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Tap into the experiences of NASA’s technical workforce as they develop missions to explore distant worlds—from the Moon to Mars, from Titan to Psyche. Learn how they advance technology to make aviation on Earth faster, quieter and more fuel efficient. Each biweekly episode celebrates program and project managers, engineers, scientists and thought leaders working on multiple fronts to advance aeronautics and space exploration in a bold new era of discovery. New episodes are released bi-weekly on Wednesdays. 

NASA Administrator Bill Nelson, Deputy Administrator Pam Melroy, and Associate Administrator Bob Cabana discuss the importance of a strong safety culture.

The 20th anniversary of the Space Shuttle Columbia accident was February 1, 2023. During a NASA Day of Remembrance town hall in January, NASA leadership honored members of the NASA community who lost their lives while furthering the cause of exploration and discovery, including the crews of Columbia, Challenger, and Apollo 1. NASA leaders engaged in a dialogue with the workforce about workplace safety culture and lessons learned over the years.

In this episode of Small Steps, Giant Leaps, you’ll learn about:

  • NASA leaders’ personal connections to the Challenger and Columbia crews
  • The importance of listening and speaking up
  • Ways to avoid groupthink


Related Resources

Safety Culture Town Hall for NASA Day of Remembrance

Video: NASA Remembers Fallen Heroes

Kennedy Space Center Honors Day of Remembrance

Apollo, Challenger, Columbia Lessons Learned Program

Office of Safety and Mission Assurance

Apollo Era Resources

Shuttle Era Resources

NASA Lessons Learned Information System

APPEL Courses:

Pay It Forward: Capturing, Sharing and Learning NASA Lessons (APPEL-vPIF)

Risk Management II (APPEL-vRM II)

Space Launch and Transportation System (APPEL-vSLTS)

Cognitive Bias in Engineering Decision-Making (APPEL-vCBED)


Bill Nelson Credit: NASA

Bill Nelson
Credit: NASA

Sen. Bill Nelson was sworn in as the 14th NASA Administrator in May 2021, tasked with carrying out the Biden-Harris administration’s vision for the agency. Nelson chaired the Space and Science Subcommittee in the U.S. House of Representatives for six years and the U.S. Senate for 12 years. He then served as the Ranking Member of the full Senate Commerce, Science, and Transportation Committee. Nelson was recognized as the leading space program advocate in Congress. In 2010, Nelson and Sen. Kay Bailey Hutchinson (R-Texas) passed the landmark NASA legislation that mapped out a new future for NASA and set the agency on its present dual course of both government and commercial missions. During his time in Congress, Nelson was a strong advocate for NASA’s Earth science programs and authored numerous pieces of legislation to combat and mitigate the effects of climate change. He has served in public office over four decades, first in the state legislature and U.S. Congress, then as State Treasurer. In 1986 Nelson flew on the 24th flight of the Space Shuttle. The mission on Columbia orbited the earth 98 times over six days. Nelson conducted 12 medical experiments, including the first American stress test in space and a cancer research experiment sponsored by university researchers. He has a bachelor’s in political science from Yale University and a Juris Doctor from the University of Virginia.

Pam Melroy Credit: NASA

Pam Melroy
Credit: NASA

Pam Melroy was sworn in as NASA Deputy Administrator in June 2021, after she was nominated for the role by President Joe Biden. As Deputy Administrator, Col. (USAF, ret) Melroy helps establish NASA’s vision and represents NASA to the Executive Office of the President, Congress, and other organizations. Earlier in her career, Melroy was one of only two women to command a space shuttle and logged more than 38 days in space on missions to build the International Space Station. As a co-pilot, aircraft commander, instructor pilot, and test pilot, Melroy logged more than 6,000 flight hours in more than 50 different aircraft before retiring from the Air Force in 2007. She is a veteran of Operation Desert Shield/Desert Storm and Operation Just Cause, with more than 200 combat and combat support hours. After serving more than two decades in the Air Force and as a NASA astronaut, Melroy took on leadership roles at Lockheed Martin, the Federal Aviation Administration, and the Defense Advanced Research Projects Agency and as an advisor to the Australian Space Agency. Melroy holds a bachelor’s in physics and astronomy from Wellesley College and a master’s in Earth and planetary sciences from the Massachusetts Institute of Technology.

Bob Cabana Credit: NASA

Bob Cabana
Credit: NASA

Robert D. Cabana is a former NASA astronaut, currently serving as the agency’s Associate Administrator, its third highest-ranking executive and highest-ranking civil servant. Cabana previously was Director of NASA’s Kennedy Space Center. In that role, he managed all NASA facilities and activities at the spaceport, including the team of civil service and contractor employees who operate and support numerous space programs and projects. Cabana was commissioned a second lieutenant in the U.S. Marine Corps and completed Naval Flight Officer training in Pensacola in 1972. He was designated a naval aviator in 1976 and has logged over 7,000 hours in 50 different kinds of aircraft. Cabana was selected as an astronaut candidate in 1985 and subsequently served in a number of leadership positions, including Lead Astronaut in the Shuttle Avionics Integration Laboratory; Mission Control Spacecraft Communicator (CAPCOM); and Chief of NASA’s Astronaut Office, A veteran of four spaceflights, Cabana has logged 38 days in space, serving as the pilot on STS-41 and STS-53 and mission commander on STS-65 and STS-88. His fourth flight was the first assembly mission of the International Space Station in December of 1998. He has a bachelor’s degree in mathematics from the U.S. Naval Academy.


Bill Nelson: A question, even a simple question, is more forgivable than a mistake that can result in a tragedy. The bottom line is this, speak up.

Pam Melroy: We need to know it can happen to us. We can make a decision or not share a concern that could contribute to an accident. And every one of us, every day, is on the line to ensure the safety of the agency.

Bob Cabana: I was the one that had to tell the families they weren’t coming home. I don’t ever want to have to do that again.

Deana Nunley (Host): Welcome to Small Steps, Giant Leaps, a NASA APPEL Knowledge Services podcast where we tap into project experiences to share best practices, lessons learned and novel ideas.

I’m Deana Nunley.

NASA’s Day of Remembrance is an annual event that honors members of the NASA community who lost their lives while furthering the cause of exploration and discovery, including the crews of Apollo 1 and space shuttles Challenger and Columbia. This year marks the 20th anniversary of the Columbia accident.

During the 2023 NASA Day of Remembrance Town Hall, NASA Administrator Bill Nelson, Deputy Administrator Pam Melroy, and Associate Administrator Bob Cabana engaged in a dialogue with the workforce about the invaluable lessons learned over the decades and the importance of a strong safety culture. NASA leadership offered compelling advice on how and why to avoid groupthink, the importance of speaking up, and why leaders need to listen to their teams.

In today’s podcast, we’ll hear the town hall remarks from NASA leadership as they reflect, share best practices, and answer employees’ questions about safety, beginning with Administrator Bill Nelson.

Nelson: Each tragedy, Apollo 1, Challenger, and then Columbia, each disaster left a gaping hole in the hearts of the NASA family, and many of us feel those personal connections. In my case, the 24th flight of the space shuttle. We had been through four scrubs. The first attempt in December when we were scrubbed for a different reason. It ended up being 41 degrees that morning. We didn’t think anything about that. On through three more scrubs, a total of four, of which if we had launched and we had gotten down to T-minus 13 in the count, another morning T-minus 31, any one of which would’ve been a bad day. Only to launch into a sixth day, almost flawless mission, and to return to Earth on January the 18. Hoot Gibson’s crew, Charlie Bolden, pilot. And 10 days later Challenger launches and blows up.

It so happened the night before the Challenger launch, the temperature had gotten down to 25 degrees. There were icicles hanging on the launch tower. And there were people that had serious doubts about launching. But I’ll tell you who had the doubts were the engineers out in Utah who were begging their management at Morton Thiokol to stop the count because of the cold weather, and the cold weather stiffening rubberized gaskets called O-rings in the field joints of the solid rocket boosters.

I asked those engineers later, I said, ‘How were you sensitized to that?’ And then when almost a month earlier, on our first launch attempt, it was 41 degrees, Challenger was 36 degrees at launch time. ‘How was it that you were not sensitized to our first launch attempt on the 24th flight?’ And they told me. They said, ‘It was when we got back your solid rocket boosters, when you’d launched on the fifth try, and it was a relatively warm 56 degrees, and we saw blow-by.’ The blow-by of the hot gases in the field joints. And he said, ‘Then we remembered that the previous January that had happened. And we asked what’s common to January?’

And the management would not listen to the engineers begging them to stop the count. And that went up all the way to the top. As a matter of fact, the NASA Administrator wasn’t allowed to be at the Cape because he had been indicted for something that was 10 years before and he knew he could clear himself. So, he was in his office in Washington in the Headquarters watching the count and seeing the icicles on the launch tower. And he’s calling the Cape, begging them to stop the count, and they won’t take his call because he’s not the Administrator. There was an Acting Administrator.

Just one other personal commentary. Of course, I think the world of Hoot Gibson and Charlie Bolden. And I remember years later Hoot telling me on subsequent missions that he would get out and inspect the orbiter after his flight and he’d look at the underside or the sides of the orbiter with those delicate silicon tiles. And he said it was like somebody had taken a shotgun and just shredded a warning about what was to come, in 2003 in February. And that was the foam coming off the external tank and it just so happened to hit at the right place, on ascent, as the shuttle accelerated. It hit the leaning edge on that carbon carbon fiber and knocked a hole in the front edge of the wing. Our Deputy and our Associate Administrator, they have seen all of this firsthand, and they’re going to explain their own personal experiences.

But the bottom line on all this is every day at NASA we have an opportunity. We have a duty to carry the memories of those that we lost and carry their dreams onward and upward. And these are the enduring lessons from each of these tragedies. And the bottom line is this, speak up. A question, even a simple question, is more forgivable than a mistake that can result in a tragedy. And each of us has a responsibility to cultivate a work environment where every member of the NASA family feels empowered to voice doubt, make your concerns heard, communicate openly. We saw the power of speaking up and listening. We saw it just recently at the successful launch of Artemis 1, because while they were loading the liquid cryogenic propellants into this powerful rocket, teams encountered a small leak on a hydrogen valve inside the mobile launcher. And although the engineers attempted to remotely troubleshoot the issue, managers ultimately decided that they needed a Red Team.

So, three, Chad Garrett, Billy Cairns and Trent Annis made the trip out to the launchpad. This is a fully loaded rocket. They entered that danger zone. They entered as that mobile launcher, at its zero deck. And Trent tightened the bolts at the leaky valve while Billy communicated with the launch team and the Red Team. It worked. And the Red Team not only demonstrated heroism and professionalism that day, and it helped us to do it safely, and then we could go on and complete the mission.

And what they did also reminds us of how critical each team member is in the integrity and the safety of every NASA mission. And that’s an example of what happens when we speak up and we listen. Safety is our responsibility.

So as I said earlier, with our leadership here to discuss more about the importance of safety and to honor this Day of Remembrance, I want to introduce my colleague, our co-leader, Deputy Administrator Pam Melroy.

Melroy: Thank you so much, Bill.

I have to say that while I love honoring the crews, this can be a hard day. And I get so much comfort from Bill and from Bob because you’ve been through this, and you understand. It’s so important that we focus the whole week, and in fact the whole year, and every day on remembering our fallen colleagues while also celebrating their legacy. As I said, it won’t just be this week. We’ve talked about this for a while coming up on the 20th anniversary of Columbia. We plan to keep the dialogue going through safety workshops and discussions at several of the centers and to make sure that this dialogue continues to be very inclusive but also real, vital, informative. And just the whole goal of talking about this and keeping these lessons learned alive.

There are so many lessons learned from Apollo 1 to Challenger to Columbia. We work with such complicated systems and we’re building them to do things that no one has ever done before. And when I look at the complexity, especially of what we are doing in our human spaceflight program, we continue to be at the cutting edge. So, we all know when we’re trying something new, we’re never going to be 100 percent safe because there are things that we can’t predict that might happen. But each of us should remember that it could happen to us. So that’s one of the messages that I want to give and I’ll tell a short story about that.

I was a Cape Crusader, helped strap crews in and unstrap crews, as my first technical assignment working at the Cape. And one of the things that was so wonderful was to work with people who’d been trained by the famous Guenter Wendt, who was really the grandfather of all of our procedures for safety out at the pad. And they had had experiences with Apollo 1 that immediately changed and affected, not just the way we operated out at the pad, but also the hardware that we used, the accessibility of it, and then of course to pass those lessons on. And I have to say that I listened eagerly to all of those things, and I was proud of the procedures that we did at the time because I was like, ‘Wow, we’ve really made this safe.’

I came back from my second flight, and I was asked to lead the Cape Crusader team. So, I was in Florida to get my familiarization training for unstrapping the crew of STS-107. And I was out at the runway with Bob Cabana. And the crew didn’t land on time. We all stared out, looking as you did for the shuttle, listening for the sound of the distinctive double boom. And we didn’t hear it and the time came and went. Now, as a person trained in physics, I understood perfectly well that this just can’t happen. When you come back at those speeds from space, you’re going to land when they say you’re going to land, within a second, and that’s just how it is.

But I couldn’t fathom it. I just simply couldn’t fathom it. And the only person standing around there at the runway, as we all looked at each other, Bob knew. Cabana knew before the rest of us. And it’s because he’d been through it with Challenger. He was the first to say to all of us, ‘They’re not coming home.’ And I just realized that in my head, I had gotten into a place where this was something that had happened before and that we’d fixed everything, and it was going well.

We need to know it can happen to us. We can make a decision or not share a concern that could contribute to an accident. And every one of us, every day, is on the line to ensure the safety of the agency. I just want to remind everyone that the responsibility is on all of us, and it can happen to you, whether you’re in that hard place and you know it at the time you’re making the decision or not.

Wayne Hale, our former Space Shuttle Program Manager, has said, ‘Just because you’re younger or smarter or read history lessons,’ or for me, listen to really smart people who learn from Apollo 1, ‘don’t think that you won’t make mistakes, and especially that events can’t get away from you. Nobody is smart enough to avoid all problems and that sliver of fear, the knowledge that the universe is out there waiting for the least lapse in attention to bite, is motivation that just might help you avoid catastrophe.’

So having a little bit of a preoccupation with risk and failure, if you will, can lead to high reliability organizations. I think it’s critically important in everything we do, in program management, in the way we do our business every day, to always be thinking about risk and not just as a, ‘Yeah, I get it. That could happen. I’m going to put it to the side,’ but, ‘What am I actually actively doing about protecting for that?’

So, after each tragic accident, we’ve managed to not only discover the technical problems that led to them, but also to work very actively to nurture and encourage a culture where speaking up is encouraged. And, really, I think that’s very important to Bill and Bob and I, and the Administrator has talked about speaking up. We need to make sure that dissenting opinions are heard and that questions aren’t insulting.

There’s a living connection to the vital importance of safety that crosses generations, as older people transition out of the workforce and newer members of the NASA family may not have experienced a tragedy and are now on the front lines in making launch decisions. I want to encourage any of you who were not here when Columbia happened to seek out someone who was and ask them to tell their story, how it affected them, and how it affected the agency. That acute awareness of why we must always focus on safety and not pressure to launch, why we must be rigorous as teams to make sure we’re not applying group think to a complex issue. And so many other tools that we have now for making our astronauts, and in fact, our whole workforce safe, they’re critical.

So, I trust that everyone will be taking the Columbia case study training in SATERN very soon. So many of us still here at NASA knew these folks personally, and this year marking 20 years since they’ve been gone. Hey, let’s face it, this is a hard topic for all of us, but I want to reiterate again, it could happen to you, to us, and we have to do our utmost to ensure that if it does happen to us, we have the potential to change the course of events.

The tools we’ve been developing to ensure a thriving safety culture and the backbone of support from your teams are benchmarks that we rely on to extend the reach of science and human exploration out into the solar system and beyond. What we do is so hard, and so worthwhile, and each team member’s knowledge, intuition, and compassion are essential. So, thank you for everything you do every day for our grand mission and to honor the memories of our fallen comrades.

Now, let me hand it over to my dear friend, our Associate Administrator, Bob Cabana.

Cabana: Thank you all so much for joining us today. For those of you that know me, this is a topic very dear to my heart. It’s very important to me. Safety, after all, is our top core value. And all I can say is the Administrator talked about the importance of speaking up, Pam talked about how it can happen to us, and it’s really important that we keep our focus as we go into this new year, and we take stock of what we are doing to ensure that we’re doing things safely.

I want to put things in perspective for me. When I first got to NASA, back in July, June, of 1985, we were flying the shuttle, things were looking great, and I’d been at NASA about seven months when we lost Challenger. I was in a single systems trainer, learning about the OMS RCS system, and they came and interrupted our session. They said, ‘We lost the Challenger.’ And I was in there with another astronaut, and we said, ‘The crew’s OK. They got out.’ Well, there’s no way they can get out. They weren’t OK. And I was hard to accept that we had actually lost a vehicle.

And then I thought about it a little bit. And I’d just come from Patuxent River, as a test pilot, and we’d lost three crewmen while I was there, three fatalities. And I looked at what we were doing in space as well, this is part of the business that we’re in. This is going to happen. And that was my perspective as a young astronaut candidate having just come from the Naval Air Test Center. But that’s not the case. It was totally preventable. You’ve heard that. People needed to speak up. People needed to listen. People needed to act. It could have been prevented. Now, how did my perspective on all of that change?

I was Chief of the Astronaut Office for three years, and I rode out to the pad with every crew. And I want to tell you, flying in space is a lot easier than asking somebody else to take that risk. And I saw all those crews off and I was on the runway to see them all home safely. I went off and had other jobs between that, and I was assigned as the Director of Flight Crew Operations in Houston. And Columbia, STS 107, was my very first flight as the Director of Flight Crew Operations. And I rode out to the pad with that crew again, and that’s the last time I saw them. And as Pam mentioned, 20 years ago, we were standing on the midfield at the runway waiting for the crew to come home. And they didn’t come home. And I knew the Challenger crew, but I really knew the Columbia crew, and I knew that it was preventable. I knew we could have done something in retrospect when we learned about it.

And it’s very hard. I was the one that had to tell the families they weren’t coming home. I don’t ever want to have to do that again. We can prevent accidents with people flying in space. That’s why our Day of Remembrance is so important. That’s why it’s so important that we don’t forget these lessons that we’ve learned. And more than technical, it was really cultural. It was creating that environment to be able to speak up, to be heard, to focus on the task at hand, because it can happen to us. But we can explore space. We can break the boundaries without having to suffer the loss of crew if we do our jobs, if we stay focused, if we create an environment where everybody can be heard, and that we actually listen. And there’s a difference between hearing and listening. That we actually listen to what’s being said and that we encourage everybody to be part of the discussion, to be part of answering the solutions that we need to ensure that we fly safely.

And I don’t want to ever forget. I don’t want any of us to forget. And there are so many of us that are new. When I was down at the Kennedy Space Center six years ago, probably, when I was the Director, I was having an all hands. And I asked everybody in the auditorium, the auditorium was packed, and I said, ‘How many were not here when we stopped flying the shuttle?’ And there was over a third of the audience raised their hand. They weren’t working at NASA when we were flying the shuttle. So how many were not here when we lost Columbia? That’s why we can’t forget. We have to continue to keep these lessons that we’ve learned alive. That’s up to us.

And I just want you to know how much I enjoy working with the Administrator and Pam because they know what it’s all about. And, believe me, they put safety above all else in the decisions that we make. I’ve been at meetings with the Administrator, and nobody pulls harder on it than he does when we’re talking about sending crews into space. So, I ask all of you, please don’t forget.

If you get down to the Kennedy Space Center, go to Forever Remembered at the Atlantis facility, pay honor to those crews, and do not forget the lessons that we’ve learned in the past, because we are going to continue to move ahead, to inspire the world through discovery. And we got the best mission of any agency anywhere, and that’s to explore the unknown in air and space, to innovate for the benefit of humanity, and inspire the world through discovery, and we can do it safely. Thank you.

Host: The next segment of the town hall is a Q&A session facilitated by NASA Press Secretary Jackie McGuinness.

Jackie McGuinness (Facilitator): Our first question will come from Brian at Ames. He asks, ‘How do we change the mindset of safety versus mission progress to help us internalize that safety is mission progress?’

Cabana: I think I’d like to take that one for starters, and you can chime in. But first off, safety is part of our mission. We put the mission first, but when you talk about safety and the mission, if you do not execute the mission safely, what happens? You damage people and equipment. And then what happens? It takes longer and you’re not successful. So, safety has to be inherent in everything that we do. If we do things safely and correctly, we actually make up more time, it costs us less, nobody gets hurt. It is absolutely what we need to do. So, I don’t see them as separate. I see them as safety is part of executing the mission correctly.

McGuinness: Thank you so much. Our next question is from Stephanie here at Headquarters. She asks, ‘How can parts of the NASA workforce who are not engineers contribute directly to our safety culture?’

Melroy: I’d like to take that one. I think that actually we are a team and that everybody is contributing. And in fact, what’s really interesting is often the person in the room who knows the least about the subject asks the most penetrating and basic question that causes everybody to take a step back and say, ‘Huh.’ So that’s core to our values of speaking up, to our safety culture. I often say diversity and inclusion is actually a part of our safety culture. And in fact, it’s really important that people feel empowered whether they are the expert in an area or not to speak up because we actually saw it on the space shuttle all the time. It was often the crew member who knew the least who would ask a simple question. ‘Why can’t we try it like this?’ Now sometimes it was like, ‘Well, we can’t and here’s why.’ But a lot of times it was what ended up solving the problem. So please do speak up.

Cabana: And I will just add to that, it’s not just the non-technical folks, it’s new technical folks. When you’re at a meeting, oftentimes when we’re brand new to a situation, we don’t feel like we can speak up. We look at the table and we see all these really experienced people and we think, ‘Oh, they know everything.’ Well, they don’t always know everything. And you bring a new experience when you come. That’s why diversity and inclusion is so important. If you have a question at a meeting, it’s incumbent upon you. It’s mandatory that you speak up and ask it because it’s probably something somebody else may not have thought of. So, whenever we have a meeting, everybody needs to be engaged. And if you’re brand new to an organization, don’t think that everybody else knows it all. And if you have a question, please ask that question.

Melroy: Yeah, a lot of times people are grateful someone asked it.

McGuinness: Thank you both. Nicholas at Marshall asked, ‘As new human spaceflight vehicles are planning to become operational, with less direct NASA oversight compared to previous systems, how is NASA ensuring that the safety of government and private astronauts remains the top priority for the wider industry?’

Nelson: Well, it’s a challenge. But it is the responsibility of us, as the overseers. Even though we may have a partner in the public-private sector that is executing the contract, but who at the end of the day, if it’s a NASA mission is responsible? It’s us. And therefore, we’ve got to look over their shoulder, we’ve got to ask the questions, and use the same degree of rigor that we would if it were a government mission only, even though it is a commercial mission doing a government payload.

Cabana: And I can assure you on these private astronaut missions that go to the ISS, this man asks more questions than anybody to ensure that it’s being executed safely. Now, I’ll also add, on the purely private missions that are not under NASA, that don’t go to the International Space Station, if you look at SpaceX for example. They have learned from us on the NASA missions that we fly to ISS. And if you look at how they run their totally private astronaut missions, they run them in the same manner as they execute the missions for us. So, what we have learned in the many years of human space flight that we’ve developed all the procedures and safety checks that we have in place, we share those. And you’ll find that others follow our example. We lead.

Melroy: And I’ll kind of wrap it up by saying if commercial human spaceflight takes off, which we think it will the same way commercial aviation did, at some point the industry will have to learn its lessons on its own.

We are in a very interesting place right now. We have a close relationship with the FAA, which licenses our cargo and crew launches, but only for public safety. And so, we work closely with them and we will continue to work closely with them as they take on more responsibilities in this area. Right now, we have a lot of engagement. A lot of people don’t realize how closely we scrutinize all the activities on our commercial cargo, commercial crew, our private astronaut missions . We’re very, very involved. As time goes on, we hope to transfer that knowledge, as things go forward. But I think for at least a decade or more to come, we’re going to be extremely engaged with all those commercial partners as we go forward. But eventually they’re going to have to grow up and have their own regulator someday, and we’re going to support that as best we can with all the knowledge of the agency.

Nelson: We learn from our commercial partners, but they learn from us as well, and especially they learn from us about our insistence of safety.

McGuinness: Thank you all. Our next question from Darren at Goddard is for you, Administrator Nelson. He asked, ‘How did you feel about the risks brave astronauts faced after the Challenger disaster knowing you had just flown a shuttle mission earlier the same month?’

Nelson: 10 days before. Well, the honest answer is I collapsed to my knees, and I cried out, ‘Why were we spared?’ And I think you’ve heard the experience of Bob, that rode out to the pad with the crew of 107, Columbia, and they didn’t land.

It’s now our obligation to try to share with you what we feel intensely, that is so important for NASA as we venture out into this unknown. We’re going back to the Moon, but a lot of it’s unknown, because we’re doing things on the Moon that we’ve never done. We’re going to a different part of the Moon. You ought to see what the south pole of the Moon looks like. It’s not this bright, shiny, equatorial area where we landed on Apollo. It is a hazardous, severely shadowed and therefore dark, depressions and craters. And we’ve got to be right on the money. So not only are we going back to a new Moon, we’re going to do new things in order as we venture out. And that’s going to bring a lot of hazards, and that’s where safety is going to be so important.

McGuinness: Thank you, sir. Our next question comes from Lewis at JSC. He asked, ‘How do you feel about groupthink and do you see that at play today in NASA?’

Melroy: Groupthink occurs wherever there are groups. That is just part of human nature. It’s just a part of who we are. There’s a reason why it’s called that. I think the key thing is to put the processes in place and the culture in place and the encouragement in place to fight against it every single day. And this, again, gets to the ability to speak up, the ability to imagine what if the worst happened, and then ask the question and then work together as a team to try to find a creative solution to mitigate the risks.

McGuinness: Thank you. Our next question is from Jeffrey at Johnson. ‘What are we doing as an agency to keep our lessons learned alive beyond an annual Day of Remembrance?’

Cabana: Oh my gosh. We got SATERN Training. On the ninth floor we have a monthly safety meeting that we have where bring up different topics. There are just so many ways this needs to be brought out. Every time I give a briefing to a new group of senior executives, I always bring up safety. I always bring up the lessons learned. I always bring up the need to have interactive discussions and make sure everybody speaks up. So, it’s incumbent upon us as leaders to not let this be forgotten. All supervisors, when you take that training, it’s not just for you, it’s for the team that you’re leading. It’s so that you learn so that you can create an environment to keep this going. There’s just so many ways that we continue to reinforce this.

Melroy: Yeah, I’m excited about the workshops that we’re going to have on a series of topics that the Office of Safety and Mission Assurance has put together for us on some key topics.

I would also like to echo what Bob said. I think what’s critically important is not that you’re all passive listeners to this today, but you are active proponents. It’s on you to listen. So, the senior leaders, the frontline supervisors, and the individuals, you are responsible for carrying this message and to continue to promote it every day. This isn’t just something that you’re listening to us saying and go, ‘OK.’ You actually have a responsibility to help communicate it. Bill, I don’t know if you have anything to add.

Nelson: And we take very seriously our responsibility with the Safety Advisory Panel. We have frequent meetings with them. And that panel is populated with not only former NASA Flight Directors and scientists and engineers, but also astronauts. They ask the probing questions. Interestingly, there are only two advisory panels set up by law to NASA. One is the NASA Advisory Council, and the other is the Safety Advisory. Set up in law. And that’s just another check and balance on us as trying to offer some leadership to NASA, to get that outside information. That’s why the three of us take so seriously these town hall meetings when we’re coming to each of the centers. We want you to show up. And if you’ve got any concern, especially about safety, please bring it up. If you don’t want to bring it up in front of everybody else, pull us aside. That’s why we’re going out there, to hear from you.

Cabana: And I’d also like to add, down at the Kennedy Space Center, within the Vehicle Assembly Building, is where the debris from Columbia is stored. And Mike Ciannilli is responsible for that, within the safety organization at NASA Headquarters, detailed down there. There’s an Apollo Challenger Lessons Learned group that he’s in responsible for. He has resources available to anyone on Challenger, Columbia, Apollo 1, that you can use as training aids for your team. Just send Mike a note and I’m sure he’d be happy to get with you.

For me, I think it’s important. I encourage every new senior executive at some point to walk through that Columbia, where the Columbia debris is, and stored down there, and see the consequences of the decisions that we make. Nobody that made the decisions on Challenger and Columbia thought they were putting the crew at risk. They thought they were making a good decision. But they didn’t have all the data. And we have to ensure that we have all the data so that we make informed decisions. That’s why it’s so important to engage everyone, to ask questions, and to listen.

Nelson: And Bob already recommended to you in his remarks something that he’s responsible for. And that is in the Atlantis Exhibit at the Visitor Center at KSC is a memorial for the two space shuttle crews that we lost. If you just walk in there, and walk into that darkened section, and the first thing you see, in a total dark room, in a black backdrop, is a piece of the side of Challenger with the American flag. And then you turn to the right and in that similar darkened background, you see the steel frame of the cockpit of Columbia. There are not many people that can walk out of that room with a dry eye.

McGuinness: Thank you. And our last question is from Jimmy at Johnson. ‘With Day of Remembrance coming up, how can we remind ourselves that normalization of deviance can play a role in accidents small and large alike?’

Cabana: This is really important. And we’ve seen it in flying on our SpaceX vehicles, even today, where something’s not right, but nothing goes wrong, so we come to accept it. And we have to question everything. I think the main thing we do is we have to question when something’s not right. And some will say that Apollo was the failure of imagination. What could go wrong? And anything that isn’t exactly as it was meant to be, we have to question, ‘What could go wrong if that happened?’ We can’t accept just because nothing bad happened. If it’s not right we need to understand it and do our best to mitigate the risk and to fix it.

Melroy: Yeah, I’ll just add. To me a key part of normalization of deviance is complacency. It’s the sense that, again, it can’t happen to us. It hasn’t happened the last five flights or 10 flights or five years or whatever.

One of the amazing things that we do, and I think, Bill, you talk about it very eloquently, is the amazing things that we do in our mission. We just have to remind ourselves every day, we are doing hard stuff, and we kind of get used to being awesome. Last year was a great example of that. We were awesome, awesome, awesome. But that also can bring with it that sense of complacency. And so, I think that belief that it can happen to you is a very important part of that. Asking the question, ‘Hey, that was a deviation, and what could go wrong?’ So, I think it’s taking that personal step to both own the coolness of what we do and the hardness of it, and then a reminder that it comes with risk.

Host: You’ll find links to topics discussed during the town hall on our website at along with the speakers’ bios and a show transcript.

If there’s a topic you’d like for us to feature in a future episode, please let us know on Twitter at NASA APPEL – that’s APP-el – and use the hashtag Small Steps, Giant Leaps.

As always, thanks for listening.