A failure to ‘speak up’ in meetings and the catastrophic Columbia Space Shuttle Disaster

Studies in psychological safety regularly demonstrate how employees may have a really important point to make in a meeting but hold back for fear of judgement, rejection or embarrassment.

Take, for example, Rodney Rocha. He was a highly experienced and skilled engineer, who was deeply involved with the Columbia Space Shuttle mission which launched for the 28th (and last) time on 16 January 2003.

Within 80 seconds of the launch, a piece of foam insulation broke off from the solid rocket booster and struck the left wing, causing undetected damage. Despite similar incidents in previous missions, the extent of the damage this time was not fully understood due to insufficient imaging and the fact that the video footage available was very unclear.

Rocha thought he had witnessed the foam strike and was concerned about potential damage. His requests for additional information to assess the damage were either denied or ignored by his immediate managers who, amongst other things, viewed it as an ‘in-family’ issue and also used previous foam strike history as a benchmark for assessment (German, 2003).

During a large mission management team meeting eight days into the mission, where senior management were in attendance, Rocha did not voice his concerns, thus missing an opportunity for contingency plans to be put in place to address the damage from the foam strike.

Rocha later explained … 

“I just couldn’t do it [speak up in the meeting about the foam risk]. She [referencing his senior manager] was way up here [gestures with hand overhead] and I was way down here [gestures with low hand]”.

On 1 February 2003, as Columbia re-entered Earth’s atmosphere, the damaged left wing led to the shuttle’s disintegration over Texas, tragically killing all seven crew members.

Rocha’s lack of communication was due to an absence of a psychologically safe environment for raising such issues.  The organisational culture at NASA emphasised hierarchy, and a strict adherence to the chain of command; the culture made it challenging for lower-level employees to question or contradict their superiors even when they had legitimate safety concerns (Bohmer et al, 2009). 

A similar theme can be observed with the Challenger Space Shuttle Disaster where those with safety concerns about ‘o-rings’ failing below a certain temperature “conformed to cultural understandings about hierarchical reporting relationships” (Vaughan, 1996) and didn’t speak up. The o-rings ultimately allowed the escape of hot gasses between segments of the solid rocket boosters thus igniting the external fuel tank.

Whether you are offering a different perspective on a new product launch, raising a concern about company strategy, or you simply want to encourage employees to report governance, risk and compliance (GRC) issues, such as health and safety near misses, this disaster underscores the critical importance of fostering an environment where team members feel safe to speak up about potential risks and concerns.  

Steps to take:

1. The impact of management structures on levels of team psychological safety. In hierarchical organisations, employees may have reduced power as they need to report to their line managers to get anything done. Information is also likely to be diluted as it travels up the chain dependent upon the view taken by the line manager who is relaying the information.
2. Your culture strategy. For years NASA had worked under the safety mantra of “if it is not safe, say so”. This was later replaced, in 1992, by the safety slogan do things “better, faster, cheaper, without compromising safety” (Mars, 2000) due to pressure from the US government to reduce costs (Lambright, 2007). How does your culture drive behaviours?
3. Create an environment that promotes psychological safety. Encouraging open communication can help prevent small issues from escalating into catastrophic failures. 
   • Elaine Lin Hering (2024) former lecturer at Harvard Business School also promotes the following steps:
     • Make people aware you are happy to hear about the good, the bad and the ugly. Consider how line managers react to bad news – are they responding with anger? Or are they expressing appreciation and seeking to destigmatise the failure?
       • Use standard questions. Don’t just ask ‘what do you think’? as that may feel like a trap. Instead ask ‘what are the pros and cons of this idea’? What feature of this idea work/ don’t work?
       • Discuss communication preferences and be specific. Just saying ‘my door is always open’ should instead be replaced with ‘if thoughts come up after this meeting please email me’. Better still ask the employees what communication channels they prefer to use.
       • Lend Social Capital – deliberately give people the floor where you feel they have been underestimated, interrupted etc.

For more information on this topic or for details about in-house psychological safety training please get in touch with our Elizabeth Hyde at Hesper GRC.

References

Space Shuttle Columbia Disaster, ABC News Interview of Rocha

R.M.J. Bohmer, A.C. Edmondson, M. Roberto, L. Feldman & E. Ferlins, “Columbia’s Final Mission” Harvard Business School Case 304-090, April 2004. (Revised May 2010)

H.W. Gehrman, National Aeronautics and Space Administration (2003), Columbia Accident Investigation Board Report

Harvard Business School Cold Call Podcast with Edmondson (2016)

L.Henry (2007). Leading Change at NASA: The case of Dan Goldin

E.L. Herring, How to Get your team to actually speak up (2024) Harvard Business Review

Mars Program Independent Assessment Team (2000), Mars Program Independent Assessment Team Report

A. Vaughan, The Challenger Launch Decision (1996)