![]() ![]() Organizations that do not internalize and apply the lessons gained from their mistakes relegate themselves to static, or even declining, levels of performance. Barriers to lateral communications (e.g., between work groups) can also impede the free flow of safetycritical information. This is done through established protocol, procedures, and norms that dictate the manner in which subordinates communicate with management, and the manner in which management receives and responds to the information. A dysfunctional organizational culture can discourage honest communications, despite formal appearances to the contrary. Ensuring Open and Frank Communications.Organizations that do not actively engage in qualitative and quantitative “what can go wrong?” exercises, or that fail to act on recommendations generated by the risk assessments that are done, miss the opportunity to identify and manage their risks. Without a complete understanding of risks, and the options available to mitigate them, management is hampered in making effective decisions. Performing Valid/Timely Hazard/Risk Assessments.The CAIB report makes a compelling argument for ensuring strong, independent “sanity” checks on the fundamental safety integrity of an operation. In the case where valid safety concerns are ignored, the success of the enterprise can be put in jeopardy. Establishing an Imperative for Safety. An organization that is focused on achieving its major goals can develop homogeneity of thought that often discourages critical input. ![]() When pre-established engineering or operational constraints are consciously violated, with no resulting negative consequences, an organizational mindset is encouraged that more easily sanctions future violations. This can occur despite well-established technical evidence, or knowledge of operational history, that suggests such violations are more likely to lead to a serious incident. Eliminating serious incidents requires constant reminders of the vulnerabilities inherent in hazardous activities. Operating diligence and management effectiveness can be easily dulled by a sense of false security – leading to lapses in critical prevention systems. Catastrophic incidents involving highly hazardous materials or activities occur so infrequently that most organizations never have the unfortunate, but educating, opportunity of experiencing one. Key organizational cultural themes emerging from the CAIB report include: Although NASA is a unique organization, with a focused mission, the organizational cultural failures that led to the Columbia disaster have counterparts in any operation with a potential for significant incidents. Through its report, the CAIB has provided a service to all organizations that operate facilities handling hazardous materials or that engage in hazardous activities. Which of the cultural patterns emerging from the Columbia accident were the same as those first identified after the Challenger tragedy (almost exactly 17 years earlier) andwhy were they still present?.Why was it that serious concerns about the integrity of Columbia, raised within one day of launch, were not acted upon in the two weeks available between launch and return? With little corroborating evidence, management had become convinced that a foam strike was not, and could not be, a concern.In pursing the investigation beyond immediate causal contributors, the CAIB was trying to understand two issues in particular: At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work it defines “the way we do things here.” An organization’s culture is a powerful force that persists through reorganizations and the departure of key personnel.” CAIB Report, Vol. “Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution.
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