Assessing NASA’s Safety Culture: The Limits and Possibilities of High‐Reliability Theory

Abstract

After the demise of the space shuttle Columbia on February 1, 2003, the Columbia Accident Investigation Board sharply criticized NASA’s safety culture. Adopting the high‐reliability organization as a benchmark, the board concluded that NASA did not possess the organizational characteristics that could have prevented this disaster. Furthermore, the board determined that high‐reliability theory is “extremely useful in describing the culture that should exist in the human spaceflight organization.” In this article, we argue that this conclusion is based on a misreading and misapplication of high‐reliability research. We conclude that in its human spaceflight programs, NASA has never been, nor could it be, a high‐reliability organization. We propose an alternative framework to assess reliability and safety in what we refer to as reliability‐seeking organizations.

Responding to project uncertainty: Evidence for high reliability practices in large-scale safety–critical projects

“…Additionally the majority of the research on high reliability organising has been descriptive in nature, based on case studies of particular organisational contexts. There has not yet been clear articulation of the mechanism by which the characteristics and processes of high reliability organisations translate into safe and reliable performance (Boin & Schulman, 2008). For example, which are the most important high reliability characteristics?…”

“…A number of authors have sought to characterise HROs (notably Boin & Schulman, 2008;La Porte, 1996;Roberts & Rousseau, 1989;Weick et al, 1999;Weick & Sutcliffe, 2007) . Saunders (2015) synthesised an "ideal-type high reliability organisation" from this literature which comprises five main features: clear organisational objectives, a strong organisational culture, the presence of redundancy and slack, mindful behaviour and the ability to prosper in the paradoxes.…”

Toward High Reliability Project Organizing in Safety-Critical Projects

“…Several authors have sought to articulate a set of attributes, exhibited by high reliability organizations, which differentiate them from other organizations (see, for example, Boin & Schulman, ; La Porte, ; Roberts & Rousseau, ; Weick et al, ; Weick & Sutcliffe, ). Table summarizes the high reliability organization literature and synthesizes it into five core characteristics, which underpin an “ideal‐type of high reliability organization.” These are a strong organizational culture, clarity of organizational objectives, the presence of redundancy and slack, mindful behavior and the ability to prosper in the paradoxes —recognizing that this differentiation is a subjective and theoretical one and that there are areas of commonality between the various characteristics.…”

Enhancing mindful coordination in fragmented utility construction practices : by developing, implementing and evaluating virtual design and construction models

“…The concepts constituting the HRO lens originate from the lively and dynamic HRO domain that hosts debates and promotes a flow of strategic, managerial and technicalsystem perspectives on reliability (Boin and Schulman, 2008). Our research extends the lens to a CM domain which is notorious for its high rate of overruns, failure costs and accidents, often due to non-goal action and non-goal events.…”

“…LaPorte, 1996;Boin and Schulman, 2008;Schulman, 2011) All organizations are driven by goals and invest money and effort to reach targets reliably. It seems that this second premise lumps together and substitutes the term reliable and the safety first goal, due to the fact that 'HROs' in high hazard environments strive for 'reliably safe'.…”