When pre-established engineering or operational constraints are consciously violated, with no resulting negative consequences, an organizational mindset is encouraged that more easily sanctions future violations. This can occur despite well-established technical evidence, or knowledge of operational history, that suggests such violations are more likely to lead to a serious incident. Eliminating serious incidents requires constant reminders of the vulnerabilities inherent in hazardous activities. Operating diligence and management effectiveness can be easily dulled by a sense of false security – leading to lapses in critical prevention systems. Catastrophic incidents involving highly hazardous materials or activities occur so infrequently that most organizations never have the unfortunate, but educating, opportunity of experiencing one. Key organizational cultural themes emerging from the CAIB report include: Although NASA is a unique organization, with a focused mission, the organizational cultural failures that led to the Columbia disaster have counterparts in any operation with a potential for significant incidents. Through its report, the CAIB has provided a service to all organizations that operate facilities handling hazardous materials or that engage in hazardous activities. Which of the cultural patterns emerging from the Columbia accident were the same as those first identified after the Challenger tragedy (almost exactly 17 years earlier) andwhy were they still present?.Why was it that serious concerns about the integrity of Columbia, raised within one day of launch, were not acted upon in the two weeks available between launch and return? With little corroborating evidence, management had become convinced that a foam strike was not, and could not be, a concern.In pursing the investigation beyond immediate causal contributors, the CAIB was trying to understand two issues in particular: At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work it defines “the way we do things here.” An organization’s culture is a powerful force that persists through reorganizations and the departure of key personnel.” CAIB Report, Vol.
“Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution.