontodownplayambiguousthreats;thatthisisanaturalpatternofbehavior.We’veseenitinmanydifferentorganizationsnow.Sowethinkthere’smoretoitthanjustpersonalmalfeasance.

Factorscausingunderresponse

Sowhatisthisnaturalunderresponse?Whydoesithappen?Whatcausesit?Wethinkit’scausedbyfactorsatthreelevels:factorsthatgooninthehumanbrain,thatareatthehumancognitionlevel;factorsattheteamlevel:Howareteamsorganizedandledinorganizations?;andthen,broaderorganizationalforcesregardingthestructureandthecultureatNASA,oratanyorganization.

ThreeLevelsofAnalysis

Andwewanttotalkyouthroughthosethreelevelsofanalysis.I’lltakeyouthroughcognition.MycolleagueRichardBohmerisgoingtotakeyouthroughtheteamlevelandtheorganizationallevel,andhelpexplainwhytherewasthisunderresponse.Andthen,AmyEdmondsonisgoingtotakeyouthroughadiscussionofhowmighttheyhaveresponded

differently.What’sanalternativewayofrespondingtoambiguousthreatsthat’smoreeffective?And,interestingly,wewilluseasanexampleanothercaseofathreatatNASAtohelpustalkaboutthatissue.

Sowhatdowemeanbythesethreelevelsofanalysis?

Thecognitivelevel

Well,first,atthecognitivelevel,itturnsouttherearetwothingsgoingoninthemindsofpeopleatNASAthatarenotuniquetotheindividualsatNASA,butthatgooninallofourmindsthatcontributetodownplayingambiguousthreats.

First,weallholdcertainbiasesinthewaywemakejudgments.They’renatural,theyhappentoallpeople—experts,novices,peopleofallages,inallfields—andthey’reshapingtheactionsofdecisionmakershere.Andthesecondis,weallframeproblems,weallframeissues.

We’lltalkaboutwhata“frame”means.It’saroundhowwedefineissues.Andhowwedefineproblemsandissuesaffects,then,thesolutionswecomeupwith,theanswerswegetto.Andsothat’salsogoingon.Itaffectshowweorganizethewaywework,andwe’llseethataswell.Soatthecognitivelevel,therearethingsgoingonthatcausepeopletodownplaythesethreats.

Thegrouplevel

Atthegrouplevel,thewayyoudesignteams,andtheclimateinwhichtheyoperate,affectshoweffectivethoseteamsareatinvestigatingandexaminingambiguousthreats.Andwe’lllookattheproblemsinteamdesignandteamclimateatNASA.Andwe’llshow,andwe’llgiveyouexamples,andhelpyouunderstandhowthoseproblemshappeninallkindsoforganizationsandcontributetotheseproblems.

Theorganizationlevel

Andlastly,issuesofstructureandculture,whichcontributetothedownplayingofambiguousthreats,tounderresponse.Again,we’llgiveyouexamplesfromNASA.We’lljustseethatmanyofthesepatterns—structuralcomplexity,culturalissues—happeninmanykindsoforganizations.SoNASA’snotuniquehere.Obviously,theconsequencesaremorecatastrophicthaninmanyotherorganizations,butthey’renotunique.

Sowiththat,let’smakeonefinalpoint,whichisthattheselevelsofanalysisarenotalternativeexplanationsofthetragedy,buttheyworktogether.Cultureaffectshowteamswork,itaffectshowpeoplethink,andthelike,andsothesearerelated.Andwe’lltalkaboutthataswegoon.

Cognition

Withthat,that’sdiveintocognition.

Cognitivebiases

Whatdowemeanbycognitivebiases?Itturnsoutthatthewayourmindsnaturallytendtoworkcausesustodownplayambiguousthreats.Thisissortofascarything,right?Thatinfact,we’rehardwiredtodownplayambiguousthreatsinallaspectsofourlives.Andpsychologistshavebeenshowingthisnowformany,manyyears.

Letmetalkyouthroughsomeofthosebiases.Thefirstandmostimportant,here,isthetendencytorelyoninformationthatconfirmsexistingviews,whilediscountingevidencethatdisconfirmsinitialpositions.

Theotherbiasrelatedtothisisthat,infact,viewstendtopolarize.Peoplelookingatthesameinformationoftenactuallywatchtheirviewspolarizeovertime,notcometogether,becausepeoplearerelyingontheinformationthatconfirmstheirexistingview,andthey’rediscountinginformationthatisnotconsistentwiththeirexistingview.

Andthat’sgoingonhere.PeoplehavealongstandingbeliefatNASA:Foamisnotdangerous.Andeverypieceofinformationanddatathattheygetduringthemissiongetsinterpretedthroughthatlens.Andthat’snatural.Turnsoutwealldoit.

Whyisthat?RobertaWohlstetter,whostudiedPearlHarbor,andthefactthatwedownplayedthepossiblethreatofJapanattackingus,said,interestingly,thatindividualpoliticalandmilitaryleadershadthisstubbornattachmenttoexistingbeliefs—existingbeliefsaboutpeopleattackingtheAmericanhomeland,aboutJapan’sintentions,andthelike.

AndpsychologistDanielGolemansays,well,itgoesbeyondjustthefactthatsomepeoplearemorestubbornthanothers.It’sactuallyhardwiredintothebrain.Themindcanprotectitselfagainstanxietybydimmingawareness.Andso,ambiguousthreatscauseanxiety,right?Thepossibilitythattheseastronautscoulddieissomethingwewanttoavoidinourminds.Andthat’sgoingon.

Sothishappens.Whataretheconsequences?Well,itturnsoutthat,notonlydowediscount,butthere’salsothisphenomenonofescalationofcommitment.Thatistosay—ifwe’vehadthislongstandingbeliefforalongperiodoftime;ifwe’vebeenembarkedonthiscourseofactionforalongperiodoftimethatsayswe’regoingtokeepsendingshuttlesup,eventhoughweknowfoamisthere—webecomeweddedtothispriorcourseofaction,evenifthesignsarethatitmaynotbeaprudentcourseofaction.Andnotonlydowecontinuewithit,weescalateourcommitment.Wesendmoremissionsup,andatafasterrate.Weescalateourcommitmenttofailingcoursesofaction.Thisisatendencyofallofus.

Andwebecomemoreandmoreoverconfidentovertime.Overconfidence,again,isabiasthataffectsallofus.TheLakeWobegoneffect,right?Weallthinkwe’rebetterthanaverage.

CognitivebiasesatNASA

HowdidthismanifestitselfatNASA?Well,beforeeverymission,theydosomethingcalledaFlightReadinessReview.Thisisaveryimportantmeetingwheretheygothroughallpossibleissuesthatcouldimpairthesafetyoftheastronautsandofamission.Andtheyhavetoresolveallofthosebeforetheycanflythatmission.

Well,thinkabout,ifyouareamanager,likeshuttleprogrammanagerRonDittemore,orMissionManagementTeamleaderLindaHamm,oreventheengineers.You’vebeeninthosemeetings.You’vebeenatthosemeetingswhereeveryonepubliclyconcludesthatfoamisnotdangerous.You’vetakenastandonthatinfrontofallofyourcolleagues,perhaps.Andnow,howcanyougoagainstwhatyousaidpubliclyjustafewweeksearlier,duringtheFlightReadinessReview?

So,infact,bymakingthispubliccommitment,bygoingthroughthisanalysis,bydrawingaconclusionwithallofyourcolleaguesthatfoamisnotdangerous,it’sprettyhard,then,whengivensomeevidencethatmaybeitisonthisparticularmission,togoagainstwhatyou’vejustconcludedpubliclyinameeting.

Ofcourse,eachsafereturnoftheshuttleconfirmsyourinitialhypothesisaboutfoam.Everytimethethingkeepscomingbacksafe,andyoulook,andyes,foamdislodged,butitonlycausedasmall,littlehole,andthat’snotdangerous—andtheholehastobequitelargerthanthattobedangerous—you’vegotevidence,right,thatconfirmsyourexistingview.

AndthelanguagesystematNASAwasveryinteresting.Overtime,itmadepeoplemoreandmorecomfortablewiththisverydangerouscondition.Theyhadawordforsomethingthattheyweren’texpectingonamission.It’scalledan“in-flightanomaly.”Anin-flightanomalyissomethingthatyouneedtoaddressandresolve,becauseit’spotentiallydangerous.

And,overtime,theyslidtosomethingtheycalled“outoffamily,”meaningit’snotsomethingwe’veseenbefore,it’snotsomethingconsistentwithourspecifications—it’soutoffamily.But,ofcourse,thenslowlytheykindofmeanderedto,“maybeit’sinfamily,”becausenowwe’veseenitfortenorfifteenyears,andeachonekeepscomingbacksafely.

Sowe’vegonefrom“it’sananomaly,”whenitfirsthappened,to“it’soutoffamily,”meaningit’soutofourexperiencebase,to“oh,it’spartofthefamily.”Andwe’llhearfromoneofthemembersoftheAccidentInvestigationBoardaboutthatslipperyslide,fromit’ssomethingtotallyunexpectedto,aswesaid,theunexpectedbecomestheexpected,becomestheaccepted.

There’salsothefailuretoseedisconfirmingdatagoingonatNASA.Letmegiveyousomeexamples.Duringthemission,managementrepeatedlysoughttheadviceofaninternalexpertwhoconfirmedtheirexistingsharedbeliefsaboutfoam.But,interestingly,hewasn’tanexpertonthematerialontheleadingedgeofthewing.Hewasanexpertonthetilesunderneaththewing,whichiswheremostofthefoamhadhit,overtheyears.

Andso,goingtohim—andtheyknewverywellhisverypublicviewonfoam—theywenttohimearlyandoftentoconfirmtheirlongstandingbelief.Thinkaboutthedynamicthatcreatesintheorganizationifaveryprominentexpertonthewingearlyandoftenreaffirmsthatexistingbelief.

Worsethanthat,itturnsouttheyactuallyhadn’tmaintainedthecamerasthattookpicturesofthelaunch,overtheyears.Sotheywouldn’thavehadtorequestimagery,additionalimagery,ifthey’dhadwell-workingcameras,well-functioningcamerasthatweretakingpicturesofthelaunch.Theadditionalimagerywe’retalkingaboutwouldhavehadtocomefromtheDepartmentofDefense,fromspacesatellites,frommilitarysatellites.

Buttheycouldhavehadbetterimagesfromtheirowncameras.But,again,becausetheyweren’touttherelookingfordisconfirmingdata,theyweren’teventakingpictures.Theyhadjustletthecamerasfallintodisrepair.Afterall,theshuttleworks.It’sworkedsince‘86—seventeenyearsofsuccess—andsotheyhadn’tmaintainedthem.

Evenworse,onlyoneoftheshuttleshadaflightdatarecorder,likeeveryairplaneonearthhas—onlyone,thefirstone.Andafterthat,theysaid,“Jeez,well,wedon’tneedoneof

these.Thisthingworks.”Sotheyweren’toutlookingforanyevidence,anyissues,duringflights.Theywereactuallynotlookingfordisconfirminginformation.

Soweseethebiasesactuallymanifestthemselvesintheirbehavior,bothintheirattachmenttoexistingbeliefsandintheirfailuretolookfordisconfirmingdata.Let’sactuallyhearfromtwomembersoftheAccidentInvestigationBoardaboutsomeoftheseissues.Thesepeoplespentanenormousamountoftime,overthecourseofayear,studyingthisincident.Theyaretheworld’sexpertsonissuesofsafetyandorganizationalcatastrophes.

SheilaWidnall,whomwe’llhearfrom,isaformersecretaryoftheAirForce.ShewasamemberoftheAccidentInvestigationBoard.SheisanaeronauticsprofessoratMIT.RogerTetrault,long-timeexecutiveintheaerospaceindustry,alsowasontheboard,andhere’stheirtake.

ROGERTETRAULT(video):AsImentioned,foamhadbeenstrikingthebottomofthewing.Andeachtimethatitstruckthebottomofthewing,oreventhebellyoftheaircraft,andnothingbadhappened,aconfidencegrewwithintheorganizationthatitwasanacceptablecondition,eventhoughitwasatotallyunacceptableconditionfromtheperspectiveofthespecificationsthathadbeenwritten,andthepeoplewhohaddesignedtheaircraft.Butthisconfidence,unfoundedconfidence,grew.

PROFESSORROBERTO:SoTetraulttoldus,inaninterviewweconductedwithhim,justafewmonthsago.Theseareall,bytheway,clipsfrominterviewsweconductedwiththeboardmembers,onourown.

Here’sSheilaWidnall.

DR.SHEILAWINDALL(video):Now,thiswholequestionof“outoffamily”—that’saverycasualterm.Idon’tbelieveithasaprecisetechnicalmeaning.Andso,IthinkwhatIsawhappeningatNASAwasNASAwasslidingfromaprecis