C H A P T E R 6Organizational CultureNASA’s ORGANIZATI.docx

C H A P T E R 6
Organizational Culture
NASA’s ORGANIZATIONAL CULTURE has been the subject
of an
enormous number of popular and scholarly works. Thomas
Wolfe’s 1995 The
Right Stuff, and the subsequent film, observed the self-
confident, can-do ethos
of test pilots and its early influence on NASA and its astronaut
corps. The 1995
film Apollo 13 celebrated the dedication and ingenuity of
NASA’s engineers on
the ground that were able to improvise a device to scrub carbon
dioxide from
the air and replot a return path for the crew of the badly
damaged lunar landing
craft in 1970. A darker view of the agency’s culture is described
by Diane
Vaughan (1996), who traced the widespread acceptance of the
increasingly clear
evidence of faulty seals in the solid rocket boosters before the
Challenger acci-

dent. Adams and Balfour in Unmasking Administrative Evil
(1998) attribute what
they see as the isolated and ‘‘defensive organizational culture’’
(108) of the Mar-
shall Space Flight Center to its early management by a team of
German rocket
scientists with links to Nazi forced labor camps.
Cultural elements are also thought to have contributed to the
two shuttle
accidents. Both of the official investigations of the shuttle
disasters identify cul-
ture as a cause. The Rogers Commission ‘‘found that Marshall
Space Flight Cen-
ter project managers, because of a tendency at Marshall to
management
isolation, failed to provide full and timely information bearing
on the safety of
flight 51-L to other vital elements of shuttle Program
management’’ (Rogers
Commission 1986, 200). Based on this finding, the commission
indirectly rec-
ommended culture change as one remedy: ‘‘NASA should take
energetic steps

to eliminate this tendency at Marshall Space Flight Center,
whether by changes
of personnel, organization, indoctrination or all three’’ (200;
emphasis added).
The Columbia Accident Investigation Board went into much
more detail about
the failings of the shuttle program culture, identifying cultural
issues behind
several of the patterns of behavior that led to the accident. The
board found that
a ‘‘culture of invincibility’’ permeated the management (CAIB,
199), particularly
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EBSCO : eBook Academic Collection (EBSCOhost) - printed on
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AN: 280524 ; Mahler, Julianne, Casamayou, Maureen Hogan.;
Organizational Learning at NASA : The
Challenger and Columbia Accidents
Account: s3268531.main.eds
Organizational Culture 141
as it used past successes to justify current risks (179). There
were also ‘‘ ‘blind
spots’ in NASA’s safety culture’’ (184). Excessive hierarchy
and formalization,
intolerance of criticism, and fear of retribution kept those with
concerns silent.
The CAIB identified lapses in trust and openness, contributing

to blocked com-
munication across the shuttle organization, a finding that had
also been identi-
fied in the Rogers Commission report and in 2000 by the Shuttle
Independent
Assessment Team (179). In both accidents, information and
events had been
interpreted though cultural frames of reference built up over
years of experience
(CAIB, 200).
In line with the approach taken in the previous three chapters,
we will exam-
ine the evidence that similar patterns of cultural beliefs and
assumptions contrib-
uted to both accidents. We then look at the efforts that were
made to change
these assumptions or learn to overcome their effects after the
Challenger accident.
Because underlying cultural assumptions tend to persist in
organizations, we do
not necessarily expect to find wholesale or rapid changes in the
agency’s culture,
but rather some recognition that certain cultural beliefs
contributed to the man-
agement patterns that led to the accidents. Finally, we search
out the efforts that
were made to understand the impact of cultural beliefs, to
initiate changes when
possible, or to make intelligent adaptations.
There are many characterizations of NASA’s culture and
subcultures. We can-
not hope to track them all. Instead, we will consider the
evidence surrounding
four core cultural beliefs and assumptions about the work at

NASA and the
shuttle program particularly, each of which bears directly on the
decisions and
actions surrounding the accidents. They are, very briefly, the
sense of rivalry and
grievance that contributed to lapses in reporting and
management isolation at
Marshall, the dismantling of the hands-on laboratory culture at
Marshall that
left engineers without an effective means of judging reliability,
the low status of
safety work that contributed in both cases to a silent safety
program, and the
unwillingness to report unresolved problems based on what
some have termed
the ‘‘climate of fear’’ in the agency or, less elegantly, what
contractors have called
‘‘NASA chicken’’ (Wald and Schwartz 2003).
I N V E S T I G AT I N G T H E C U L T U R E O F
T H E S H U T T L E P R O G R A M
All of the examples offered in the paragraphs above illustrate
NASA’s organiza-
tional culture, defined as the deeply held, widely shared beliefs
about the charac-
ter of work, the mission, the identity of the workforce, and the
legacy of the
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142 Analyzing the Causes of the Shuttle Accidents
organization’s founders. These kinds of cultural beliefs may not
be overtly
acknowledged by members. In fact, such beliefs may not be
recognized as ‘‘the
culture’’ but rather simply as the way things are done (Martin
2002). This ‘‘taken
for granted’’ character of organizational culture makes it
especially difficult to
identify or to change, but it also means that the beliefs exercise
a significant and
lasting effect on the perceptions and actions of members.
Culture is especially
important to organizational learning because lessons learned
across organization
levels become embedded in culture as often-told stories, rituals,
or tacit knowl-
edge, as well as in new formal policies and procedures (Schein
1992; Levitt and
March 1988). This link to learning also reflects the ways in
which culture evolves
as a product of the history of an organization. Van Maanen and
Barley note that
‘‘culture can be understood as a set of solutions devised by a
group of people to
meet specific problems posed by the situations they faced in
common’’ (1985,
33). Thus cultural meanings accrete over time and uniquely in
response to the
experiences of organization members.
There are many ways to conceptualize and study the culture of
an organiza-
tion (Martin 2002). Particularly useful here is Schein’s (1992,
1999) approach

that distinguishes the visible artifacts, behavior patterns, and
articulated or
espoused values from the underlying cultural beliefs and
assumptions that may
not be either visible or overtly articulated. These core
assumptions describe the
patterns of meaning in an organization (Martin 2002, 3), and
they help account
for how members think, feel, and act. Assumptions about the
worth of the mis-
sion, the identity of members, and professional norms all inform
the meaning of
artifacts to organization actors. The overt manifestations of
these underlying
beliefs may include stories, architecture, and rituals, but also
structures and poli-
cies (Martin 2002, 55). Public statements about the underlying
beliefs may or
may not be accurate. The tensions between core beliefs and the
exigencies of the
day may emerge in espoused statements of values that are
clearly at odds with
actions or with the actual operative beliefs about the
organization and its mem-
bers (Schein 1999).
I N T E R C E N T E R R I VA L R I E S A N D G R I E VA N
C E S
Rivalry among the centers, poor communication within the
shuttle program
hierarchy, and a reluctance to share information across centers
emerged as pat-
terns in both shuttle accidents, though much more strongly in
the case of the
Challenger. The Rogers Commission directly identified

intercenter rivalries as a
factor in communication lapses between the Marshall Space
Flight Center in
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Alabama and the Johnson Space Center in Houston. Marshall
was criticized for
management isolation and failing to provide ‘‘full and timely’’
information to
other program offices (Rogers Commission 1986, 200). The
CAIB found that
one of the reasons that the mission management team failed to
take vigorous
action to acquire images of the orbiter wings was that Marshall
and Langley
engineers had been the first to identify the problem (CAIB 201),
and ‘‘the initial
request for imagery came from the ‘low status’ Kennedy Space
Center’’ (201). In
contrast, another member of the debris assessment team, who
was without par-
ticular credentials on this issue but who had an office in the
higher-status shuttle
program office at Johnson, was instrumental in defining the
problems as incon-
sequential early on (201–2). The implication is that the
Johnson-based mission
management team was unwilling to listen carefully to outsiders.

While it appears
that the rivalries between Johnson and Marshall were more
directly implicated
in the Challenger accident than in the Columbia disaster,
struggles over status
had impacts on communication and coordination in both cases.
The rivalry between the Marshall center and the Johnson center
was of long
standing and has been well documented. The centers had
competed for resources
and control of projects since at least the early 1960s, when they
begin to plan for
the lunar programs. The emerging proposals pitted Marshall’s
labs against the
Manned Spacecraft Center in Houston, which became the
Johnson Space Center
in 1973, over whether a lunar landing craft would launch from
an Earth orbit,
favoring Marshall’s heavy-propulsion systems, or would rely on
new, lighter
lunar orbital spacecraft designed at Houston. Lobbying by the
Manned Space-
craft Center resulted in success for the latter plan, giving
Houston the lead in the
lunar program and setting up a pattern that was replicated many
times in subse-
quent years (Dunar and Waring 1999, 56).
In the Apollo program, Marshall’s role was to provide the
propulsion systems,
the Saturn rockets. Wernher von Braun, who was then center
director, accepted
this resolution so as not to jeopardize the project (56), but this
was only one of
many compromises. Marshall engineers were later given the

Lunar Rover project
as well, but they were required to design it to Houston’s
specifications. This was
irksome to the engineering teams that had been successful in
launching the first
U.S. satellite, and it left them with a sense of grievance.
Describing the arrange-
ments that essentially made Marshall a contractor working for
Houston, the
Lunar Rover’s project manager regretted that Marshall ‘‘
‘always seemed to get
the short end of the string’ ’’ (102).
As noted in previous chapters, the funding for NASA projects
diminished
rapidly even before the lunar landing was achieved, as national
attention began
to focus elsewhere. To improve prospects for new projects to
keep his team of
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scientists together, von Braun led efforts to diversify Marshall’s
capabilities and
enlarge its mission. The center was able to secure initial work
on space telescope
projects for the Apollo astronomical observatories and later on
the Voyager
probes to Mars. Such strategies often put the centers in new

competition as each
jealously guarded its own project areas (Dunar and Waring
1999, 138). Dunar
and Waring, for example, note that ‘‘Houston challenged any
proposal from
Marshall that related to operations, astronauts, or manned
systems’’ (139).
Rivalry intensified in planning for the post-Apollo projects.
Marshall proposed a
small space station based on reusing the spent rocket stage,
making the best use
of the center’s own technologies, but Houston strenuously
objected since this
crossed the line into their province of manned spacecraft (181).
To clarify the division of labor and head off some of the
increasingly bitter
feuds, the headquarters associate administrator for manned
space flight, George
Mueller, brought these and other center staff to a retreat in 1966
to work out a
formal division of labor (Dunar and Waring 1999, 139). It was
here that the
concept of lead center was formalized. The lead would have
overall managerial
responsibility and set hardware requirements for the support
centers. In princi-
ple, Marshall and Houston would each be lead centers on
different elements of
the Apollo projects. But in practice the division between the
modules was diffi-
cult to specify, and the sniping continued.
Rivalries also continued in planning for the shuttle, but by the
mid-1960s, the
centers had signed on to an agreement similar to that worked

out for the Apollo
project. Marshall would design and manage the contracts for the
solid rocket
boosters and, when it was added to the plan in 1971, the
external tank, while
Houston would management the orbiter project. This
arrangement, however,
effectively made Houston the lead center on the shuttle project.
Commenting on
this, a shuttle program developer noted, ‘‘There is a certain
amount of competi-
tiveness and parochialism between the Centers that makes it
difficult for one
Center to be able to objectively lead the other. . . . That was the
real flaw in that
arrangement’’ (282). In fact, Houston took firm control of the
shuttle project
management and disapproved some of Marshall’s facility
requests while filling
its own. Again, Marshall staff agreed to this so as not to imperil
the project
overall (285), but it was another example of the center’s ‘‘short
end of the
string.’’
In fact, relinquishing lead status to Houston was a blow to the
sense of excep-
tionalism that was the hallmark of the engineering culture at
Marshall. When
von Braun and his 127 fellow engineers and scientists came to
the United States
in 1945 and later in 1950 to what was then the Redstone Arsenal
in Huntsville
(Dunar and Waring 1999, 11), they brought with them a team
identity and a

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culture built upon German technical education and years
together under his
leadership in the German military rocket program. Others have
described the
moral and ethical issues surrounding their work on the
American rocket pro-
gram (Adams and Balfour 1998; Dunar and Waring 1999), but
here we focus on
the laboratory culture they established at Huntsville. Hands-on
experience and
the combination of theory and practice was part of their training
and defined
the culture they came to call the ‘‘arsenal system’’ (Dunar and
Waring 1999, 19).
They prided themselves on their capacity for ‘‘dirty hands
engineering,’’ which
combined design and development work with the ability to
execute and exhaus-
tively test the project. They designed and built their own
prototypes with a staff
of technicians. In contrast, at most other centers, contractors
typically did this
work to the specifications of NASA employees. The hallmark of
the arsenal sys-
tem was conservative engineering. Engineers deliberately
designed-in redun-
dancy to improve reliability and performance, and would then

‘‘test to failure’’
(Sato 2005, 572; Dunar and Waring 1999, 43) to determine the
limits of the
design. The system was very successful. In the 1960s, no Saturn
launch had failed,
a remarkable record of reliability given the complexity of the
technology (Dunar
and Waring 1999, 92). This approach was also known for
building in wide mar-
gins of safety and containing costs while still speeding the
development of new
designs. In one often-told story, to avoid delay and the $75,000
that a contractor
wanted to charge for a rocket test stand, Huntsville engineers
cobbled together
their own stand for $1,000 in materials (20).
The technical strengths of the arsenal system as a whole also
came under
severe pressure as the resource-rich early years of the Apollo
program came to
an end. The hands-on lab culture eroded as reductions in force
took first the
younger engineers and then cut into the original team of German
engineers. This
was a particular blow to the Marshall workforce under von
Braun, who
believed that a good team did not work by a clear-cut division
of labor. Rather,
it depended on identity, honesty, mutual respect, and trust,
which could
develop only through a long period of collective effort . . . [and
were] the

prerequisites for any sound rocket-building organization. (Sato
2005, 566–67)
Von Braun’s group was forced to move from its heavy reliance
on in-house work
to the more typical Air Force model of development by
contracting its work.
Using a wide array of contractors also helped NASA maintain
its political base
by creating constituency support at a time when the space
exploration became a
lower national policy priority. However, as a result, the
Marshall team’s ability
to develop, manufacture, and test its prototypes was diminished.
It lost its shops
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and technicians and with them some of the basis for its lab
culture (Dunar and
Waring 1999, 165; McCurdy 1993, 136). The cuts also
compromised the ability
of the engineers to closely monitor contractors’ work and thus
maintain their
own quality and reliability standards. Earlier, 10 percent of the
Marshall work-
force had been on permanent assignment at contractor facilities
to monitor the

quality of the work, a system they called ‘‘penetration.’’
Marshall managers felt
forced to accept these changes even though they threatened their
identity as
an ‘‘exceptional workforce.’’ As McCurdy summarized it: ‘‘The
requirements of
survival were simply more powerful than the organization
culture during the
period of decline’’ (1993, 138).
The management isolation cited by the Rogers Commission and
the unwill-
ingness of the Marshall managers to report unresolved problems
thus emerge in
the midst of a long history of competition and distrust between
the centers.
Recognizing the cultural context of their actions, the severe
threats to Marshall’s
distinctive and successful lab culture adds to our understanding
of Marshall’s
reluctance to acknowledge problems with the solid rocket
booster joints or to
delay launches to deal with the redundancy status of the seals. It
helps explain
Houston’s sometimes dismissive responses toward Marshall’s
concerns about
possible damage to Columbia’s wing. As the CAIB noted
regarding both the
Challenger and the Columbia cases, ‘‘All new information was
weighed and inter-
preted against past experience’’ (2003, 200). Long-held cultural
beliefs affected
judgments about the launch and influenced the assessment and
communication
of information about risks.

The Rogers Commission recommendations for remedying the
management
isolation at Marshall included changes in personnel and in their
training or
‘‘indoctrination’’ (Rogers Commission 1986, 200). While the
commission’s dis-
cussion of its findings appears to recognize the issues of
competition and rivalry
behind the charges of management isolation, NASA’s response
of the recommen-
dations took a formal, structural approach. As noted in chapter
3, in the report
on the implementation of recommendations issued a year after
the Rogers Com-
mission Report, NASA strengthened the shuttle program office
at Houston’s
Johnson Space Center by making it a headquarters office and
adding a shuttle
project manager at Marshall to coordinate the Marshall elements
and report on
them to the shuttle program office. This solution addressed the
formal commu-
nication issues, but not the underlying cultural beliefs that
complicated the com-
mand and communication structures, because Houston was still
the site of the
‘‘headquarters’’ office. By 1990 the Augustine Report on
NASA’s role in U.S.
space policy noted internal and external evidence of continuing
reluctance by
‘‘the various NASA centers to energetically support one another
or take direction
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from headquarters,’’ but also noted that ‘‘an intense effort by
the current center
and headquarters managements has been underway to redress
these long-build-
ing trends, yet much remains to be accomplished in this most
difficult of man-
agement challenges, a cultural shift’’ (NASA 1990, subsection
‘‘Institutional
Aging’’). In any case, the structure reverted back to the
concentration of program
authority at the Johnson center when the shuttle program office
was repositioned
under the control of that center in 1996. Reorganizations and
downsizing also
created overlaps between program management roles and safety
functions. These
changes were linked to efforts to improve the willingness of
NASA employees
and contract personnel to voice their safety concerns. We
consider these issues
below.
R E L I A B I L I T Y A N D R I S K A S S E S S M E N T
Investigations of both shuttle accidents found that the shuttle
program suffered
from lapses in safety and reliability. The Rogers Commission
found that NASA
failed to track trends with the erosion of the O-rings and failed
to act on the

evidence they did have. The commission stated that ‘‘a careful
analysis of the
flight history of O-ring performance would have revealed the
correlation of O-
ring damage and low temperature’’ (Rogers Commission 1986,
148), and it con-
cluded that ‘‘NASA and Thiokol accepted escalating risk
apparently because they
‘got away with it last time’ ’’ (148). The Columbia accident
investigators found
similar evidence of a willingness to assume that known hazards
that had not
produced a catastrophic accident did not require urgent action.
As Vaughan
found in the case of the Challenger (1996), the damage from
foam debris had
become ‘‘normalized’’ and was seen as simply a maintenance
issue by program
managers (CAIB, 181). The Board concluded, ‘‘NASA’s safety
culture has
become reactive, complacent, and dominated by unjustified
optimism’’ (180).
But the assumptions about safety and how to judge safety were
also rooted in
the culture of the organization.
Reliability had been a central value of the arsenal system at
Marshall under
von Braun. The center’s tradition of conservative engineering
meant that engi-
neers included wide margins of safety and reliability with built-
in redundancies
(Dunar and Waring 1999, 44, 103). Testing was done both on
project compo-
nents and on the assembled result, and the severity of test
conditions was

increased to allow engineers to find the point at which the
design would fail.
Then engineers would isolate and fix the problems (100). As
noted, early results
were impressive. Under this model, however, quantitative risk
analysis was not
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seen as appropriate or feasible. Statistical analysis and random
testing, while
acceptable in a mass-production setting, was not appropriate in
the zero-error
environment of manned flight (45) in which failure was not
permitted. Reliabil-
ity assurance at Marshall thus rested on these premises, among
others: a funda-
mental belief in engineers’ vigilance, an emphasis on
engineering judgment
founded on broad experience, and a conservatism nurtured in a
particular social
structure (Sato 2005, 571–72). However, in the shuttle era, as
resources were cut
and the in-house arsenal system was dismantled, the ‘‘agency
could no longer
afford the conservative engineering approaches of the Apollo
years, and had to
accept risks that never confronted an earlier generation of
rocket engineers’’

(Dunar and Waring 1999, 324). They did not do this willingly,
holding instead
to the importance of conservative engineering and the need for
thorough testing
even though they no longer had the resources to sustain that
approach
(McCurdy 1993, 150). The reliability of the arsenal system had
been lost, but no
culturally workable replacement was forthcoming.
The antipathy of shuttle program managers to statistical
analysis has also been
linked to the many frighteningly pessimistic figures about the
shuttle’s survival
that had been circulated. Estimates of the reliability of the
shuttle’s rockets varied
by source. A NASA ad hoc group put failure rate at 1 in 10,000,
while a 1983
Teledyne study estimated failures at 1 in 100 flights (Dunar and
Waring 1999,
399). Johnson Space Center managers offered figures of 1 in
100,000 flights,
while Rogers Commission member Richard Feynman polled
NASA engineers
who put …
Lessons in Organizational Ethics from
the Columbia Disaster:
Can a Culture be Lethal?
RICHARD O. MASON
‘‘Houston We Have a Problem.’’ A
Message Never Sent or Received.

On February 1, 2003, the Space Shuttle
Columbia, on its way to its landing site in
Florida, blew apart in the skies of East Texas.
Its seven-member crew perished. The $2 bil-
lion ship was lost; some destruction occurred
on the ground, and considerable cost was
incurred to recover debris scattered over
several states. The disaster sounded an eerie
echo from the past. Seventeen years earlier
the shuttle Challenger exploded 73 seconds
into flight due to an O-ring malfunction.
All seven crewmembers were also lost.
And, about 11 years before that, the cabin
of Apollo 1 burst into flames on its pad. Three
crewmembers were killed.
Within a day, as NASA policy requires,
an internal investigation team of six ex officio
members was formed. Harold Gehman Jr., a
retired admiral who was NATO supreme
allied commander in Europe, was appointed
to chair it. A veteran of several military
investigations, including the bombing of
the U.S. Cole, Gehman, in an initially unpop-
ular move, broadened the inquiry to include
the agency’s organization, history and
culture. Sean O’Keefe, NASA’s administra-
tor, was incensed that the investigation
would reach beyond the confines of the
shuttle project alone, and his relations with
Gehman became strained and stiff. Based on
his experience, however, Gehman persisted.
An Accident Investigation Board (hereafter
referred to as the Board) was appointed with

six additional members who represented
a broader set of relevant constituencies.
In addition to the chair, the 13 member
Board included three other military aviation
experts, a former astronaut (Sally Ride), a top
NASA official, a retired corporate executive,
several senior civil accident investigators and
two distinguished engineering professors.
The Board’s overarching questions were
those inevitable ones: Why did the accident
occur? Who (or what) is to blame? What is to
be done?
It was a mammoth task. During less than
seven months, the Board’s staff of more than
120 worked with over 400 NASA engineers
examining more that 30,000 documents, con-
ducting over 200 formal interviews, hearing
testimony from dozens of expert witnesses
and receiving and reviewing thousands of
inputs from the general public. On Tuesday,
August 26, 2003, the 248-page report of the
Columbia Accident Board (Board Report) was
released.
The Board’s report pointed the finger at
NASA’s culture and its history. ‘‘The bitter
bottom line,’’ lamented New York Times cor-
respondent David Sanger, ‘‘. . . comes down
to this: NASA never absorbed the lessons
of the Challenger explosion in 1986, and
four successive American presidents never
Organizational Dynamics, Vol. 33, No. 2, pp. 128–142, 2004
ISSN 0090-2616/$ – see frontmatter
� 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.orgdyn.2004.01.002
www.organizational-dynamics.com
Acknowledgments: The author appreciates helpful comments
made by John Slocum, Ian Mitroff
and Gerald A. Turner.
128 ORGANIZATIONAL DYNAMICS
decided where America’s space program
should head after the cold war—and what
it would cost in dollars and risk to human life
to get there.’’ The Board’s findings were
scathing. NASA’s current culture, they con-
cluded, was largely to blame for the tragedy
because it stifled dissenting views and bred
complacency over persistent risks. The press
seized on phrases such as ‘‘NASA’s culture
of complacency,’’ ‘‘deeply flawed culture’’
and ‘‘a broken safety culture.’’
In an interview with William Lange-
wiesche for the November 2003 issue of
The Atlantic Monthly, Gehman described
the flaws he observed in NASA’s culture.
‘‘They claim that the culture in Houston is
a ‘badgeless society,’ meaning it doesn’t mat-
ter what you have on your badge—you’re
concerned about shuttle safety together.
Well, that’s all nice, but the truth is that it
does matter what badge you’re wearing.
Look, if you really do have an organization
that has free communication and open doors
and all that kind of stuff, it takes a special

kind of management to make it work. And
we just don’t see that management here. Oh,
they say all the right things. ‘We have open
doors and e-mails, and anybody who sees a
problem can raise his hand, blow a whistle,
and stop the whole process.’ But then when
you look at how it really works, it’s an inces-
tuous, hierarchical system, with invisible
rankings and a very strict informal chain of
command. They all know that. So even
though they’ve got all of the trappings of
communication, you don’t actually find com-
munication. It’s very complex. But if a person
brings an issue up, what caste he’s in makes
all the difference. Now, again, NASA will
deny this, but if you talk to people, if you
really listen to people, all the time you hear
‘Well, I was afraid to speak up.’ Boy, it comes
across loud and clear. You listen to the meet-
ings: ‘Anybody got anything to say?’ There
are thirty people in the room, and slam!
There’s nothing. We have plenty of witness
statements saying ‘If I had spoken up, it
would have been at the cost of my job.’
And if you’re in the engineering department,
you’re a nobody.’’
A C H U N K O F F O A M F R O M T H E
B I P O D R A M P T H E P R O X I M A T E
C A U S E
Although the Board placed special emphasis
on the Space Shuttle Program’s history and
culture, the identifiable causes of the disaster
were deemed to be both physical and orga-
nizational. The infamous chunk of foam that

dislodged from the craft’s ‘‘bipod ramp’’ and
struck a heat shield tile on the left wing was
determined to be the immediate physical
cause of the disaster. More precisely, the
proximate cause of the accident was ‘‘a
breach in the Thermal Protection System
on the leading edge of the left wing, caused
by a piece of insulating foam which sepa-
rated from the left bipod ramp section of the
External Tank at 81.7 seconds after launch,
and struck the wing in the vicinity of the
lower half of Reinforced Carbon-Carbon
panel number 8. During re-entry this breach
in the Thermal Protection System allowed
superheated air to penetrate through the
leading edge insulation and progressively
melt the aluminum structure of the left wing,
resulting in a weakening of the structure
until increasing aerodynamic forces caused
loss of control, failure of the wing, and
breakup of the Orbiter. This breakup
occurred in a flight regime in which, given
the current design of the Orbiter, there was
no possibility for the crew to survive.’’
H I S T O R Y A N D C U L T U R E A S
D I S T A N T , B U T E F F E C T I V E ,
C A U S E S
The famous economist, Alfred Marshall,
once argued that all problems of political
economy should be analyzed using a systems
approach. ‘‘People must be warned off by
every possible means from considering the
action of any one cause,’’ he wrote, ‘‘without
taking account of the others whose effects are

commingled with it.’’ The Board acted con-
sistently with Marshall’s advice when it
expanded the scope of its quest to include
NASA’s history and culture in its investiga-
tion, and when it sought to identify the social
129
conditions that served as contributing root
causes of the accident. This leaves us, how-
ever, with another prerequisite question. In
what sense can history or culture be a cause?
A key notion is that NASA is a socio-
technical system. Its technology is designed,
produced and operated by people working
in groups under the guidance of human-
made policies. The agency’s ‘‘socio’’ compo-
nent has a nearly fifty-year history. From a
systems perspective, past events as well as
the values and beliefs of previous managers
are all interactive partners in a system that
collectively produced the disaster. As moral
agents, managers bear some of the moral
responsibility for the result—good or bad.
Historians have grappled with this
notion of remote or distant causes as a ser-
ious methodical issue. Causal chains may be
long—conceivably infinite—and devilishly
complex, as readers of James Burke’s Con-
nections realize. Nevertheless, we all recog-
nize that many of the things that happen
today do not appear de novo. They are to

some degree the culmination of effects put
in place some time ago and perhaps far away.
In What is History? E.H. Carr, for exam-
ple, poses the following scenario to illustrate
some of the complexities involved. ‘‘Jones,
returning from a party at which he has con-
sumed more than his usual ration of alcohol,
in a car whose brakes turn out to have been
defective, at a blind corner where visibility is
notoriously poor, knocks down and kills
Robinson, who was crossing the road to
buy cigarettes at the shop on the corner.’’
Among the parties that may be held causally
responsible are the following: Jones for
drinking, the tavern for selling alcoholic
drinks to him, the mechanic who serviced
Jones’ car, the car manufacture, the city trans-
portation department for poor design or fail-
ing to put up adequate signs, Robinson for
failing to look carefully enough, Robinson for
his addiction to tobacco, and the tobacco
companies for selling their products to peo-
ple like Robinson. Significantly, these possi-
ble co-producing events may have taken
place quite a long time ago or at a distant
location. Any of the agents involved may be
also be held morally responsible if three
conditions are satisfied: they (1) did indeed
serve as a co-producer of Robinson’s death,
(2) they acted knowingly (or should have
known what they were doing), and (3) they
acted voluntarily and without coercion. A
complete causal analysis, as attempted by
the Board, must pinpoint these contributing

sources up to some degree of relevance and
determine their relative degree of effect.
Every individual causal element has a
context. To ignore its context is often to miss
the essence of a problem. This kind of tunnel
vision results in ineffective solutions. ‘‘When
the determinations of the causal chain are
limited to technical flaw and individual fail-
ure,’’ the Board argues, ‘‘typically the actions
taken to prevent a similar event in the future
are also limited: fix the technical problem and
replace or retain the individual responsibil-
ities. Putting these corrections in place leads to
another mistake—the belief that the problem
is solved. The Board did not want to make
these errors.’’ In complex systems few, if any,
causes are independently sufficient, there are
many additional contributory necessary
causes, perhaps from far and wide sources.
The Board concluded that the dislodging
of the foam was sufficient to cause the Colum-
bia disaster but it did not stop its examination
there. It then proceeded to inquire as to why
the ship was launched in the first place with a
potential vulnerability in its design. ‘‘What
was the context?’’ the investigators asked.
That is, what were the other general, neces-
sary conditions that allowed the foam to sepa-
rate, and, given that it separated, kept NASA
from actively trying to understand what
damage may have resulted from the loose
foam’s striking the shuttle’s left wing. These
are the more penetrating questions of cause.
Finding answers requires an examination of

the accident’s fuller socio-technical context.
D E L V I N G I N T O T H E
N E C E S S A R Y C A U S E S
An event’s context may reach back quite far
in time or space. For this reason causes are
often labeled in three categories: distant,
intermediate, and immediate or proximate.
Some powerful distant causes may propel a
system on a path that almost assures a future
outcome. The Board’s report identifies several
types of distant and intermediate causes that
in their judgment played a significant role in
causing the disaster. These include organiza-
tional decisions made by or affecting NASA
during its forty-plus-year history—including
the founding of NASA, the early decisions the
agency made, decisions made by the admin-
istration and Congress that provided expec-
tations and budgetary limitations, the people
NASA recruited, its early success, and the
way of working it developed from its begin-
ning. All of these shaped NASA’s culture.
One pivotal event was President Nixon’s Jan-
uary 5, 1972 announcement of the U.S.’s new
philosophy for exploring space. ‘‘This system
will center on a space vehicle,’’ he boasted,
‘‘that can shuttle repeatedly from Earth to
orbit and back. It will revolutionize transporta-
tion into near space, by routinizing it’’ (italics

added in the Board Report). This commitment
to reusable vehicles and routine operations set
the agency on a definite course. It influenced
subsequent decision-making and reshaped
the agency’s culture. If there is a crucial con-
textual point at which NASA began to transi-
tion from a culture focused on excellence to a
culture focused on bureaucracy and produc-
tion it is this 1972 pronouncement.
One unintended consequence of Nixon’s
policy was to reduce NASA’s emphasis on
safety. The Board concluded that for the last
decade or so the agency’s culture had not been
robust in its dedication to safety. As a result
important signals were ignored and opportu-
nities to take remedial action missed. In order
to understand how the Board believed this
change in culture evolved we need to consider
a few ideas about the concept of culture.
W H A T I S C U L T U R E ?
Drawing on anthropological and organiza-
tional theories, the Board treated culture as
‘‘the values, norms, beliefs, and practices that
govern how an institution functions.’’ Cul-
ture is, accordingly, a crucial determinant of
human behavior. Organizational psycholo-
gist Edgar Shein offers up one of the most
useful definitions. Culture, for Shein, is a
‘‘pattern of shared basic assumptions that a
group learned as it solved problems of exter-
nal adaptation and internal integration, that
has worked well enough to be considered

valid and, therefore, to be taught to new
members as the correct way to perceive,
think, and feel in relation to those problems.’’
This pattern of shared assumptions shapes
the way people will behave. It forms the
context for the decisions they make and the
actions they take.
An important attribute of culture is that
it is learned. An individual or a group
acquires patterns of thought and behavior
by processes of socialization and accultura-
tion. Consequently, leaders play a major role
in establishing an organization’s culture.
Founding leaders are especially influential.
Emerson famously said, ‘‘An institution is
the lengthened shadow of one man.’’ While
this may oversimplify the point, an argument
can be made that a few founders like Thomas
Watson of IBM Corp., J. Erik Jonsson of Texas
Instruments Inc., Ross Perot of Electronic
Data Systems Corp. (EDS) and Jack Lowe
Sr. of TDIndustries had enormous influence
on the culture and ethics of their companies.
The essential point, however, is that a leader
or a group of leaders can and do affect an
organization’s culture. Culture is malleable,
but not easily so. Mike and Slocum’s study of
changing the culture of Pizza Hut and Yum
Brands illustrates the degree of creativity and
perseverance that is required to reinvent a
culture.
N A S A ’ S I N I T I A L C U L T U R E
Wernher Von Braun, German rocketry

wizard and aerospace legend, was largely
responsible for shaping NASA’s early cul-
ture. The agency’s much respected original
technical and management culture—its
culture of excellence—was formed at the
131
Marshall Space Flight Center in Huntsville,
Alabama beginning in 1958. Diane Vaughan
states that it arose ‘‘out of a military heritage
that made discipline a core cultural ele-
ment.’’ The center grew out of the army’s
Redstone Arsenal (named for the battlefield
missile developed there, the Redstone
rocket). After World War II, the Defense
Department established the Army Ballistic
Missile Agency (ABMA) in Huntsville, which
designed and tested rockets for military use.
The ABMA was operated at the Redstone
Arsenal, run by a rocket team of 120 German
engineers who had escaped to the United
States after the war. There, under the leader-
ship of Von Braun they recreated their strong
precision/verification German research cul-
ture.’’ Von Braun was appointed the director
of Marshall when it opened in 1960. Just
as Admiral Hyman Rickover fostered a
culture of excellence for the U.S. Navy’s
nuclear-powered submarines, Von Braun
and his associates set the technical standards,
demanded the superior knowledge and
expertise, mandated the hands-on strategies,
inculcated an awareness of risk and failure,

and opened up communications. All of these
formed Marshall’s original technical culture.
Following the 1972 decision to make a
reusable shuttle, however, NASA began
transitioning toward a ‘‘culture of produc-
tion’’—a managerial culture which tends to
stress efficiency over safety and effective
reproducibility over creative problem sol-
ving. Dan Goldin, the NASA administrator
from 1992 to 2001, sought to raise this pro-
duction culture to a high art form with his
mantra ‘‘Faster, better, cheaper.’’ But the
results were not always salutary, as former
astronaut Sally Ride explains: ‘‘It’s very dif-
ficult to have all three simultaneously. Pick
your favorite two. With human space flight,
you’d better add the word ‘safety’ in there,
too, because if upper management is going
‘Faster, better, cheaper,’ that percolates
down, it puts the emphasis on meeting sche-
dules and improving the way that you do
things and on costs. And over the years, it
provides the impression that budget and
schedule are the most important things.’’
The culture of production was reinforced
with the George W. Bush administration’s
appointment of Sean O’Keefe as director. A
former deputy at the Office of Management
and Budget, he was assigned the task of
tackling the difficult problems of NASA’s
cost overruns and its failure to meet delivery
schedules. He is not imbued deeply with
scientific or technological values.

Another attribute of an organization’s
culture is that a significant portion of it lies
below the level of conscious awareness. It is
tacit, not tangible. An organization’s culture
is difficult to describe adequately in words;
but you can experience it, feel it. In their
studies of crisis systems Ian Mitroff and his
associates have employed an ‘‘onion’’ model
of organizations to locate the role of culture.
Its layers form concentric circles, each of
which describes a deeper degree of tacitness.
On the outer layer, the most tangible one, is
technology. It is the easiest to observe and,
accordingly, the easiest to understand and
change. The Board recognized a technologi-
cal failure with respect to the foam as the
most readily observable cause of the acci-
dent, but it persistently sought to probe sev-
eral levels deeper.
The next level of the onion is the organi-
zation’s infrastructure. An infrastructure por-
trays the formal power structure, and includes
the bureaucratic mechanisms used to assign
job responsibilities, allocate resources and
make decisions. NASA, as has already been
noted, during its later years had developed a
rather unyielding hierarchical structure char-
acterized by levels that served as invisible
barriers.
How people and technology interact lies
one more level down. Deeper still is the
organization’s culture and below that, at
the onion’s core, is the organization’s emo-
tional structure. Emotional states like anxiety

and fear of reprisal drive an organization’s
behavior.
Tracing the causes of an accident gener-
ally starts where the Board did, at the tech-
nology layer, and works inward. That is, the
inquiry begins with the physical, observable
manifestations of the problem and then
delves down until the emotional and social
sources are uncovered. To engage in organi-
zation learning and to change an organiza-
tion’s behavior, however, one usually must
start at the emotional layer and work out-
ward. The dislodged foam from the Colum-
bia, like the O-rings of Challenger, is an artifact
at the technology level. It can be observed,
studied and re-engineered. The foam was the
physical cause. But to prevent other acci-
dents like Columbia from happening, change
must be geared first to address the emotional
and cultural layers. So, the Board wisely
based its recommendations on its analysis
of the culture, history and emotional state
of the agency.
A C U L T U R E I S B A S E D O N
D E E P L Y H E L D A S S U M P T I O N S
There are several additional characteristics of
an organization’s culture that are related to
its tacitness. First, although it is possible to

create a culture out of whole cloth for a new
organization, a culture once formed is tena-
cious and difficult to change. This is because
a culture serves the deep psychological func-
tions of reducing human anxiety and provid-
ing members with identity. In the face of
external threats or internal failures, a culture
tends to go into survival mode and to engage
in rationalization and denial. These are
among the reasons that an organization’s
culture exhibits an active resistance to
change. An established culture has a ten-
dency to fight to preserve itself and its mem-
bers and remain the same.
NASA officials initially rejected the foam
strike as the proximate cause of the accident
and, thereafter, as a matter of faith held
steadfastly to that belief, even in the face of
accumulating evidence and the pleas of engi-
neers. Indeed, the assumption was held so
firmly by some, that requests to find more
evidence by acquiring satellite or telescopic
imagery were denied. That the foam had
separated off on previous flights with no
negative consequences nurtured a firmly
held core belief which, if denied, would
unravel a chain of other deeply held assump-
tions and expose flaws in the agency’s pre-
vious decision making. Gehman understood
this cultural process well. ‘‘It has been
scorched into my mind that bureaucracies
will do anything to defend themselves,’’ he
explains. ‘‘It’s not evil—it’s just a natural
reaction of bureaucracies, and since NASA

is a bureaucracy, I expect the same out of
them. As we go through the investigation,
I’ve been looking for signs where the system
is trying to defend itself.’’ Gehman’s experi-
ence told him that when an organization
holds a position with so much emotion and
certainty it should be probed deeply. ‘‘Now
when I hear NASA telling me things like
‘Gotta be true!’ or ‘We know this to be true!’
all my alarm bells go off.’’ It was the Board’s
persistence in continuing to test the hypoth-
esis that the foam strike was the immediate
cause that finally led to the truth, despite
active resistance on the part of NASA.
R E S I S T A N C E T O C H A N G E
During the last thirty years, the agency has
experienced one crucial shift in its culture.
The Von Braun culture established beginning
in 1958 was rigorous in engineering precision
and detail oriented. It put safety first. Over
time, however, those emphases receded as
the agency became more managerially and
production oriented. Efficiency subsequently
became the agency’s core value. NASA’s
emergent culture of production proved to
be very hardy and resistive. As a result,
the space shuttle program, despite the
wake-up calls of Apollo and Challenger and
other mishaps, successfully fought to main-
tain its new culture of production. Moreover,
following its reorganization after the failings
of 1986, NASA’s culture fought even harder
to return to its efficiency-based value system.
Partial evidence of this is found in the

Board’s report that cited eight ‘‘missed
opportunities’’ when NASA engineers could
have possibly averted the Columbia tragedy.
The report concludes that NASA’s flawed
culture kept its employees from reading
133
these signals and responding adequately to
them. The NASA culture of the 1960s and
early 70s would have responded to these
signals; its culture of production of the
1980s and 90s did not.
A C U L T U R E E X P R E S S E S I T S
U N D E R L Y I N G E T H I C S
A culture stems from fundamental ethical
values and subsequently structures its mem-
bers’ patterns of thought and perception. The
distinctions people make about the reality
they face, the values they place on them,
and the language they use to describe them
are all first created by a culture as it evolves.
Subsequently, the new language and work
norms are learned by others as ‘‘the way
things are done around here.’’ As a conse-
quence, an organization’s culture influences
the range of choices that managers will view
as rational or appropriate in any given situa-
tion. It provides them with a worldview that
confines and directs their thinking and beha-
vior. When norms of safety, respect, honesty,
fairness and the like are integral parts of a

culture, its people make ethical decisions. A
climate of trust evolves. Cultures that lack
these ethical norms (e.g., Enron Corp., World-
Com Inc., Tyco International) can make
terribly harmful choices; and, often its mem-
bers do not realize it. For most members
the assumptions of a culture are taken for
granted. Consequently, leaders must make
clear to all involved that their organization’s
culture and its ethics are inextricably linked.
It appears that by stressing cost cutting and
meeting delivery dates so stringently NASA’s
leaders, perhaps inadvertently, encouraged
less than forthright behavior on the part of
some members of the organization.
A C U L T U R E A N D I T S
M E M B E R S A R E N O T
N E C E S S A R I L Y T H E S A M E
A culture is different from the managers
who are its members. Good, morally upright
managers may participate in a complacent,
flawed or broken culture. For example,
General Motors Corp.’s Corvair automobile
maimed or killed numerous innocent people
during the 1960s and cost the company mil-
lions of dollars in legal expenses and out-of-
court settlements. At GM, a culture that put
costs, profit goals, and production deadlines
above consumer safety largely ignored evi-
dence of stability problems with the automo-
bile until Ralph Nader published his exposé
Unsafe at Any Speed. Nevertheless, most of
the executives who made these decisions

were considered to be men of high moral
values, dedicated to their company and to
their families, civic leaders and typically
churchgoers. They would not deliberately
send Corvair drivers to their death.
This phenomenon appears to be the case
with NASA. Thousands of individual work-
ers there would have never condoned send-
ing a craft into space with known flaws that
compromised any astronaut’s safety. They
were distraught to learn that they had been
a party to it. Yet, the overwhelming force of
the organization’s culture and decision-mak-
ing structure at the time effectively overrode
their instinctive moral concerns. Or perhaps
it served to salve their consciences. These
NASA stalwarts believed that the agency
could do no wrong. Why? One reason is that
the agency’s culture had become infested
with hubris.
H U B R I S A N D A F L A W E D
C U L T U R E A T N A S A
The Von Braunean dedication to flawless
performance was replaced by an emphasis
on efficiency during President Nixon’s term
in office. At about the same time, NASA also
implemented a hierarchical decision structure
that separated decision making into levels
and accorded substantial power to decision
makers at the top level. Many managers oper-
ating in this new arrangement lulled them-
selves into believing that NASA’s early
successes were due to the agency’s—and per-

haps their—invulnerability. Moreover, fewer
of NASA’s current employees understood or
appreciated the crucial role that its original
research culture had played in its previous
accomplishments.
Although the Board concluded that some
key seeds of the disaster were planted when
NASA was founded, the agency’s early mis-
sions had been sometimes successful, spec-
tacularly so. So successful, in fact, that during
its early days NASA deservedly acquired a
‘‘Can …
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Copyright 2004 The Electronic Hallway
EXPRESS TRANSIT MAINTENANCE DIVISION (A)
Martin Jiles, Executive Director of Express, was still stunned as
he walked home from the local
7-Eleven with the morning paper that September Saturday. The
page one article of the
Centerville Globe had caught him completely unaware, its
headline screaming: “ARE
EXPRESS BUSES UNSAFE? Drivers, mechanics say bosses
falsify maintenance records.”
In the article, bus drivers and mechanics alleged that Express
supervisors had doctored
maintenance records to conceal decisions allowing unsafe and
environment-damaging buses on
the streets of Progress County. Further, transit workers alleged
that Express management
pressured them to falsify inspection reports, and they accused
Express of suppressing dissent
through harassment and intimidation. The article also cited
numerous sources who said Express

had adopted a covert policy of allowing buses to leak oil,
because that was cheaper than
repairing them. Workers and union representatives said
maintenance problems were the worst
at Express’s North Side Base. There, a “phantom mechanic” –
the common nickname for a
computer code number representing a supervisory mechanic who
does not exist – frequently
overruled front-line inspectors’ “bad order” directives meant to
keep unsafe or mechanically
defective buses off the streets. (See Exhibit 1)
Not only did the article’s damaging revelations come as a
complete surprise to Jiles, but its
timing could not have been worse: Express had just launched a
marketing campaign to reverse
a decline in bus ridership.
Express
As Express Executive Director, Jiles headed a major public
corporation with the responsibility
to provide countywide transit (bus and related) services.
Express Transit employed 2,700
persons (full-time-equivalent) and had an annual budget of more
than $300 million.
Express Transit Maintenance Division (A)
2
Over the years, Express had earned a national reputation as a
successful, innovative
organization, one that took risks but still maintained

accountability to the public. The Transit
Division, in particular, had received many national
acknowledgements and awards for its
management abilities, safety records, and use of new
technologies, as well as for having one of
the lowest ratios of service personnel to fleet size. Express ran
the first articulated buses in the
nation, and it was among the first transit systems to add
wheelchair lifts to its entire fleet.
Express had also pioneered a free-ride district in downtown
Centerville.
All of these accomplishments related directly to the “can-do”
philosophy and results-oriented
management style that Martin Jiles’s predecessors had instilled
in the organization. Jiles
regarded the organization’s staff and its culture very positively
and was proud of its past record
and continuing accomplishments.
Management Environment
Jiles had headed Express for about eight years, coming from a
strong background in senior
public service positions around the country. Frank Preston, the
Transportation Services
Director, had come to Express about four years earlier from a
position as deputy transportation
coordinator for a large transit system. Although only forty
years old, Preston was well known
within industry circles for his abilities as a transit manager.
The Transit Division faced significant challenges: declining
bus ridership, flat revenues,
dramatically decreased federal funding, and an aging bus fleet,
which numbered 1,300.

Approximately 61 million passengers annually rode Express
buses, down from 66 million six
years earlier. However, ridership in the vanpooling program,
the largest such program of any
transit system in the nation, was growing.
The Transit Division, in keeping with its can-do, results
oriented organizational culture, took a
Management by Objectives (MBO) approach to ensure
maximum efficiency and effectiveness
at all organizational levels. Specific targets were established
for all divisions, and performance
towards achieving these targets was monitored through
sophisticated data collection systems.
Data, in the form of summary statistics and reports, provided
the management offices in
downtown Centerville with the necessary indications of how
well the system was performing.
Express used these same reports and statistics in annual
performance evaluations of managers
under its Pay-For-Performance (PFP) plan. The PFP plan used
specific indicators of each
manager’s effectiveness to award monetary incentives and merit
pay increases. For example,
the base supervisor was evaluated by the following summary
reports: 1) miles between trouble
calls; 2) expenditures within approved budget; 3) yard delays;
4) parts delays due to
unavailability; 5) adequate stock quantities in the Unit Rebuild
Division; and 6) maintenance
costs per coach operating hour. The PFP system extended from
the top of the organization’s
management structure downward through the base supervisors
in the Maintenance Division.

3
“Safety is Express’s number one priority,” said Transit Director
Preston. “Next is service, then
the budget.” It was the job of each manager to balance these
three competing demands.
“Efficiency is the key,” he said. “The system we have pursued
provides resources efficiently,
smartly.” But he also acknowledged that the system exerted
real pressure on the Manager of
Vehicle Maintenance and the base supervisors. It was a daily
pressure, said managers in the
Maintenance Division, who responded by containing costs
where they could. There was a
pervasive belief among managers that they were perceived as
poor performers if they “bucked
the system” by asking for more money. Never was this pressure
felt more keenly than during
annual budget meetings.
This was certainly the case when Clayton Baker, Manager of
Vehicle Maintenance, had gone
into the most recent round of budget meetings with a request for
a large budget increase. When
Preston asked him to justify such a large increase, Baker
pointed to an aging bus fleet and rising
labor costs owing to higher mechanic salaries and increased
repair times. Senior management
then asked Baker to put together the numbers to support his
request, so they could better
understand his situation. After the meeting, Baker re-evaluated
his budget requests and decided

that they were not high priorities. Besides, he knew that his
mechanics had always been able to
make do with what they received and that they could do so
again if necessary. Only about
thirty-five years of age, Baker, like Preston, had advanced
significantly since coming to Express
just four years earlier.
Preston later explained that operating costs per hour of service
delivery had been increasing for
all divisions, but that the maintenance portion of these costs
was rising at a faster rate. He also
explained that Express had not purchased any new buses in the
previous three years and that, at
the same time, Express’s service area was increasing. When
Clayton Baker failed to return with
a report to justify his requests, however, Preston believed Baker
had figured out how to make
ends meet.
Line Management
The Transit Division divided maintenance work among its four
bases, each one responsible for a
specific number of buses within a well-defined service area.
Base supervisors managed the day-to-day operations for the
Vehicle Maintenance Division.
Although they played a limited role in budget hearings, the base
supervisors’ ability to perform
their jobs successfully with the funds allocated to them
determined whether they would receive
any additional compensation under the PFP plan. Fulfilling
their responsibilities could be tough
in years with lean resources. No matter the level of resources
they received, the base

supervisors still were expected to ensure that there were enough
buses operating to cover the
runs within their service areas.
Whenever Baker had a problem regarding performance at one of
the bases, he contacted the
4
base supervisor directly. Otherwise, for the most part, Baker
remained at his downtown office.
There he could easily monitor the activities at each base
concerning repairs, man-hours, and
costs by reviewing the reports, summary statistics, and other
data that were generated by a
technologically advanced computer system known as MIRS
(Maintenance Information
Reporting System).
Maintenance Bases
Each maintenance base divided the work across three eight-hour
shifts. Mechanics
performed all repairs and maintenance functions at each base.
Their immediate
supervisor was the lead mechanic, who acted as the foreman for
a team of five to seven
mechanics. Lead mechanics reported to a chief. There was one
chief per eight-hour
shift, whose responsibility was to decide what work received
priority. The lead
mechanics assigned the repair work to individual mechanics

after receiving the priorities
from the chief. Some workers complained that a great deal of
favoritism was shown in
this process, in that select individuals always received the
easier tasks.
Chiefs were the first-level managers in the maintenance
division. Most were in their mid-50s,
and were predominantly ex-mechanics who “crossed the line”
into management. One chief, in
describing her responsibilities, said, “The chief’s job is to carry
through on projects, to get
information transmitted on through. A chief is the base
supervisor’s go-fer.” It was a very
demanding job, she added, but mechanics didn’t perceive it that
way. “Mechanics don’t view
chiefs as overworked. Some mechanics think chiefs just sit
around and drink coffee.”
Each shift also had one or two inspectors who reported to the
shift chief. Inspectors were
former mechanics and generally had a very good understanding
of the mechanical components
they were asked to inspect. During routine inspections, the
inspectors used a checklist to
monitor bus condition and identify potential hazards. After
conducting an inspection, the
inspector signed the checklist to verify that he had indeed
inspected each item and noted its
condition. If a deficiency was so bad as to represent a threat to
passengers in its current state,
the inspector could “Bad Order” (BO) the bus. According to
Express policy, “Bad Ordered”
buses had to be repaired before returning to service.
In “The Trenches”

The traditional adversarial mode prevailed in labor-management
relations. While the work of
the mechanics was relentless, their union, Local 231 of the
United Transportation Employees
Union, ensured that they were treated equitably with respect to
salaries and benefits. Newly
hired mechanics progressed upwards in salary during their first
three years before reaching the
top pay bracket at the end of the third year. From that point on
until they retired, mechanics
5
received only a Cost of Living Adjustment (COLA), unless they
obtained a promotion to lead
mechanic, inspector, or chief.
Most mechanics had been with Express for a long time, and
retirement was the primary form of
exit from the mechanic ranks. While the newer mechanics, who
were fewer in number, usually
strove to do a good job, the common feeling among many
veterans was that they only needed
to do enough to get by and thus avoid being fired.
One chief who rose up from the mechanic ranks attributed this
attitude to two factors: Lack of
employee recognition and accountability. “There are no
sanctions or recognition, no positives
for hard work,” he said. “Management can put a written
commendation in your file, but it

doesn’t happen much; and it’s done with no fanfare, no
publicity, no money.”
The only recognition maintenance personnel received was for
their number of years in service at
Express – mechanics received lapel pins showing years of
service and, after twenty years, a
coffee-and-cake ceremony. In contrast, bus operators received
regular recognition of their
contributions to the organization’s service delivery. In fact,
there were even “Driver
Appreciation” days to reinforce their can-do attitude.
Regarding accountability, the chief said, “There is no
accountability for getting the job done
right. A coach can come back for the same problem over and
over, and no one holds the
mechanic accountable for getting it fixed. It is the lead’s
responsibility to follow up on
problems, but it is not done.”
There also was a problem with mechanics’ lack of respect
towards Express equipment,
which frequently was abused and, consequently, often broken.
Waste was another
problem. For example, mechanics would go through can after
can of brake cleaner
rather than steam clean a coach before doing repairs. In a
system as large as Express, it
was virtually impossible for the leads and chiefs to see all that
was going on. In fact,
chiefs were convinced that maintenance employees regularly
stole smaller items during
their shifts.
To deal with any disciplinary problems, Express used a

“positive performance counseling”
(PPC) program. The “counseling” was done by a chief who
received two four-hour training
courses and a program manual. No one could be dismissed
without a PPC. The process
consisted of three warnings, two of which were verbal. The
third was written and could lead to
an employee’s being fired. In reality, however, management
used the PPC program very little
because of unwillingness to spend the time required to
document disciplinary actions or to buck
strong union support for disciplined employees. Union
representatives had expressed serious
concerns about the fairness and objectivity of discipline being
meted out.
6
“Because of the union, people feel safe,” said one chief.
“People are fired and the union
brings them back. We appreciate the benefits of the union, but
there are big problems
too.”
Coordination Problems
Together, the three chiefs at each base decided which buses
would be repaired on any given
day or throughout the week. The chiefs were given a great deal
of discretion in determining the
priority of repairs – so long as each work order submitted was
completed and they maintained

an adequate number of buses to make the runs. In addition, the
base supervisor continually
stressed the need for efficiency in all maintenance tasks. That
required a great deal of
coordination among the chiefs, as a majority of the work
required more than one shift to
complete; but the necessary coordination was not always
present.
For example, if repairs required more than one shift, a bus was
simply left on the hoist for the
incoming shift. The preceding shift mechanics, however,
seldom left information to indicate
where they had left off in the repair process, or even what the
problem was that they were trying
to repair. That created friction among the shifts, as well as
delays in the repair time required to
fix a coach.
Further, if the next crew’s chief did not agree with the repair
priorities decided upon at the
weekly chiefs’ meeting, he would roll the bus off the hoist at
the beginning of the shift and direct
the leads to assign repairs for other buses he thought were more
important. This led to
additional conflict among the chiefs and the shifts, each
believing that the other shift was not
doing its “fair share” of the repairs.
This practice of bypassing buses that were on the hoists at the
beginning of a shift was adopted
by the individual mechanics, as well. A mechanic might roll a
bus off a hoist and find other
repairs to do simply because the repairs required for the initial
bus were complicated or
distasteful.

Monitoring Maintenance Division Work
The primary goal of the base supervisor and each chief was to
ensure that enough buses were
available to handle the runs scheduled for each day. That meant
they had to monitor the “float”
very carefully. The float was the difference between the
number of buses allotted to a base and
the number required to cover all the runs for which a base was
responsible, in effect a reserve.
If there was an insufficient float, preventative maintenance and
other repairs removed too many
buses from service and the chief was unable to provide the
number of buses needed to make
runs.
7
To monitor the maintenance and repair requirements (and hence,
the float) of the individual
bases, Express relied on its MIRS computer system. While
several other transit operations
around the country refused even to deal with the system because
it was “too complicated and
difficult to use,” MIRS was implemented at Express with
powerful support from Transit
Director Frank Preston. MIRS had been in place for about nine
months. When the system was
installed, each base had a one-week training course on how to
use it. The “can-do” attitude at
Express played a large role in getting MIRS up and running.

Another fan of the computer system was Clayton Baker, who
had been a quantitative analyst in
the private sector before coming to Express. Baker said MIRS
provided information never
before available, including labor performance statistics, failure
monitoring, a log of the types of
defects reported, work order monitoring, and a complete
maintenance record for each coach.
The impetus behind MIRS was management’s desire for a
complete package of all Express
maintenance information, which could be used to help project
maintenance requirements for the
upcoming year’s budget.
MIRS compiled the maintenance information from work orders
entered into the computer.
Work orders were initiated four ways:
1. Operator Request: A bus driver noted a problem on a bus and
turned in an Operator
Request.
2. Shop Request: Shop personnel, such as a mechanic, noted a
problem on a coach while it
was in the yard and issued a Shop Request.
3. Trouble Call: A coach broke down while on a route, and the
repairs necessary to get the
bus back on the road were initiated via a Trouble Call work
order.
4. Preventative Maintenance: The bulk of all repair requests,
however, originated from
inspectors who identified problems during routine bus
inspections and prepared a

Preventative Maintenance work order. These included instances
where inspectors issued
“Bad Orders” to prevent a bus from returning to service until
the deficiency was repaired.
The work orders submitted by the inspectors were a constant
source of additional work for
the chiefs and the base supervisors to deal with.
To ensure the accuracy of the information compiled by MIRS,
the system was equipped with a
two-level security access. Mechanics and base supervisors only
had “read capabilities” on
MIRS. That meant they could get information from MIRS, but
they could not alter the
information on the computer files.
Chiefs, lead mechanics, and some clerks had “read and write
capabilities” on MIRS. These
individuals could access information and input information or
alter the files on the computer.
Employees with “read and write” access had individual
passwords, so they could gain access to
MIRS.
Once a work order was entered into the computer, it could be
removed in one of only three
8
ways:
1. Entry of a completion notice. The ID number of the

mechanic who did the work was
entered alongside a completion-notice entry. The lead
mechanics were responsible for
entering this information, but only after they completed a visual
inspection or verification of
the repairs.
2. Entry of the “Repaired By Other Item” (RBOI) code. RBOI
referred to the fact that the
repairs were actually completed as required, but the work was
indicated on another work
order. This process was used to eliminate duplicate work orders
generated by different
sources. The chiefs used the RBOI code when sorting through
work orders and preparing
the work distribution for their shifts.
3. Entry of a default employee number. At North Base (the base
highlighted in the newspaper
article), the employee default number was 00005 and appeared
on numerous work orders.
The default number was used for new employees who completed
repairs during their first
few days on the job and did not yet have an identification
number. (See Exhibit 2)
Entering MIRS data accounted for most of the lead mechanics’
and chiefs’ time on each shift.
Consequently, they seldom got around to observing the
mechanics at work. In fact, pressured
chiefs sometimes used RBOI codes to eliminate backlogged
repair work if they believed the
repair was not necessary. Consequently, there were instances
where a work order was
recorded as RBOI, but no repair actually took place. In
addition, on most RBOIs, there was

no reference to the other, supposedly duplicate, work order.
North Base
The work load in the Maintenance Division, combined with the
necessity of maintaining enough
buses to meet service demands, often generated tension among
the inspectors, chiefs, and base
supervisors. These tensions were especially apparent at –
although not restricted to – North
Base, the base cited in the newspaper article as having the worst
maintenance problems.
Tom Rogers was the North Base supervisor. Rogers had risen
through the ranks in Express
Maintenance and had been with the organization for twenty-
seven years. He was keenly aware
of the details of the maintenance work done at his base. On the
floor, some workers described
Rogers as “impatient,” saying he often displayed a “bad
attitude.” One mechanic, while
agreeing with these perceptions, said that Rogers’ image
resulted from the extreme pressures he
encountered as base supervisor.
Two years before, North Base had fallen behind in its workload
and could not accomplish all
the repairs noted on work orders. Management had solved the
problem by transferring
mechanics from other bases. Rogers was determined not to let
that happen again.
He knew, perhaps better than anyone else, exactly how much
mileage could be obtained from a
coach before maintenance became absolutely necessary.
Consequently, inspectors said Rogers
told them to ignore various items on the different inspection

cards, in order to do the inspections
9
more quickly, but to sign the inspection card indicating
everything listed had been accomplished.
Rogers also asked inspectors not to “Bad Order” certain
deficiencies, even if they appeared
during the course of an inspection.
About six months before the newspaper article appeared, James
Hensley, the inspector quoted
in the article, had brought the situation to the attention of the
union’s Vice President, Fred
Lowder. Lowder had outlined Hensley’s concerns in a letter to
Vehicle Maintenance Manager
Clayton Baker and requested a meeting.
Nearly a month later, Baker replied by letter that he had
reaffirmed the current policies with the
base supervisors, “and they, in turn, with the chiefs, leads, and
other Vehicle Maintenance staff.”
He confirmed that, “all items on the inspection cards are to be
inspected. A mechanic should
never intentionally not inspect an item on a card…. Inspectors
should BO any defect they find
that is, in their judgment, in need of repair.” But inspectors also
“should limit their inspections to
the items on the card for the inspection step scheduled.”
However, inspectors said they continued to feel pressure to
curtail the lists of defects and

neglect specific deficiencies. Hensley finally concluded that
the formal system was not going to
resolve the situation, so he decided to meet with Centerville
Globe reporter Ron Mendez to
discuss the problem. Supported by anonymous reports from
other employees, the allegations
against Express made their way to the front page of the
Centerville Globe on that Saturday in
September.
Deciding What to Do
Martin Jiles sat back in his chair after returning home and
reading the paper. He contemplated
calling his upper-level managers but decided to wait until later
in the day to ensure they each had
time to see the newspaper story. While he doubted all the
allegations were true, he knew one
thing for sure – he had a problem.
10
Exhibit 1:
ARE EXPRESS BUSES UNSAFE?
Drivers, mechanics say bosses falsify maintenance records
by Ron Mendez
Globe staff reporter
Express supervisors have doctored maintenance reports to
conceal decisions allowing unsafe

and environment-damaging buses on the streets of Progress
County, bus drivers and mechanics
allege.
The transit workers, many of whom requested anonymity
because they fear for their jobs, also
allege that Express management has pressured them to falsify
inspection reports.
Backed by transit-union officials, they accuse Express of
suppressing dissent through
harassment and intimidation – including threats of dismissal and
assignment to the "brake room,"
where mechanics must work alone in hot and cumbersome safety
gear to protect themselves
from exposure to cancer-causing asbestos.
Numerous sources said Express has adopted a covert policy of
allowing buses to leak oil
because that is cheaper than it is to repair them. They estimated
that Express buses leak 1,000
gallons of oil a day.
Jerry McMann, president of Local 231 of the United
Transportation Employees Union, said the
sources' allegations are supported by an overwhelming majority
of the 2,950 members.
Express, in response to orders from the state Department of
Environment, says it is studying
ways to reduce the amount of oil that its buses leak. The
department issued a compliance order
against Express on July 25, primarily because oil and grease
pollution from the transit system’s
Westview maintenance yard and Annex was contaminating
Turnmill Creek.

Workers and union representatives said maintenance problems
are the worst at Express's
Northside Base and annex. They said at that yard, a "phantom
mechanic” – the common
nickname for a computer code number that represents a
supervisory mechanic who does not
exist – has frequently overruled the “bad order" directives of
front-line inspectors to keep unsafe
or mechanically defective buses off the streets.
The workers contend that the phantom mechanic was conceived
so supervisors could avoid
individual liability, should one of the buses found faulty by an
inspector be involved in an
accident after a supervisor sent it out. McMann noted that only
a supervisor can approve a bus
for service after a line inspector has ordered it kept off the road.
11
“That's where the phantom mechanic comes in. When nobody is
willing to OKS (OK for
service) something, it goes into the computer as 00005 (code
number)," McMann said. Only
supervisors have access to the computer, he added.
Tom Rogers, Express’s top maintenance supervisor on the
Northside, was reported to be
attending a management conference in San Diego and could not
be reached for comment.

Clayton Baker, Express's manger of vehicle safety, said the
number was intended as a catchall
to be used temporarily by new supervisors who had not been
assigned a permanent
identification number under a computer program adopted the
first of the year. He said some
lower level mangers, however, misunderstood its use and
mistakenly used the number as a
matter of convenience. He said that with a few rare exceptions
misuse of the number was
stopped in July. "I don’t think we've got a problem there and no
abuse of it," he said.
Baker dismissed the accusations of the union and workers as the
unfounded claims of
overzealous drivers and mechanics.
He said Express’s safety record is superb and that the small
number of accidents …
Case Study 2 – Express Transit Maintenance Division
Assignment Checklist
Before submitting the assignment, did you…
Introduction
1. Summarize the case?
2. Identify the problem(s) Centerville Globe mentions?
3. Identify key actors in the case?
Analysis of Culture
4. Identify the building blocks of culture (values, ethics,
motives) in the Maintenance division?
5. Discuss how structural factors such as budgets and positions
as well as accountability mechanisms shape the culture in the

Maintenance division?
6. Discuss the structural factors (loosely coupled organizations,
reputation and trust, etc.) organizational mission, contributing
to the formation of micro cultures in Express Transit?
Recommendations
7. Make recommendations to Jiles to address cultural problems
in the Maintenance division?
8. Make complete arguments to support your recommendations?
9. Use course materials in your arguments/recommendations?
Mechanics
10. Check your report for typos, grammar mistakes, and styling?
Did you paginate your report?
11. Did you cite relevant course materials in APA style and
present references on a separate page at the end of the report?
Case Study 2 – Express Transit Maintenance Division
Welcome to case study 2. This is the second big case study
assignment this semester. In this assignment, you will read the
"Express Transit Maintenance Division" case. This case
combines considerations of internal culture and operations with
the need to respond to public perceptions of internal operational
problems. In this case, the manager of the Express Transit,
Martin Jiles, learns a potentially large problem in his agency by
reading the Saturday newspaper. Mr. Jiles faces a crisis because
the safety of bus brakes in a municipal transit system is being
questioned in a major investigative media story.
This case study has a few purposes.
1- The primary purpose of this case is to apply the theoretical
knowledge that you learned in this course into a case study.
That will take your learning from comprehension level to
application, analysis, and synthesis levels. As a result, this case
study will help you improve your learning. Other goals are
2- To understand how culture influences organizational

outcomes
3- To analyze the relationship between organizational structure
and culture
4- To synthesize a solution to a given problem using the
knowledge you learned in this course
To accomplish these goals, you will read the case study
provided as an attachment. After reading the case, you will
answer the questions below regarding cultural and structural
issues in Express Transit.
Questions
Please answer the following questions after you read the
"Express Transit Maintenance Division" case
1- What is the situation at the Transport Maintenance Division
and what problems with the Express Transit were mentioned in
the Centerville Globe article?
2- Frank Preston emphasized that “Safety is Express’s number
one priority. Next is service, then the budget” (p. 3). Why isn’t
safety the priority in the Maintenance division of Express
Transit? What are the cultural roots of problems? To analyze
the cultural roots, please address the questions below:
a. What are the cultural (ethics, values, motives) factors and
contribute to the faulty safety culture in the Maintenance
division?
b. How do structure and culture influence each other in the
Express Transit Maintenance division? In other words, how do
structural factors such as budgets and positions influence the
culture in the Maintenance division?
c. Why do micro-cultures (e.g. culture in the management team
vs. culture in the Maintenance division) occur at the Express
Transit? Do some structural elements contribute to creation of
micro cultures?
3- What specific actions or decisions should Jiles take to
address the faulty safety culture in Express Transit specifically
in the Maintenance division? Make complete arguments to
support your recommendations.
Instructions for the case report

In this assignment, I want you to write approximately a 4-page
(single spaced) essay type report (hint: there is no page limit,
but usually 4 pages is enough). In this report, you should have
the following sections:
1- Start with an introduction section (recommended length is
approximately 1 page) in which you will summarize the case (do
not forget to explain what happened, what organizational units
were involved, and who were the key individuals in the case)
and explain the problems mentioned in the Centerville Globe
article.
2- In the second part (recommended length is approximately 1-2
pages), you will analyze the cultural environment in Express
Transit and how it interacts with the structural aspects of the
organization.
· Question 2.a: Identify the building blocks of culture (values,
ethics, motives) in the Maintenance division and discuss how
they contribute to a faulty safety culture.
· Question 2.b: Explain how structural factors such as budgets,
positions as well as accountability mechanism shape the culture
in the Maintenance division.
· Question 2.c: Apparently there are cultural differences
between the management of the Express Transit and the
Maintenance division. Discuss what structural factors (e.g.
loosely coupled organizations, reputation and trust, etc.) may
have contributed to the micro culture in the maintenance
division.
3- In the third part (recommended length is approximately 1
page), make recommendations to Martin Jiles to address the
cultural problems in Express Transit specifically in the
Maintenance division (answer to question 3). Please make
complete arguments to support your recommendations. Use
course materials (textbook, lectures, videos, other assigned

readings) in your arguments as needed.
Please use the course material in your report and cite them in
APA style.
Please remember, if you do not cite a source in your report, do
not put it in your references. If you put a source in your
references, make sure you cite it in your report.
Please check this link if you need help with APA style.
Please use the reading materials from weeks 11 and 12 (the
cultural dimension) and from other weeks that you find useful
(e.g. accountability, structural dimensions).
I highly recommend reading the case report at least twice before
start writing your report. Make sure you do not misunderstand
the story or confuse different events in the case.
The difficult part of this assignment is writing succinctly. You
can write as long as you like; however, please do not write
irrelevant things for the sake of writing a longer report.
Please be careful about citations and references. Improper
citations and references (or no citation and references) might be
considered as plagiarism. I trust none of you would be engaged
in plagiarism, but being careless in writing may create
undesirable situations. Please check with the university policies
regarding academic integrity. (Click here)
To clearly communicate my expectations and help you with this
assignment, I provide you a rubric and a checklist that clearly
lays out what you have to do in this assignment.
In this assignment, you will find the following documents
attached:
· Express Transit Maintenance Division (a).pdf (the case
document)
· Analytical Rubric Case 2 (the rubric that I will use for

evaluating your report)
· Checklist Case Study 2 (the checklist that lists everything you
need to include in your report)
· Case Study 2 - Instructions (the same instructions on this
page in Word format for your convenience)
Please let me know if you have any questions.
Good Luck
Dr. Demiroz
Case 2 – Express Transit Maintenance Division
Exceeds Expectations
Meets Expectations
Needs Some Revisions
Needs Significant Revisions
Missing
Introduction
Case summary and problem definition
The report clearly summarizes the case and identifies the
problems mentioned in the Centerville Globe article.
(7 points)
The report summarizes the case but misses some minor points
(6 points)
The report either misses some important points in the case
summary or misses important points regarding the problems in
the Centerville Post article
(4 points)
The report misses the summary of the case and some important
points regarding the problems the problems in the Centerville
Post article
(2 points)
Missing many or all of the important points
(0 points)

Analysis of Culture
Building blocks of culture
The report identifies the building blocks of culture in the
Maintenance division and discusses how they contribute to the
faulty safety culture in the Maintenance division.
(6 points)
The report identifies almost all of the building blocks and
discusses how they contribute to the culture but misses some
minor points.
(5 points)
The report does not identify some important building blocks or
does not explain how they contribute to the culture in the
Maintenance division
(4 points)
The report does not identify several building blocks AND does
not discuss how they contribute to the culture in the
Maintenance division.
(2 points)
No analysis of the culture
(0 points)
The relationship between structure and culture
The report explains how factors such as budgets, positions as
well as accountability mechanism shape the culture in the
Maintenance division.
(6 points)
The report explains how structural factors and accountability
mechanism shape the culture in the Maintenance division but
misses some minor points.
(5 points)
The report explains how structural factors and accountability
mechanism shape the culture in the Maintenance division but
misses some major points.
(4 points)
The report misses several important points regarding how
structural factors as and accountability mechanisms shape the
culture in the Maintenance division.

(2 points)
No explanation regarding how structural factors and
accountability mechanisms shape the culture in the Maintenance
division.
(0 points)
Micro cultures
The report discusses the structural factors contributing to
formation of micro cultures in the Express Transit. The report
makes strong arguments.
(6 points)
formation of micro cultures in the Express Transit. The
arguments that report makes have weaknesses.
(5 points)
formation of micro cultures in the Express Transit. Its
arguments are weak or incomplete.
(4 points)
formation of micro cultures in the Express Transit. There is no
argument made to back the discussion.
(2 points)
The report does not make any discussion regarding the
structural factors contributing to formation of micro cultures.
(0 points)
Recommendations
The report makes recommendations to Jiles to address the
cultural problems in the Maintenance division.
It makes complete arguments to support the recommendations.
It uses course materials in recommendations.
(6 points)
The report makes recommendations to Jiles.
It makes arguments to support recommendations either
recommendations have some weaknesses or does not use course
materials completely.
(5 points)

The report makes recommendations to Jiles.
&
The recommendation is weakly linked to the evaluation of the
reorganization decision (4 points)
The report does not adequately address a problem.
&
The recommendation
is not linked to the evaluation of the reorganization decision.
(2 points)
No meaningful recommendation
Or the recommendation does not make sense.
(0 points)
Mechanics
The report is professionally prepared. It is free of grammatical
errors and typos. Formatting is good.
(4 points)
The report is professionally prepared.
It has some grammatical errors or typos. Formatting is good.
(3 points)
The report is professionally prepared.
It has major errors in grammar, spelling, or formatting.
(2 points)
The report fails to meet professional writing standards.
(0 points)

C H A P T E R 6Organizational CultureNASA’s ORGANIZATI.docx

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