Safety News

Shoot the Messenger No More: In the days after Columbia was lost, Ron Dittemore was the face of the search for why that orbiter and its crew of seven were lost. NASA's shuttle program manager, he daily updated us on the details of the Columbia investigation.

Overlooking the fundamental problem that the man in charge was investigating what went wrong with his operation, Dittemore did a fine job–at least from a public-relations point of view. He appeared frank and truly concerned about finding answers.

When we began hearing within days of the accident, for instance, that NASA engineers may in fact have had concerns about the safety of clearing Columbia’s crew to attempt a meteoritic descent, Dittemore said he wasn't aware of this. He didn't understand, he said, why anyone with such concerns wouldn’t have raised them to the highest levels of NASA.

"Now I am aware," he said two days after the February 1 accident, "that there have been some reservations expressed by certain individuals. They weren't part of our playbook at the time because they didn't surface. They didn't come forward."

The general public may have found those words understandable, sympathizing with a manager who hadn't been presented with all the information his subordinates had.

I found Dittemore's words chilling. Reading between the words, as underlings might do when listening to a boss, I heard this message to everyone who worked under him: "If you had concerns, you should have made them known. If you didn't, it's your butt on the line. If you had concerns and didn't make them known, it would be prudent to keep your mouth shut."

Too often, big organizations–including those in aviation maintenance–react to big problems, be they the loss of life and aircraft or the reports of critical inspectors, this way: find the one guy who can be blamed for failing to head off the problem and sacrifice him. If need be, offer up a supervisor or two. But never, ever admit there are problems with "the system." Fortunately for safety and everyone concerned about it, this approach may be near its end.

As Roy Allen points out on page 24, European regulators are requiring aviation operators to account for how their organizations, practices, and culture–that is, the system–add or detract from safety.

Their new requirements to manage not just operations but the human factors therein, if successfully enforced, mean operators could no longer shoot the messenger who raises concerns before or after an incident and move on, content that the bad egg had been handled. Columbia is just the latest example that problems are rarely limited to one bad egg. As shown by the revelations since Dittemore's February 4 comments–that many engineers had concerns, that they repeatedly voiced concerns, and that NASA managers ignored or rejected chances to figure out just how much jeopardy Columbia and her crew faced–too often the whole batch of eggs is rotten from a safety standpoint.–By Jim McKenna