1. Columbia Mission

2. Response To An Ambiguous Threat—Reasons for Under-Reaction to Ambiguous Threats Under-responsiveness is characterized by: –Active discounting of risk –Wait and see orientation –Discipline based analysis Response pattern driven by: –Cognitive Bias –Team design –Organizational Culture

3. Cognitive Bias Confirmation Bias—Faced with ambiguous situation we tend to rely on information that confirms our previous views. Discount information that disconfirms our initial position Sunk Costs Bias—Tendency to escalate commitment to a course of action to which we have invested time, money and resources.

4. Examples –Maintain Beliefs –Readiness review for Columbia foam shedding was an acceptable risk—makes it more difficult to see it as highly dangerous. –Safe return of shuttle over the years affirmed belief that foam was a maintenance concern-effort was on to fix it on ground for quick turnaround –Began to treat foam strikes not as an anomalies that need to be solved before next flight. NASA could not easily solve this problem. Tended over time to treat an “out of family event” where the unexpected became the expected.

5. Management looked to Schomburg for advice. He said foam strike should not be a problem we just need to replace a few tiles. Was not the appropriate expert to ask. Ham told the mission management team, that there was nothing they could due about the foam strike. She was committed to a view and made it difficult to disagree. Not recognize that crater model was not calibrated for foam strikes

6. Considered the shuttle routine operation not basic exploratory research. Sunk Costs Pressures to maintain schedule, behind at the current moment Source of finding external to the organization. Had to do more with less money—delays expensive

7. Faulty Team Design DAT an ad-hoc group with no clear lines of authority and limited access to resources Team not a cross functional team which was trained to problem solve in stressful situations. Tone and agenda of MMT emphasized concise and efficient discussion. Discouraged novel lines of inquiry- Some members of MMT participated via teleconferencing inhibiting cues (nonverbal) and may have limited confidence to speak up

8. The astronauts, those closest to the problems were not consulted during the assessment of the foam strike.—NASA nothing to worry about.

9. Lack of Psychology Safety People felt that they might be rebuked, marginalized, or penalized for speaking up. People not admit mistakes or possibly that they could miscalculate the problem. –Ham stated foam strike was not likely to be a problem. Made it difficult to disagree with her. –Did not make it explicit that she wanted to hear divergent views. –Rocha never sent his e-mail saying it was not safe after his request for imagery was declined. Only sent e-mail to other engineers (Shack, the head did not respond). –Rocha, I was just to low down in the organization to speak up and voice his opinion. Ham is way up there.

10. Organization Factors Hierarchical and Complex nature of NASA. –Strict protocol across levels –engineers not interact with managers. Defined channels of communication— Request for imagery made to DOD through unofficial channels. Ham canceled because it was placed outside of appropriate channels. Two other requests dissipated because not through official channels. –Information Filtering—DAT presented analysis to McComack, mission evaluation room manager. In presenting the report he did not effectively communicate the engineers concerns due to the lack of data. He lacked confidence in his views. MMT should have heard directly from the concerned engineer Rocha.

11. Tight budgetary constraints Personnel Downsizing Leadership Turnover Political Uncertainty

12. What Could Have Been Done In Response to An Ambiguous Threat Deliberating acting as if the threat is real—ask what if Provide teams with responsibility and authority or direct access to those with the authority and the resources. Do not micro-manage the content of the discussion or move team towards a premature conclusion Act in a way that preconceived notions may have to be eliminated. Encourage dissent—alternative views. Before crisis fix technical issues, have alternative plans in place if crisis situation occurs Here is the source for the story of the Rocha - Schomburg confrontation described on. On Page 3 http://www.nytimes.com/2003/09/26/national/nationalspecial/26ENG I.html?pagewanted=1&ei=5007&en=10772541a545b410&ex=13799 08800&partner=USERLANDhttp://www.nytimes.com/2003/09/26/national/nationalspecial/26ENG I.html?pagewanted=1&ei=5007&en=10772541a545b410&ex=13799 08800&partner=USERLAND