NASA Issues Investigative Report About Starliner Failure

Twenty-three years ago, the Columbia Accident Investigation Board issued its comprehensive report on the 2003 Space Shuttle Accident.  My colleagues Amy Edmondson, Richard Bohmer, and I began an intensive research project about the tragedy, and we published a case study, book chapter, and Harvard Business Review article with our analysis.  We argued that the failed mission demonstrated how and why organizations and their leaders actively downplay ambiguous threats at times.  We examined how the culture and team dynamics made it difficult for technical experts to express dissenting views and share bad news.  

Sadly, it seems that many of these same challenges led to the problems on the 2024 Starliner mission which left astronauts stranded on the space station for approximately nine months.  Yesterday, NASA issued its investigative report on the Starliner failure.   Here is the excerpt from the report that caught my attention: 

A posture of risk acceptance was communicated by CCP (NASA's Commercial Crew Program) and Boeing leadership, creating division within the large working/joint team and eroded trust. During the mission, CCP and Boeing operational leadership consistently conveyed a position of risk acceptance and readiness to undock, which many perceived as premature and dismissive of unresolved technical concerns. This was particularly apparent regarding the Service Module RCS 138thruster anomalies. This posture gave the impression that completing the sortie mission was prioritized over a thorough assessment of crew safety risks.  

One interviewee noted, “People said, ‘Why bother? He’s driving in one direction and that’s what he wants.’”   

Some interviewees also mentioned the shuttle operational background of the SMMT Chair, NOM, and CCP PM, and the possible preconceived notion that accepting risk to return the vehicle and crew was the only real path forward. This mirrors decisions made for the shuttle when no safe haven in LEO or alternative return capability was available. 

This forward leaning approach led to a breakdown in open dialogue. NASA institutional stakeholders, including ISSP, FOD, and Technical Authorities, felt their input was undervalued or ignored, requiring governance intervention to ensure additional data analysis occurred before a final crew return decision. The perception that CCP leadership had formed a position before hearing all viewpoints created organizational silence, resistance to collaboration, and stagnation in decision making. 

Strong personalities within CCP and Boeing were seen as overly optimistic in presenting data, which some interviewees interpreted as lobbying rather than objective analysis. This dynamic discouraged dissenting views and contributed to a growing sense of distrust. As one interviewee described, opposing positions felt like “pushing a rock uphill.” 

The situation improved later in the mission when key personnel changes were made within the Boeing team and there was collective recognition that senior leadership should have played a more active role in facilitating respectful engagement across differing perspectives. These changes allowed for more productive conversations regarding the technical qualification campaign of the hardware and testing at the WSTF. The lack of early intervention to address team dysfunction allowed conflict to overshadow mission objectives and delayed consensus on critical decisions. 

Organizational silence, discouraging of dissenting views, dismissed technical concerns, overly optimistic analysis... the pattern is clear.  Once again, we see ample evidence that leadership did not create a culture in which open and candid dialogue could occur about ambiguous risks.  I'm glad to see a careful after-action review taking place here, with transparency about the organizational problems that have been identified (rather than only focusing on the technical problems).  Having said that, now the challenge is clear: can NASA turn these lessons into action and fundamentally change the way future programs are led?