NASA Langley Research Center Response to the Agency Safety and Mission Success Week November 17-21, 2003 (part 1)

Langley Research Center Response to the Agency Safety and Mission Success Week November 17-21, 2003

December 4, 2003

Report Introduction

NASA Administrator, Sean O’Keefe, designated the week of November 17, 2003, as Safety and Mission Success (SMS) week. During this week, NASA employees and contractors were asked to review key sections of the Columbia Accident Investigation Board (CAIB) Report, especially its findings on cultural aspects of the accident. They were also asked to reflect on the report’s relevance to their own situations, and to recommend changes to elements of the Agency’s culture that contributed to the Columbia accident.

Langley Research Center held a kick-off meeting at the beginning of the week, chaired by the Center Director, to put the week’s activities in context. Langley organizational unit managers (OUM’s) transmitted more specific instructions for activities to their branch heads, and the branch heads held discussions with their employees. OUM’s consolidated the results of these discussions for presentation to the Center Director through their chain of command. Additionally, managers and individuals could post comments to a website established for this purpose. The week’s activities culminated with a town hall meeting, also chaired by the Center Director, to allow individuals and OUM’s to speak publicly about their concerns. This report consolidates the comments received in writing on the website as well as points made verbally at the town hall meeting.

To guide the week’s discussion, Langley employees and contractors were asked to respond to the following three questions:

• How is the CAIB Report/Diaz team matrix relevant to your work unit?
• What are some organizational causes that impact you, the Center, and NASA the most?
• What needs to be done to help your organization, your Center, and NASA move forward?

This report summarizes the comments of the Langley community in response to the Agency Safety and Mission Success week. The specific comments, including detailed recommendations for actions, will be reviewed for further analysis in order to develop appropriate and effective responses.

The SMS week provided Langley a valuable opportunity to understand the CAIB Report findings in the context of our daily activities. The free exchange of perspectives and opinions about problems and proposed solutions is of great value to our mission effectiveness. While “many employees did not believe there was a connection between the CAIB and their work…it became apparent that many areas of the report pertained not only to the Space Shuttle Program but to their own work units as well.”

Participants in this activity demonstrated sincere concern for making Langley and NASA a more efficient and effective national resource. Their frank and thoughtful comments, deep insight, and wide-ranging perspectives offer many improvement opportunities for Langley and the Agency to become more effective and efficient, and more relevant to our stakeholders.

Data Management and Assessment

A subset of the Langley One NASA team, sponsored by Lesa Roe, Associate Director for Business Management, summarized and categorized the responses.

In addition to Ms. Roe, participants of the team included:

• Mark Saunders, Programs
• Jim VanLaak, Programs
• Kathy Dezern, Research & Technology
• Ed Waggoner, Research & Technology
• Manjula Ambur, Business Management
• Buena Crawford, Business Management
• Susan Shockcor, Business Management
• Steve VanGundy, Business Management
• Sherri Yokum, Business Management

The team sorted the responses into the following categories, which were derived from the systems approach used by the

One NASA Team:

• Vision, Mission, and Strategy
• Leadership
• Organizational Structure
• Organizational Culture
• Human Resources
• Tools & Business Practices
• Communication
• Measurement

The Systems Approach model illustrates the interrelationship of all elements to the whole:

The SMS team generated two additional categories as a result of the data inputs received from this exercise, which likewise interact with all other elements and are subject to external influences as illustrated above:

• Safety
• Schedule/Budget

Initial analysis of the employee responses to the SMS questions shows that no single element caused the organizational and cultural issues identified in the CAIB report. Rather, combinations of these categories at Langley and NASA create organizational and cultural conditions reflective of those that the CAIB Report identified as critical factors contributing to the loss of Columbia. These conditions are or could be detrimental to the safety and reliability of Langley’s and NASA’s products and services.

Executive Summary

Agency-Level Issues and Recommendations

Although most of the input we received at Langley during SMS week is applicable to both Langley and the Agency, the following 5 key issues and associated recommendations are submitted for Agency consideration:

1. Vision: Lack of a clear vision and mission that all employees can relate to and understand. Our current vision lacks sufficient clarity to enable program/project and subproject decisions that are consistent with the Agency objectives.

Recommendations:

• Develop a compelling mission with the national debate about priorities.
• Expand the NASA charter to enable broader Agency research and ideas to improve our planet’s environment.
• Make the case to Congress for NASA to perform medium- to long-term science programs.
• Define a steady-state vision and expectation for how the Agency conducts projects and builds systems, and the reward system needs to be adapted to steer behavior towards that vision.

2. Budget and Schedule: Missions and programs are being driven by budget and schedule and “faster, better, cheaper” philosophy. Cost and schedule pressures have surpassed technical quality as the drivers for decision making for projects.

Recommendations:

• As an Agency, we should be more realistic in our planning and advocacy.
• We should do it right the first time not letting personal, organizational and political influences drive us to poor quality and inadequate safety decisions.
• Schedule changes for valid reasons should be acceptable; initial schedules are often unrealistic and as more information is received the schedule should be refined.
• There needs to be realism in deciding schedule, budget, and workforce requirements so that shortcuts and workarounds in processes are not taken and staff does not become overworked and stressed with a reduced awareness and increased likelihood of making errors.

3. Leadership: Lack of effective decision-making, trust, accountability, and fear of reprisal for openly communicating dissenting opinions.

Recommendations:

• Have our leadership thoroughly evaluate the system of safety and mission success with regard to the plethora of organizations having responsibility for overseeing the safety and quality of work performed with the express intent of making it simpler, safer and higher quality/reliability while reducing the overlapping responsibilities.
• Have our leadership positively state that we are only going to do things that we have the necessary resources and sufficient reserves to ensure mission success, and ensure that our actions are consistent with this philosophy.
• Have an open and impartial “forum where issues can be voiced without fear of retribution” with senior leadership.
• Encourage feedback of all kinds by setting the right tone at the top, making sure that employees understand that it is both their responsibility and obligation to give their managers as much information as possible for decision-making purposes.
• Provide multiple venues for feedback (oral, written, etc.) including the option for anonymity. Follow through with suggestions and provide feedback.

4. Communications: Doesn’t flow up or down effectively; too many filters and secrecy across the management chain.

Recommendations:

• Assume that communication is not occurring effectively; Work hard to ensure what is said or written is in fact what is received.
• Every individual needs to take responsibility for ensuring that “proper things are being done for the right reasons. When they are not, we need to speak up.”
• Have a prime focus and provide clear and consistent communications for Agency-wide initiatives.

5. Culture: “Can do” attitude is our strength and weakness; competition among Centers conflicts with One NASA philosophy and is not conducive to leverage all Agency technical capabilities

Recommendations:

• Redefine our definition of success to avoid risky “can do” behaviors.
• Develop and implement Agency-wide policies to enhance success of One NASA philosophy of collaboration among Centers.
• Develop clear understanding of all Agency capabilities (people and facilities).

Next Steps

This report represents a very high-level summary of the comments of the Langley community in response to the Agency Safety and Mission Success week. The specific comments, including detailed recommendations for remedial actions, require further detailed review and analysis.

The following high-level steps are being planned and will be implemented in conjunction with the Agency plans regarding the SMS feedback:

• Communicate the Langley report to all employees.
• Conduct a thorough analysis of all feedback and identify major issues with associated recommendations.
• Conduct focus groups around major issues to develop corrective action plans.
• Form teams to implement corrective action plans and communicate progress to the Center and the Agency.

Conclusion

The SMS week provided Langley a valuable opportunity to understand the CAIB Report findings in the context of our daily activities. The free exchange of perspectives and opinions about problems and proposed solutions is of great value. It is important to the success and survival of the Agency, the Enterprise, and the Center, that we listen to what our employees have said in order to maximize our performance and leverage the best from our workforce. The issues and concerns discussed in this report must be addressed for the future viability of the Center and probably the Agency as a whole.

Detailed Summary of Issues and Recommendations by Category

All of the feedback, including issues and recommendations, has been summarized and categorized below.

Vision, Mission and Strategy

Our employees perceive that the Agency, the Enterprise, and the Center lack a clear vision that is relevant to their daily activity. The lack of clearly understood mission is evidenced by numerous feedback comments, such as the well-articulated statement “Lack of a vision with sufficient clarity to enable program/project and subproject decisions that are consistent with the objective of the Agency.” In turn, a lack of vision impacts:

• employee understanding of the purpose and value of our programs, projects, and operational activities;
• the ability of management to articulate a connection between whom we work for, what our Center does in terms of return on taxpayer investment, at what cost to the taxpayer;
• the ability of management to prioritize appropriate financial and human resource allocations to any given activity; and
• delineation of the roles and responsibilities of those individuals supporting the activities.

Without an understanding of the value and purpose of these activities, and how and where individuals fit into the vision, decision-making regarding allocating human capital and financial resources lacks a sound foundation. Employees are also looking for a strategic context for management decisions: “The role of Civil Servants/Technicians needs to be defined.”

The Orbital Space Place (OSP) Program is cited as an illustration of these concerns. The OSP Program is working towards a vehicle that only supports the International Space Station, but many in the Agency are working to include OSP in NASA’s longer-range plans. Unfortunately, the Agency’s longer-range plans are unknown or have not been communicated, and consequently, many groups are working to different sets of requirements, spending scarce human and fiscal resources on different approaches. A more efficient and effective approach might be to document the longer-range plans (vision) with sufficient clarity that the requirements for OSP could be clearly tied to them.

Absent a clearly communicated vision, mission and strategy, we risk operating in a reactive instead of proactive role and losing public support and funding. This, in turn, creates an even less stable, more fearful, more change-resistant, defensive working environment and operational culture.

Employee recommendations to improve these conditions at Agency, Enterprise and Center levels include:

• “articulation of clear, understandable decisions and documentation;”
• “realistic planning and advocacy;”
• “risk integration and illumination across programs and projects;”
• “definition of acceptable levels of risk;”
• “getting everyone to work on the same problems and objectives;” and
• recognizing that stability is important and enables us to prioritize what we do.

Leadership

Like the CAIB, the Langley community recognizes that some of our leadership problems originate outside the Agency. Employees cited actions by OMB and Congress as adding to the instability and programmatic pressures of their work. However, most of the comments concern leadership at the Agency and Center level. Employees perceived that NASA’s senior leadership applies different standards to themselves than to people in the field. They notice that while there have been wholesale changes of leadership at JSC, MSFC, and other field centers as a result of the accident, there have been none at HQ. Some view this as a double standard.

Many at Langley believe that the addition of the NESC and the ITA on top of the already existing oversight organizations (eg SMOs, IPAO, IG, S&MA) is driving the process of safety to be more complicated and burdensome, potentially reducing, or at best not improving, safety and mission success. These new organizations will necessitate that valuable resources be drawn away from quality R&D work making it even more difficult for performing organizations to complete their projects and activities in a safe, quality fashion. Some believe that the Agency still “doesn’t get it” and has not looked at the safety problems from a root cause perspective with the intent of implementing a simple, effective system of safety and mission success.

The Langley community does not feel empowered to contribute to the major issues of the day. This criticism applies to both Agency and Center leadership, but is more focused at Center leaders and managers. Employees were also concerned that if they disagreed with the views and policies of their supervisors, they could suffer consequences for speaking out. This concern applies broadly, but Langley employees are most alert to issues of work planning and the resources required to accomplish the mission. Employees expressed “no trust of management” as a detriment to successful leadership.

Our employees believe that the leadership issues and concerns significantly hinder our ability to do our jobs effectively, hamper communication through the chain of command, and compromise product quality or science.

Comments also reflected a skepticism about what will result from this activity. Many thought that after this review of the CAIB report, minimal action will occur, and we will back to business as usual.

A significant concern expressed about NASA’s leadership philosophy is that of the “Faster, Better, Cheaper” model. The expressed impact of the “Faster, Better, Cheaper” philosophy includes the perception that it “undermines the entire process of maintaining and flying the shuttle fleet safely and all other areas of research and development at NASA.” The “Faster, Better Cheaper” issue crosses several categories besides Leadership, affecting Organizational Culture and Communications.

A conclusion expressed by many is that we are all “trying to do too much with too little” to our detriment, a finding echoed by Section 5.3 of the CAIB Report. The effect of the cited leadership issues and concerns inhibits communication, wastes resources, and makes “doing the right thing” more difficult and ultimately leads to compromises in product quality, science, and performance objects, through acceptance of unnecessary risk.

Employee recommendations to improve these conditions at Agency, Enterprise and Center levels include:

• Have our leadership thoroughly evaluate the system of safety and mission success with regard to the plethora of organizations having responsibility for overseeing the safety and quality of work performed with the express intent of making it simpler, safer and higher quality/reliability while reducing the overlapping responsibilities.
• Developing and implementing an Agency-wide strategy for leadership and management training;
• Having our leadership positively state that we are only going to “do things that we have the necessary resources and sufficient reserves to ensure mission success,” and ensure that our actions are consistent with this philosophy; and
• Establishing an open and impartial “forum where issues can be voiced without fear of retribution” with Senior Leadership.

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