The officer in charge of spacewalks,
Karina Eversley, knew something
was wrong.
That’s not normal, she thought, and quickly recruited a team of
experts to compile questions for Luca. Was the amount of liquid increasing?
Luca couldn’t tell. Was he sure it was water? When he stuck out his tongue
to capture a few of the drops that were floating in his helmet, the taste was
metallic.
Mission Control made the call to terminate the spacewalk early. Luca
and Chris had to split up to follow their tethers, which were routed in
opposite directions. To get around an antenna, Luca flipped over.
Suddenly,
he couldn’t see clearly or breathe through his nose—globs of water were
covering his eyes and filling his nostrils. The water was continuing to
accumulate, and if it reached his mouth he could drown. His only hope was
to navigate quickly back to the airlock. As the sun set, Luca was surrounded
by darkness, with only a small headlight to guide him. Then his comms
went down, too—he couldn’t hear himself or anyone else speak.
Luca managed to find his way back to the outer hatch of the airlock,
using his memory and the tension in his tether. He was still in grave danger:
before he could remove his helmet, he would have to wait for Chris to close
the hatch and repressurize the airlock. For
several agonizing minutes of
silence, it was unclear whether he would survive. When it was finally safe
to remove his helmet, a quart and a half of water was in it, but Luca was
alive. Months later, the incident would be called the “scariest wardrobe
malfunction in NASA history.”
The technical updates followed swiftly. The spacesuit engineers traced
the leak to a fan/pump/separator, which they replaced moving forward.
They also added a breathing tube that works like a snorkel and a pad to
absorb water inside the helmet. Yet the biggest error wasn’t technical—it
was human.
When Luca had returned from his first spacewalk a week earlier, he
had noticed some droplets of water in his helmet. He and Chris assumed
they were the result of a leak in the bag that provided
drinking water in his
suit, and the crew in Houston agreed. Just to be safe, they replaced the bag,
but that was the end of the discussion.
The space station chief engineer, Chris Hansen, led the eventual
investigation into what had gone wrong with Luca’s suit. “The occurrence
of minor amounts of water in the helmet was normalized,” Chris told me. In
the space station community, the “perception was that drink bags leak,
which led to an acceptance that it was a likely explanation without digging
deeper into it.”
Luca’s scare wasn’t the first time that NASA’s
failure at rethinking had
proven disastrous. In 1986,
the space shuttle Challenger exploded after a
catastrophically shallow analysis of the risk that circular gaskets called O-
rings could fail. Although this had been identified as a launch constraint,
NASA had a track record of overriding it in prior missions without any
problems occurring. On an unusually cold launch day, the O-ring sealing
the rocket booster joints ruptured, allowing hot gas to burn through the fuel
tank, killing all seven
Challenger astronauts.
In 2003, the space shuttle
Columbia disintegrated under similar
circumstances. After takeoff, the team on the ground noticed that some
foam had fallen from the ship, but most of them assumed it wasn’t a major
issue since it had happened in past missions without incident. They failed to
rethink that assumption and instead started discussing what repairs would
be done to the ship to reduce the turnaround time for the next mission. The
foam loss was, in fact, a critical issue: the damage it caused to the wing’s
leading edge let hot gas leak into the shuttle’s wing upon reentry into the
atmosphere. Once again, all seven astronauts lost their lives.
Rethinking is not just an individual skill. It’s
a collective capability, and
it depends heavily on an organization’s culture. NASA had long been a
prime example of a performance culture: excellence of execution was the
paramount value. Although NASA accomplished extraordinary things, they
soon became victims of overconfidence cycles. As people took pride in
their standard operating procedures, gained conviction in their routines, and
saw their decisions validated through their results, they missed
opportunities for rethinking.
Rethinking is more likely to happen in a learning culture, where growth
is the core value and rethinking cycles are routine.
In learning cultures, the
norm is for people to know what they don’t know, doubt their existing
practices, and stay curious about new routines to try out. Evidence shows
that in learning cultures, organizations innovate more and make fewer
mistakes. After studying and advising change initiatives at NASA and the
Gates Foundation, I’ve learned that learning cultures thrive under a
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