The management culture at a primary NASA facility was criticized for a propensity to contain potentially serious problems and seek to resolve them internally instead of reporting them upstream. The effectiveness of risk management and compliance protocols can be severely compromised by review standards that are biased in favor of project design feasibility. The decision to launch in the presence of so many obvious “yellow flags” of safety created the impression that NASA was actually requiring a contractor to prove that it was not safe to launch, as opposed to proving that it was safe to launch. Effective risk management and compliance structures pay close attention to organizational hierarchies and administrative structures in order to assure appropriate checks and balances. Organizational structures at key shuttle project levels placed safety, reliability and quality assurance offices under the supervision of the very organizations and activities whose efforts they were responsible for supervising. Lesson #7: When the Fox Guards the Chicken Coop. Effective risk evaluation processes typically involve “give and take” exchanges with various interested parties, but provide protections against the excessive influence of purely financial pressures. This was done to accommodate a major customer of the contractor. A primary contractor reversed its opinion and recommended the shuttle launch, contrary to the strenuous safety concerns of its engineers. Lesson #6: Yielding to Pressure Rarely Works Out. This was justified, according to the commission, “because we got away with it the last time.” Effective project leaders recognize that the ability to “get away with” something is never an acceptable basis for assuming material risk. The response of NASA and a key shuttle contractor to early indications of a design flaw was to increase the amount of damage considered to be an acceptable risk. Lesson #5: Increasing Levels of Acceptable Risks. Basic principles of risk oversight make it imperative that both the establishment of project compliance checks and balances, and decisions to override them, are subject to review by higher levels of management. At some point in the launch process, NASA management made an independent decision to waive previously established launch constraints designed to assure flight safety. Lesson #4: Protecting Checks and Balances. Project information flow must provide decision-makers with access to the perspectives of all meaningful project participants. Senior launch officials were unaware of key warnings expressed by others: the most recent problem with the O-Rings a contractor’s recommendation not to launch below 53 degrees the similar warnings of project engineers and the manufacturer’s concerns with launchpad ice. Lesson #3: Those Right Hand, Left Hand Problems.
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