THINK AGAIN
Adam Grant
Quoting from folio 205, 206, 207, 208 of Chapter10
As an avid scuba dive, Luca Parmitano was familiar with risk of drowning. He just didn't realize it could happen in outer space.
Luca had just become the youngest astronaut ever to take a long trip to the International Space Station. In July 2013, the thirty six year old Italian astronaut completed his first spacewalk, spending six hours running experiments. moving equipment and setting up power and data cables. Now, a week later Luca and another astronaut Chris Cassidy were heading out for a second walk to continue their work and do some maintenance. As they prepared to leave the airlock they could see the Earth 250 mile below.
After forty four minutes in space, Luca felt something strange: the back of his head seemed to be wet. He wasn't sure where the water was coming from. It wasn't just a nuisance: it could cut off communication by shorting out his microphone or earphones. He reported the problem to Mission Control in Houston. Chris asked if he was sweating. "I am sweating," Luca said,"but it feels like lot of water. It's not going anywhere, it's just in my Snoopy cap.Just FYI." He went back to work.
The officer in charge of spacewalk, Karina Eversley, knew something was wrong. That's not normal, she thought. She quickl;y recruited a team of experts to compile questions for Luca. Was the amount of water increasing? Luca coldn't tell. Was he sure it was water? When he stuck out his tongue to capture a few of the drops that were floating in his helmet, the taste was metaliic.
Mission Control made the call to terminate the space walk early. Luca and Chris had to split up to follow their tethers, which were routed in opposite directions. To get around an antenna, Luca flipped over. Suddenly he couldn't see clearly or breathe through his nose - globs of water were covering his eyes and filling his nostrils. The water was continuing to accummulate. If it reached his mouth he could drown. His only hope was to navigate quickly back to the air lock. As the sun set, Luca was surrounded by darkness, with only a small headlight to guide him. Then his comms went down - he couldn't hear himself or anyone else speak.
Luca managed to find his way back to the outer hatch of the airlock, using his memory and the tension in his tether. He was still in grave danger. Before he could remove his helmet, he would have to wait for Chris to close the hatch and repressurize the airlock. For several agonizing minutes of silence, it was unclear whether he would survive. When it was finally safe to remove his helmet, a quart and a half of water was in it, but Luca was alive. Months later, the incident would be called the "scariest wardrobe malfunction in NASA history."
The technical updates followed swiftly.. The spacesuit engineers traced the leak to a fan/pump/separator, which they replaced moving forward. They also added a breathing tube that works like a snorkel and a pad to absorb water inside the helmet. Yet the biggest error wasn't technical - it was human.
When Luca had returned from his first space walk a week earlier, he had noticed some droplets of water in his helmet. He and Chris assumed they were the result of a leak in the bag that provided drinking water in the suit, and the crew in Houston agreed. Just to be safe, they replaced the bag. But that was the end of the discussion.
The space station chief engineer, Chris Hansen, led the eventual investigation into what had gone wrong with Lucas's suit."The occurrence of minor amounts of waer in the helmet was normalized," Chris told me. In the space station community, the "perception was that drink bags leak, which led to an acceptance that it was a likely explanation without digging deeper into it."
Luca's scare wasn't the first time that NASA's failure at rethinking had proven disastrous. In 1986, the space shuttle, Challenger, exploded after a catastrophically shallow analysis of the risk that circular gaskets called O-rings could fail. Although this had been identified as launch constraint, NASA had a track record of overriding it in prior missions without any problems occurring. On an unusually cold launch day, the O-ring sealing the rocket booster joints ruptured, allowing hot gas to burn through the fuel tank, killing all seven Challenger astronauts.
In 2003, the space shuttle Columbia disintegrated under similar circumstances. After take off, the team on the ground noticed that some foam had fallen from the ship, but most of them assumed it wasn't a major issue since it had happened in past missions without incident. They failed to rethink that assumption and instead started discussing what repairs would be done to the ship to reduce the turnaround time for the next mission. The foam loss was, in fact, a critical issue. The damage it caused to the wing's leading edge let hot gas leak into the shuttle's wing upon reentry into the atmosphere. Once again all seven astronauts lost their lives.
Rethinking is not just an individual skill. It's a collective capability, and it depends heavily on an organisation's culture. NASA had long been a prime example of a performance culture: excellence of execution was the paramount value. Although NASA accomplished extraordinary things, they soon became victims of overconfidence cycles. As people took pride in their standard operating procedures, gained conviction in their routines and saw their decisions validated through their results, they missed opportunities from rethinking.
Rethinking is more likely to happen in a learning culture, where growth is the core value and rethinking cylces are routine. In learning cultures, the norm is for people to know what they don't know, doubt their existing practices, and stay curious about new routines to try out. Evidence shows that in learning cultures, organizations innovate more and make fewer mistakes. After studying and advising change initiatives at NASA, it has been found that learning cultures thrive under a particular combination of psychological safetry and accounatbility.
Adam Grant continues in Folios 209, 210, 211 and 212 under
I ERR,THEREFORE I LEARN
In performance cultures, the emphasis on results often undermines psychological safety. A study by an engineer turned management professor, Amy Edmondson, had found that the more psychological safety a team felt, the higher was its error rates. It appeared that psychological safety could breed complacency. When trust runs deep in a team, people might not feel the need to question their colleagues or double check their own work. In performance cultures, the emphasis on results often undermines psychological safety. And people tend to censor themselves in the presence of experts who seem to know all the answers - especially if they lack confidence in their own expertise.
A lack of psychological safety was a persistent problem at NASA.
Before tthe Challenger launch, some engineers did raise red flags but were silenced by managers. Others were ignored and ended up silencing themselves. After the Columbia launch, an engineer asked for clearer photographs to inspect the damage to the wing, but managers didn't supply them. In a critical meeting to evaluate the condition of the shuttle after takeoff, the engineer didn't speak up.
About a month before tha Columbia launch, Ellen Ochoa became the deputy director of flight crew operations. In 1993, Ellen had made history by becoming the first Latina in space. Now, the first flight she supported in a management role had ended in tragedy. After breaking the news to the space station crew and consoling the family members of the fallen astronauts, she was detrmined to figure out how she could personally help to prevent this kind of disaster from ever happening again.
Ellen recognised that at NASA, the performance culture was eroding psychological safety. "People pride themselves on their engineering expertise and excellence," she said. "They fear their expertise will be questioned in a way that's embarassing to them. It's that basic fear of looking like a fool, asking questions that people just dismiss, or being told you don't know what you are talking about."
To combat that problem and nudge the culture toward learning, she started carrying a 3x5 note card in her pocket with questions to ask about every launch and important operational decision. Her list included
1. What leads you to that assumption? Why do you think it is correct? What might happen if it's wrong?
2. What are the uncertainties in your analysis?
3. I understand the advantages of your recommendation. What are the disadvantages?
A decade later, the same lessons about rethinking had to be relearned in the context of spacewalk suits. As flight controllers first became aware of the droplets of water in Luca Parmitano's helmet, they made two faulty assumptions. The cause was the drink bag. The effect was inconsequential. It wasn't until the second spacewalk, when Luca was in actual danger, that they started to question whether those assumptions were wrong.
When engineer Chris Hamilton took over as the manager of the extravehicular activity office, he inaugurated a norm of posing questions like Ellen's. All anybody would have to ask was, 'How do you know the drink bag leaked?'
The answer would have been, 'Because somebody told us."
That response would have set off red flags. It would've taken ten minutes to check. But nobody asked.
It was the same for Columbia. Boeing came in and said,"This foam, we think we know what it did." If somebody had asked how they knew, nobody could've answered that question.
How do you know? It's a question we need to ask more often, both of ourselves and of others. The power lies in its frankness. It's non judgemental - a straightforward expression of doubt and curiosity that doesn't put people on the defensive.
Ellen Ochoa wasn't afraid to ask that question. But she was an astronaut with a doctorate in engineering, serving in a senior leadership role.
For too many people in too many workplaces, the question feels like a bridge too far.
When the stake is high, failure to respond to that question would be nothing but an open invitation to disater.
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