Why Astronauts Fly Drunk

Last week an independent medical review panel set up by NASA to review health issues of astronauts found evidence of “heavy use of alcohol” by astronauts before launches on at least two separate occasions. Both flight surgeons and other astronauts warned that the drunken astronauts posed a flight risk. Yet, one flight to the international space station was cleared for launch and another flight was delayed but only for mechanical reasons.

When I first read this report, I had just written about the organizational culture at NASA for a chapter in my book on leadership. This new report echoed another report issued after the 2003 Columbia disaster. In the Columbia disaster NASA’s managers had ignored safety concerns of lower-level employees.

Given what I already knew, the new report was only mildly shocking. NASA’s leadership has a history of poor decision making. Yet one wonders: How can an organizational culture be so dysfunctional that is would allow astronauts to fly drunk?

The ongoing failures of leadership at NASA are due to NASA’s rigid hierarchy where decision makers are able to exert tremendous control without much input from others. Just as under socialistic central planning, or just as in countries run by tyrannical dictators, there is simply no mechanism to recognize and correct errors.

Consider the shuttle disasters, first Challenger in 1986 and then Columbia in 2003. In their book Hard Facts, Jeffrey Pfeffer and Robert Sutton observed that even after the Challenger disaster:

NASA remained a dysfunctional bureaucracy where, rather than deferring to people with the greatest technical expertise, leaders believed that “an allegiance to hierarchy, procedure, and following the chain of command” decrease the odds of failure. People with greater prestige and power routinely ignored and stifled those with more expertise but less power and overturned their recommendations.

In other words, the culture at NASA is a dysfunctional authoritarian culture with leaders who believed that knowledge has a “pedigree.” In such a culture it is very difficult to detect errors. In such cultures arrogant, authoritarian leaders believe their way is the correct way to see things and that others with a different viewpoint are nuisances that get in the way.

During the flight of Columbia, the Mission Management Team had knowledge that a piece of foam had broken off the shuttle’s fuel tank. The Mission Management Team’s leader was briefed by the Debris Assessment Team of the possible damage and what could be done to fix it. The Mission Management Team’s leader disastrously decided that the foam strike was inconsequential.

The Debris Assessment Team engineers, who were seriously concerned about the foam strike, never had a serious hearing. Indeed the Debris Assessment Team was reprimanded for going outside of official channels to seek satellite imagery that they needed. Instead of the foam strike being the focus of attention, a bureaucratic squabble became the focus of attention.

The Columbia Accident Safety Board in its 2003 report wrote that: “In our view, the NASA organizational culture had as much to do with this accident as the foam.” Although NASA claimed it had risk-averse philosophy that sought to avoid errors, the Board wrote sharply: “Unfortunately NASA’s view of its safety culture… did not reflect reality.” NASA’s safety culture was described as “broken.”

Back to the drunken astronauts, apparently rather than deferring to the flight surgeons and postponing the flight, NASA’s leadership ordered the flight to take place as scheduled. Flying shuttle missions with drunken astronauts is very risky behavior—apparently little has changed at NASA.

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17 Responses to Why Astronauts Fly Drunk

  1. Bob Gast says:

    Unfortunately, this kind of organization (government controlled, tax payer funded) can survive because they are insulated from the free market forces that would harshly punish their management dysfunction and incompetence.

    Bob G.

  2. Barry Brownstein says:

    Bob,

    I agree. Changing the culture of an organization is difficult even under the best of circumstances and without competitive pressures next to impossible.

  3. Alfredo Louro says:

    Bob Gast: “Free-market forces” do not “punish management dysfunction and incompetence”, of which there is plenty in the private sector. In fact, they make it even worse because they add greed to the mixture. Space exploration cannot be run as a for-profit enterprise. While NASA sends probes to the planets, the best your free-market types can come up with is inflatable casinos in low-Earth orbit.

    There is certainly a cultural problem within NASA. Using it merely to push some personal ideological agenda doesn’t make things any better.

  4. Joe X says:

    Do you know how scary it is to fly on an old poorly maintained spaceship. The fatal accident rate for astronauts is very high. You couldn’t get me on that thing drunk or sober!

  5. Bob Gast says:

    To Alfredo’s point, there is plenty of dysfunctional and incompetent management “out there” in the private sector. However, the free market does, in fact, punish management teams that are dysfunctional and incompetent.

    A cursory review of the business news on a daily basis confirms this as we read about firms that change management, business lines or markets as well as those that get bought, merged or go out of business. There is no protection for these firms if they do not respond to a consumer market that demands value added products and services in a competitive market or in capital markets that demand tighter financial closes and controls, more efficient ROI and greater EBITDA’s and EPSs.

    I do not think it is arguable that if NASA’s performance were duplicated in the free market, the entire leadership would have been changed, they would have been bought
    by another firm or they simply would have gone out of business.

    Greed is not a by-product of a free market system. It exists equally in organizations that are insulated from the judgement of a free market, like NASA. NASA is indeed insulated from the consequences of an arrogant management system that results in catastrophic consequences that would not be possible in the open market. Greed is punished in the free and open market of a general capitalist society. I can give you many examples.

    As far as the ingenuity of the private sector, I would argue that if all of the money that has been spent at NASA were spent/invested at competitive private firms that had to be accountable to investors, consumers and the marketplace in general, we would have far more to show for it.

    Bob G.

  6. Alfredo Louro says:

    Bob Gast writes: “Greed is punished in the free and open market of a general capitalist society. I can give you many examples. ”

    So can I. Enron comes to mind. The damage visited upon society by the greedy is not punished by “the free and open market” unless it also hurts someone’s bottom line, which is not necessarily always the case. Halliburton is a good example. Maybe NASA should be run by Halliburton?

    NASA’s greatest triumphs have been in the unmanned exploration of the universe, including our own planet. Would you buy shares in the Hubble telescope, or WMAP, or New Horizons? If everything had to turn a profit or provide a technological spinoff capable of turning a profit right now, you wouldn’t have science.

    What should happen at NASA is simple: Someone should go to prison.

  7. Robert W. Gast, Jr. says:

    My final point on this dialogue is simply to point out what might not be clear to many and that is that greed and profit are mutually exclusive concepts.

    The fact is that profit motivation has steered resources towards the greatest innovations ever achieved and has resulted in an exponential rise in living standards.

    Greed, unfortunately has always existed and yes it can manifest itself in any organization, economic or political system.

    It is a fundamental misunderstanding of economic drivers and history to treat the two as synonomous by suggesting a causal realtionship between profit driven activities and greed. Even the bible makes this distinction.

    Best – Bob G.

  8. Ariel says:

    Astronauts don’t fly drunk because they’re in an organization run by the government vs. a free market organization. Astronauts fly drunk because they are in an sick organization that allows it. It can happen on the launch pad; it can happen down the street at your local fire department. I was the senior officer present as our crew was being dispatched to a fire, and I ordered the engineer out of the driver’s seat because he had been drinking. Not just once, but on two different occasions in a single week this happened, and the Fire Chief refused to discipline him. That’s dangerous and dysfunctional leadership up close and personal.

    Poor leadership is inevitable in any “rigid hierarchy where decision makers are able to exert tremendous control without much input from others.” (Right on, Barry.) It is really a systems flaw aided and abetted by ignorance and arrogance. To not have a feedback mechanism in place to help “auto-correct” faulty decision-making is to risk the eventual downfall of an organization.

    Such a systemic weakness can occur, or develop over time, in any kind of group or organization. The founding fathers were wise enough to realize that and to institute a systems of checks and balance in our government. Unfortunately, it seems to have eroded somewhat since. Likewise, any smart for-profit enterprise is going to have a board of directors and/other ways to rein in leadership gone bad. A company can go down the tubes before the market can exert enough force to correct the arrogant, the stupid, the greedy, or the criminal.

    There are roles for business; there are roles for government. Capital does not always follow the public good, just as bureaucracy can become a banal exercise in self-perpetuation. But neither of those outcomes are necessarily inherent in the structures.

    Markets and laws don’t fix bad leadership, people do. And they do that by having the courage to speak up and throw the light on what has gone wrong. They do it by having the chutzpah to say, “Enough is enough,” and then do something about it.

    More cases of leaders gone amok.

  9. Barry Brownstein says:

    Ariel,

    Thanks for leaving us such a thoughtful post. The differences between your view and Bob’s may be smaller than you think.

    I completely agree with you that the problem is the choices that we and through us our organizations make. Yet, individuals do respond to the social setting that they find themselves in. Thus when organizations do not have to compete, they are more likely to condone or even reward very bad behavior and poor performances.

    This observation seems to be consistent with your own experience at the local fire department. The fire department is assured of a supply of tax dollars no matter how badly they perform.

  10. Ariel says:

    True enough that the setting influences behavior, and without incentive for excellence things can definitely deteriorate. Competition is one way to provide that. But, while some governmental roles can transfer into the private sector, I don’t see how every role can or should, or that that ultimately solves the question of poor leadership.

    Certainly emergency services can be competitively contracted. Rural Metro, in the Phoenix area, is familiar to most of us Arizonans. But in the case of a sparsely populated area like where I live – fewer than three thousand people, over a service area of more than 100 square miles – there is no economic incentive for a private company to offer fire protection.

    Our phone service company (another interesting example of no competition – a private company, yet sole provider, overseen by an elected state commission) has been trying to sell off its business in this area for several years (no one wants it!) and would have simply stopped serving us if not for the AZ Corporation Commission’s mandate. Qwest loses money on us, and has to factor that against what they make elsewhere.

    Despite NASA’s very real flaws, no private company, or even consortium of companies, would have had the resources to explore space as NASA has done. Each one of us has benefited from the knowledge and the technologies that have come out of the space program, and most especially American business. (Anyone have any solid figures as to how much of the space program’s budget went to the salaries of agency personnel vs. contracts with businesses for equipment, supplies, consulting, and all the rest? That would be interesting to know.)

    Theoretically, the fire department is not assured of tax dollars. The public can refuse to fund poor performance and elect representatives who will oversee change. That assumes, however, an informed and motivated electorate as well as representatives who keep promises – leaders in the true sense of the word. Business has other models to regulate its leadership, and those assume that market forces will be strong enough and swift enough to curb the worst excesses. Those assumptions have failed us on more than one occasion.

    Guess I’m right back to the original dilemma. How do you get, and maintain, good leadership in any type of organization?

    So, Barry, when are you going to tell us more about your book on leadership? I’m curious…

  11. Barry Brownstein says:

    Ariel,

    I would agree with much of what you said, but I would like to point you a bit in a different direction. You wrote that no one would’ve explored space “as NASA has done.” I agree with you, but the market may have explored space in different, safer, less expensive and more scientifically valuable ways. Just conjecture.

    I think you will like my book, because it begins with the premise there is no organizational change without internal transformation. The book focuses on the internal transformation needed to utilize sound leadership principles. For instance, a leader cannot give up control until they both understand the advantages of doing so and understand why they are drawn to control. Thus the title of the book is The Inner-Work of Leadership: Why You Need it and How to Do It. The manuscript is just about complete and I will begin the work of looking for a publisher shortly.

  12. Ariel says:

    I am conjecturing….space exploration from the private sector would have to have been different and less expensive, and quite possibly have been safer, though the scientific value is an open question. How does pure research figure into a free market? Few venture capitalists would sign on without knowing that there was some real prospect of economic return.

    Given the highly political motivations of the early space program and the scientific community’s eagerness for any avenue to get into space, I doubt that the principals in the program foresaw the incredible technological spin-off that would occur. Sometimes science progresses through surprising channels. It may or may not have been best served by a private space program; we’ll never know.

    And how do we weigh the transformational value of finally seeing the Earth from space, the watery, blue sphere floating in darkness, reminding us that we’re all in this together? Dr. Edgar Mitchell’s book, “The Way of the Explorer,” makes an eloquent case that that image alone, with all of its accompanying implications, may have more impact on humanity than we dream.

    I look forward to your book being published, Barry. It sounds like a great approach and much needed in today’s world. We would all benefit from better leadership in any walk of life. Congratulations on being almost to the finish line and best of luck in finding a publisher!

  13. Barry Brownstein says:

    Ariel,

    We can agree that we will never know what would have been if the billions spent by NASA would have been spent in alternative ways.

    As far as free-market pure research goes—there are quite a few examples of innovative corporations that allow for and encourage pure research; IBM, Xerox, 3M, and W.L. Gore immediately come to mind.

    I would contrast those firms with what usually (but I would agree not always) are the results of government sponsored science—entrenched interests are able to close the door to new and innovative ideas. The entrenched interests are the gatekeepers on the peer review panels. Thus for instance, if one tries to challenge the orthodoxy in health research, one is very unlikely to get any funding.

    I greatly appreciate the kind words and encouragement.

  14. Ariel says:

    Interesting to speculate on what might have been, though, if only as an exercise in imagination to explore potential directions for the future….

    I’m pretty familiar with W.L. Gore, having worked as a consultant and tester with them on their guitar strings. I’m impressed with their culture. They stand out because they deliberately veered away from “business as usual” to a flexible structure designed to encourage innovation throughout the organization. For all of PARC’s amazing advances, ultimately politics and other pressures at Xerox prevented the full realization of its potential.

    As to ways to bypass gatekeepers – it’s interesting to see some of the ideas coming out of the open-source software movement. Technology is opening up new ways to collaborate and build knowledge products that we’re only just beginning to explore. The implications for the public and private sectors are enormous.

    Your book sounds like it will address a lot of the things that keep us stuck in unproductive, outmoded mind sets. I’m looking forward to reading it.

  15. Ariel says:

    Oops. Strike the PARC comment. I was going off of an interview I heard awhile back. I just went over to their website and it looks like there is more to the story…mea culpa.

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