01 Mar 2005

Facing Ambiguity

Columbia’s Final Mission
by Julia Hanna


On February 1, 2003, the space shuttle Columbia disintegrated upon reentry into the Earth’s atmosphere, killing all seven astronauts onboard. In a new multimedia case, “Columbia’s Final Mission,” by HBS assistant professors Michael Roberto and Richard Bohmer, HBS professor Amy Edmondson, and research associates Erika Ferlins and Laura Feldman, students are assigned the parts of six managers or engineers who were involved in the Columbia mission. After logging into their password-protected role, students watch, read, and listen to documents such as actual e-mails and phone messages, as well as video interviews and audio reenactments of meetings that take them from the shuttle’s launch to Day 8. On that day, a critical Mission Management Team (MMT) meeting determined that foam strikes that had occurred during the shuttle’s takeoff were not a safety factor in its operation. (The strikes were later cited as the cause of the disaster.)

NASA’s experience offers a lesson to managers in other areas, suggests Edmondson, who, with her coauthors, came up with the concept of the “recovery window,” or the time in which an organization can respond to an ambiguous threat and avert a potential tragedy. “Most disasters, when you look into them, had smaller indicators of what might happen along the way,” says Edmondson. “We often downplay early warnings and wait to see what will happen. You almost have to go against your instincts and aggressively learn about these ambiguous threats. You may find out the threat is harmless, but that’s OK — you learned, built capabilities, and understand the system better.”

The case, which is dedicated to the memory of Columbia’s flight crew, includes a fifteen-minute documentary, produced by the HBS team, which provides background on NASA and the history of the shuttle program. When students come to class they have a general understanding of NASA but only specific knowledge — from the point of view of their assigned “character” — of what has occurred during the first half of Columbia’s mission. After some discussion, six students are selected to role-play the Day 8 MMT meeting.

Because students only receive information pertinent to their role, they have a partial picture of what has occurred. “We wanted the students to feel like part of the action, to experience the pressures and difficulties of making decisions with ambiguous, incomplete information,” notes Roberto. “This wasn’t just people shuffling paper in Houston. They were monitoring astronauts in space, and the foam strike was one small issue in a complex set of events.”

“It’s real information and real people in real time,” Edmondson adds. “Students don’t get stuck on the bias of hindsight because the fact that the foam strike was to blame isn’t general knowledge.”

A four-person production team led by HBS multimedia producer Melissa Dailey played a vital role in the yearlong collaborative process of creating the case, says Roberto. Because multimedia requires a significant commitment of time and resources, careful consideration is given to whether a case justifies the treatment.

“It’s not technology for technology’s sake,” Roberto notes. “We should only use multimedia when we have a pedagogical innovation, such as the individualized role-playing, that cannot be as successfully executed in a paper case.”

The case, which will be taught this spring in the MBA second-year course General Management: Processes and Action, debuted last fall in a customized Executive Education program for a group of pharmaceutical executives. “There are parallels, such as Merck’s experience with Vioxx, which opened up a great deal of introspection about their own industry,” says Roberto. “There was much discussion around the issue of accountability.”

When gleaning lessons from Columbia and other disasters, notes Edmondson, it’s important to be realistic in considering the controls, guidelines, and training that could be put in place to improve safety. “Risk and error will never go away,” Edmondson reflects. “But we can do better. There’s a lot of room for improvement.”

— Julia Hanna


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