February 1, 2023 marks 20 years since the Space Shuttle Columbia disintegrated while it re-entered the Earth's atmosphere.
A piece of foam insulation from the external fuel tank had broken off and damaged a thermal tile on a shuttle wing during launch. Heat from re-entry later caused the space craft to break up over North Texas and Louisiana.
Rodney Rocha was the Space Shuttle Chief Engineer at the Johnson Space Center in 2003. He said managers at the time found engineers who signed-off on the damaged tile as safe for re-entry.
Rocha said he was part of the debris assessment team, which unanimously wanted a better picture of the tile damage that had been sustained during launch.
"Our struggle in engineering was, ‘hey, that looks bad'. And we cannot tell the extent of the damage or where it hit," he said. "We need a photograph. We cannot even start a credible analysis, these thirty-something people on the debris assessment team, until we get a photo."
Rocha said despite urging for pictures from satellites, shuttle managers decided against them.
"There were certain psychological principles or cultural principles at work that do not serve safety. Some of them were the normalization of deviance. I think we're very sensitive to that now," he said.
Normalization of deviance is a term coined by sociologist Diane Vaughan. The term defines the process in which deviance from correct or proper behavior or rule becomes normalized in a government or corporate culture. Rocha credits safety issues from that time to this normalization of deviance as well as confirmation bias.
"They found people who were giving the answers managers wanted. ‘There's nothing wrong, this is just a refurbishment issue,'" he said. "‘It'll be a repair, but everything will be fine. They'll land okay."
Rocha said NASA learned from the tragedy and that they are different from the NASA of 20 years ago. They now use principles put in place in the name of safety as it begins newer programs, such as the Artemis, to return to the moon and go beyond to Mars.
For example, engineers are now given a forum to air grievances and other issues or concerns.
"Intimidation, we've learned, is not really tolerated. We can report such things," Rocha said. "And organizations that do engineering have processes in place to allow technical dissenting opinions."