Think Again

probably time to adjust. Rethinking is more likely when we separate the
initial decision makers from the later decision evaluators.

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© Hayley Lewis, Sketchnote summary of A Spectrum of Reasons for Failure. Illustration
drawn May 2020. London, United Kingdom. Copyright © 2020 by HALO Psychology
Limited.
For years, NASA had failed to create that separation. Ellen Ochoa
recalls that traditionally “the same managers who were responsible for cost
and schedule were the ones who also had the authority to waive technical
requirements. It’s easy to talk yourself into something on a launch day.”
The Columbia disaster reinforced the need for NASA to develop a
stronger learning culture. On the next space shuttle flight, a problem
surfaced with the sensors in an external engine tank. It reoccurred several
more times over the next year and a half, but it didn’t create any observable
problems. In 2006, on the day of a countdown in Houston, the whole
mission management team held a vote. There was overwhelming consensus
that the launch should go forward. Only one outlier had voted no: Ellen
Ochoa.
In the old performance culture, Ellen might’ve been afraid to vote
against the launch. In the emerging learning culture, “it’s not just that we’re
encouraged to speak up. It’s our responsibility to speak up,” she explains.
“Inclusion at NASA is not only a way to increase innovation and engage
employees; it directly affects safety since people need to feel valued and
respected in order to be comfortable speaking up.” In the past, the onus

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would’ve been on her to prove it was not safe to launch. Now the onus was
on the team to prove it was safe to launch. That meant approaching their
expertise with more humility, their decision with more doubt, and their
analysis with more curiosity about the causes and potential consequences of
the problem.
After the vote, Ellen received a call from the NASA administrator in
Florida, who expressed surprising interest in rethinking the majority
opinion in the room. “I’d like to understand your thinking,” he told her.
They went on to delay the launch. “Some people weren’t happy we didn’t
launch that day,” Ellen reflects. “But people did not come up to me and
berate me in any way or make me feel bad. They didn’t take it out on me
personally.” The following day all the sensors worked properly, but NASA
ended up delaying three more launches over the next few months due to
intermittent sensor malfunctions. At that point, the manager of the shuttle
program called for the team to stand down until they identified the root
cause. Eventually they figured out that the sensors were working fine; it
was the cryogenic environment that was causing a faulty connection
between the sensors and computers.
Ellen became the deputy director and then the director of the Johnson
Space Center, and NASA went on to execute nineteen consecutive
successful space shuttle missions before retiring the program. In 2018,
when Ellen retired from NASA, a senior leader approached her to tell her
how her vote to delay the launch in 2006 had affected him. “I never said
anything to you twelve years ago,” he said, but “it made me rethink how I
approached launch days and whether I’m doing the right thing.”
We can’t run experiments in the past; we can only imagine the
counterfactual in the present. We can wonder whether the lives of fourteen
astronauts would have been saved if NASA had gone back to rethink the
risks of O-ring failures and foam loss before it was too late. We can wonder
why those events didn’t make them as careful in reevaluating problems with
spacesuits as they had become with space shuttles. In cultures of learning,
we’re not weighed down with as many of these questions—which means
we can live with fewer regrets.

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