Introduction

The National Aeronautics and Space Administration (NASA) was established in 1958 to lead efforts in space exploration and aeronautics research. Today NASA has roughly 19,000 employees working at its headquarters and nine Centers throughout the U.S., and more than 5,000 additional staff at the Jet Propulsion Laboratory, which is operated for NASA by the California Institute of Technology. NASA's programs in space exploration, space science, and aeronautics research are widely known, with some of its most visible programs including the Space Shuttle and the International Space Station.

On February 1, 2003, the Space Shuttle Columbia and its crew of seven were lost during return to Earth. A group of distinguished experts was appointed to comprise the Columbia Accident Investigation Board, and this group spent six months conducting a thorough investigation of the causes of the accident.

The Columbia Accident Investigation Board issued its report in August 2003 with findings focused on three key areas:

  1. systemic safety cultural and organizational issues, including decision making, risk management, and communication;

  2. requirements for returning safely to flight; and

  3. technical excellence.

The Investigation Board also found that NASA's culture and related history contributed as much to the Columbia accident as any technical failure.

The Columbia Accident Investigation Board made specific recommendations for a number of structural changes to the organization, and identified a number of gaps in leadership practices important to safety. While there were no recommendations explicitly addressing leadership practices, the Investigation report identified many examples of gaps in the leadership practices that support safety, such as:

  • Failing to follow NASA's own procedures

  • Requiring people to prove the existence of a problem rather than assuming the need to assure there was not a problem

  • Creating a perception that schedule pressure was a critical driver of the program

As a result of the investigation and related activities, NASA established the objective of completely transforming its organizational and safety culture. At a minimum, NASA targeted making measurable progress in changing its culture within six months and having broad changes in effect across the Agency over a period not to exceed three years. The six-month marker was identified as particularly critical as the Agency prepared to Return to Flight.

After reviewing proposals from more than 40 organizations, NASA selected BST to assist in the development and implementation of a plan for changing the safety climate and culture agency wide. BST was asked to provide a systematic, integrated, NASA-wide approach to understanding the prior and current safety climate and culture norms, and to diagnose aspects of climate and culture that did not support the Agency's effective adoption of changes identified by the Columbia Accident Investigation Board.

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