Has NASA's culture changed since the Columbia tragedy?

As NASA grapples with whether to bring Boeing Starliner astronauts home on a SpaceX Crew Dragon, I think it’s worth talking about how NASA even makes a decision like this. How do they evaluate the risk, when everything humans do in space is inherently risky? How do they take their past failures, like Challenger and Columbia, into account when weighing risks? And is Commercial Crew, with its contractors, somehow worse or riskier than the Space Shuttle?

Let’s dive in to all of this.

Space is inherently risky

One thing that I think is getting lost in the buzz of discussion around Boeing Starliner and whether Suni and Butch will come home on Boeing Starliner or a SpaceX Crew Dragon, is a frank discussion of risk. I have seen a lot of people who simply don’t understand just how risky space is, and how taking huge risks is part of the job of an astronaut. Not undue risk, for sure, not risk that is unnecessary, but just generally, all spaceflight is risky. There’s no such thing as a safe spaceflight, because space is inherently unsafe. It is actively trying to kill you.

Astronauts know this. It’s what they sign up for, and astronauts trust that the people on the ground making these decisions have their best interests in mind. They trust the people they work with.

It’s important to remember: The Space Shuttle was not safe. Apollo was not safe. Gemini and Mercury? Not safe.

But NASA gathers all the data they can in order to mitigate risk and lower risk as much as possible. That thoroughness is why there have only been three losses of crew in NASA’s history — Apollo 1, Challenger, and Columbia.

If that’s the case then, how does NASA decide whether Starliner is safe to bring home Butch and Suni? Everyone knows that a test flight is inherently riskier than an operational flight.

And a lot of people have pointed to the fact that this is commercial space — under a Commercial Crew contract — to make it seem like it’s significantly more risky or worse than what NASA has previous done. I would remind you of two things: First, contractors built all of NASA’s spacecraft. The contract is new, but the relationship with industry has been in place since the beginning.

Second, NASA mandated 1/270 odds for loss of crew for these Commercial Crew vehicles. Boeing had 1/295. As a comparison, SpaceX’s loss of crew statistic for their crewed demonstration mission was 1/276.

An analysis of the first few operational Space Shuttle flights had the loss of crew statistic as 1 in 9. Space travel is inherently risky.

How does NASA make a decision about risk when everything is risky?

The way NASA has tackled this over the past two months is, basically, trying to gather as much data as possible. Boeing has been doing extensive testing on the ground and on orbit trying to figure out the root cause of the thruster failures. And NASA has been talking to experts from all around the country within NASA, outside of NASA, anyone they can.

The issue is the thrusters on Boeing Starliner. There are two separate problems within the propulsion system, which is housed in the capsule’s service module. One is helium leaks — now helium isn’t a propellant but it’s used for pressurization to push fuel to the thrusters. The second is thruster failures due to overheating.

It’s likely that if Butch and Suni were to undock in Starliner and make their way home, they’d be fine. What NASA is looking at is an edge case scenario in which there’s a massive helium leak, which means they lose the OMAC (more powerful thrusters used for the deorbit burn) and at the same time the RCS thrusters overheat and they lose those as well (these are less powerful thrusters used for precision and attitude). If this worst-case scenario happens, Butch and Suni could be stranded in orbit, and I don’t think it would be a stable orbit, so they’d end up re-entering in an unsafe way…and well, you can extrapolate from there.

The problem NASA is having is just getting enough data to where they feel confident that isn’t going to happen. They are struggling to quantify the risk because they just don’t have enough information. And frankly, I’m not sure they can get that data without direct examination of Starliner’s service module, which is jettisoned before re-entry and doesn’t return to Earth.

I do think Boeing has enough data now to make future versions of Starliner safe. But there’s still this one to worry about.

This being Boeing complicates everything

I’ve seen a lot of people claiming it’s easy to make the decision — if there’s any doubt, just send a SpaceX Crew Dragon up, problem solved. But that’s risky too, because all spaceflight is risky! It’s about weighing the risks against one another.

Crew Dragon is a known quantity. It’s had a lot of operational flights, both with NASA and private missions like those with Axiom. We are relatively confident that it’s as safe as it can be, but it wasn’t always that way.

It’s also easy to assume that Boeing is inherently unsafe because of the incredibly bad management practices that have been in place. It’s simple to assume that any problems the spacecraft is having are due to those kinds of mismanagement and that the vehicle is unsafe, similar to its aircraft. And that might be accurate.

But it also might not. As someone who has covered space for a long time, I’m honestly struggling to tell whether this is actually an issue of mismanagement, not enough testing, and lack of experience and care or whether this is indeed, as NASA and Boeing are both saying, a problem they really only could have found on orbit.

But the history of Boeing Starliner also doesn’t offer much comfort.

But it’s also normal to find problems on a crewed flight test! Just as a reminder, SpaceX changed the Crew Dragon heat shield between their crewed demonstration flight and the first operational flight Crew-1, because they discovered more wear and tear in spots than was expected.

All of this — including the possible mission extension, because that actually happens a lot in spaceflight — is getting more attention than usual because it’s Boeing, and because of what else is happening with the company right now.

Boeing’s aviation business and their space business are two separate divisions, but any issue of company culture is going to permeate throughout. And we did get a report from the NASA Office of the Inspector General about Boeing’s mismanagement of construction of the SLS Block 1B, I will have a newsletter on that specific report soon, but it’s also important to note — the hardware that Boeing is building for NASA goes through a much more rigorous testing and acceptance process than their aircraft because NASA is putting their own astronauts in the spacecraft and on top of the rockets.

But a SpaceX rescue also has its risks

Let’s also take into account that NASA has emphasized over and over again that they see having two providers for Commercial Crew as incredibly important. After their experience with the Space Shuttle, they determined that redundancy was crucial.

If Butch and Suni don’t return on Starliner, it’s unclear whether NASA can certify Starliner for operational flight. If that’s the case, and NASA asks Boeing to do another crewed flight test — that will likely be the end of Starliner. Boeing has lost $1.5 billion on this contract. They may just cut their losses and pull out together. NASA doesn’t want that happening.

But then there’s the risk of keeping Butch and Suni on the ISS for longer — there’s additional radiation exposure with a long-duration spaceflight. There’s two to three weeks between when Starliner would undock and Crew-9 would arrive that, if there were an emergency aboard the ISS requiring an evacuation, Butch and Suni would have to come home in Crew-8 as two additional, unsuited crew members (for more on this, check out my story on why spacesuits between Boeing Starliner and SpaceX Crew Dragon aren’t compatible).

There’s risk in everything they do in this situation, and that’s what NASA is struggling with.

Is this “normalization of deviance”?

Okay, so let’s talk about NASA’s safety culture because that’s obviously relevant here. Especially because it has failed in the past, notably with Challenger and Columbia. NASA’s organizational culture has been victim to what Diane Vaughn, in her excellent book The Challenger Launch Decision, coined as “normalization of deviance.” It’s not that NASA had “go fever,” though at times that has been a problem. But they also have a history of delaying launches due to problems, grounding the entire Shuttle fleet when an issue was detected — they’ve maintained that safety is paramount, and there is evidence of that for sure.

But “normalization of deviance” means that basically, if something was operating outside of what was normal, NASA didn’t demand answers for why it operating that way. It just accepted that some of the foam could indeed break off the external tank and hit the orbiter, but nothing happened as a result, so it was fine. They didn’t demand answers for (1) why the foam was acting that way, because it’s not supposed to break off or (2) whether that foam could do significant damage to the orbiter’s sensitive heat tiles. They normalized the deviance and moved on.

This was an issue during Challenger as well, and the Columbia Accident Investigation Board made it clear that NASA culture hadn’t changed significantly, and normalization of deviance was at the root of the Columbia tragedy. Engineers who had tried to speak up weren’t listened to.

So the question here is: Is NASA’s safety culture operating the way it should, or are we seeing more normalization of deviance? If Starliner astronauts come back on Starliner, are they just assuming it will be okay, or do they have the data to back that up?

My thoughts on NASA’s current safety culture

It’s certainly hard to make that determination from the outside, without looking at the data and test results they are. But here’s what I have observed.

First, the tone of the press conferences has been really non-hostile (that’s the best term I can think of). There have been complaints about the frequency of the press conferences — even if there’s nothing to report, or no developments, we still want to be able to ask questions and get information about this flight. That’s been getting better for sure, they’ve been listening to feedback there, but also I have attended a lot of NASA press conferences. A lot of them feel very defensive and unpleasant, where it feels like management finds press questions annoying and intrusive. These don’t have that feel. It does seem like we’re getting honest thoughts and information, and the team is just doing their best to work through the information they have and find more.

Second, NASA’s governance structure has changed. Back during Columbia, the Mission Management Team had pretty much all the power to make the decision of whether it was safe to fly, and there was no one who could really step in and say, “Hey, I have an issue here and I don’t think it’s safe.” No one had that authority. Now if there’s a safety issue anyone has a concern about, regardless of level, it gets flagged and NASA has formally implemented procedures for those to each be considered and analyzed.

As the organization moves through the Flight Readiness Review process, which is basically coming to consensus at each level and each center, they’re paying attention to the dissenting voices.

On top of that, a reporter (Marcia Smith from Space Policy Online) directly asked at the latest press conference about how this kind of decision making process has changed since Challenger and Columbia. Russ DeLoach, chief of NASA’s Office of Safety and Mission Assurance, made it clear that he specifically is thinking a lot about the organizational silence that permeated NASA during both tragedies — basically people wanted to speak up but either didn’t feel comfortable or were silenced when they tried. The fact that the organizational issues that led to these tragedies is being considered here at the highest levels? That also gives me some assurance.

Russ DeLoach pointed out that taking so many thoughts and opinions and considerations into account here means that they’re going to move incredibly slowly while making this decision. And I think that’s the sign that they are giving this the consideration it deserves, and keeping in mind past failures while they do it.

And that’s my final point — the amount of time NASA has taken to make this decision, the work they’ve put into contingency scenarios — it’s clear that they don’t think that there’s a high chance of these thruster failures happening. But there are people within the organization at whatever level who aren’t convinced about Starliner’s safety. NASA is listening to that and taking it seriously. That makes me feel secure that whatever happens with this mission, NASA is considering everything.

We’ll likely find out sometime next week how and when Butch and Suni will be returning home, as they are nearing the point where they have to make the final decision. We will see what happens.