A simplistic answer would be to ensure that incentives are aligned with safety and success. Then that leads to the evergreen problem of Goodhart’s Law (when a measure becomes a target, it ceases to be a good measure).

Even if it can't ever be truly fixed, at least recognizing the issues and shining daylight on decisions for some form of accountability should be a base-level approach.

> people who make it into management are often egoists

> they were incapable of accepting humiliation

I agree mostly but here is a different take on it: I think these are normal human feelings and behaviors - not the best of us, but not unusual either. If we want to get good things done, we need to work with and through human nature. Power corrupts everyone and shame is generally the most painful thing for humans.

Putting people in a position where they need to treat their power with absolute humility or accept humiliation (and a major blow to their careers) in order to do the right thing is going to fail 99% of the time. (I'm not saying people can't do those things and that we shouldn't work hard and aspire to them, but it's not going to happen reliably with any but a few people.) That expectation itself is a culture, organizational and managerial failure. If you see a system in which so many fail, then the problem is the system.

And when I say 'managerial' failure, I include leadership by everyone and also 'managing up'. We're all responsible for and agents of the team's results, and whatever our role we need to prevent those situations. One important tactic is to anticipate that problem and get ahead of it, putting the team in a position where the risk is proactively addressed and/or they have the flexibility to change course without 'humiliation'. We're all responsible for the team's culture.

I think many blaming others underestimate their own human nature, the effect of power on them and their willingness to endure things like humiliation. Rather than criticising others, I keep my attention on the one in the mirror and on strategies to avoid situations equally dangerous to my own character; otherwise I'll end up doing the same very human things.

EDIT: While I still agree with everything I wrote above, there is an exceptional cultural problem here, one which you'll recognize and which is common to many SV leaders, the Trump administration, and others you're familiar with (and which needs a name ...). From the document referenced in the OP by "heat shield expert and Shuttle astronaut Charles Camarda, the former Director of Engineering at Johnson Space Center."

"Instead, the meeting started with his [Jared Isaacman, the new NASA Administrator's] declaration that the decision was final. We would launch Artemis II with a crew, even though the uncrewed Artemis I mission around the Moon returned with a seriously damaged heat shield, a failure in my opinion. I was not going to be allowed to present my position on why the decision was flawed. Instead, the public would hear, through the two reporters allowed to attend, the Artemis Program narrative, only one side of the story. They would be bombarded with technical information which they would have very little time to understand ...

Jared could claim transparency because the only thermal protection expert and public dissenter, me, was present. ...

I was allowed only one-day to review some of the technical documents which were not open to the public and which were classified Controlled Unclassified Information/International Traffic and Arms Regulations (CUI/ITAR) prior to the Jan.8th meeting. ..."

https://docs.google.com/document/d/1ddi792xdfNXcBwF8qpDUxmZz...

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Learn about failures.

Inviting Disaster: Lessons From the Edge of Technology was one of the texts for an aerospace class I didn't take but friends did, but honestly you can just read the book.

There are lots of frameworks for teaching safety and programs for compliance and such but they are far too easy to cargo cult if you don't appreciate safety and the need for safety culture and UNDERSTAND what failures look like.

And when you really understand the need and how significant failures happened... "state of the art" tools and practices take a back seat, they can be useful but they're just tools. What you need is people developing the appropriate vision, and with that the right things tend to follow.

I just had a conversation about engineers not understanding the need for grounding.

I'm wondering if every generation has to relearn the basics for themselves through experience.

Each generation has to make the same mistakes. Because book learning doesn't seem to do it for some things.

Isn't NASA run by the government? Why not pay people to do their job correctly?

It can't be solved 100%, but it can be _mostly_ solved with systemic buy-in to the safety culture. Commercial aviation is a great example IMO.

We've spent the last several decades making sure that every single person trained to participate in commercial aviation (maintenance, pilots, attendants, ATC, ground crew) knows their role in the safety culture, and that each of them not only has the power but the _responsibility_ to act to prevent possible accidents.

The Swiss Cheese Model [1] does a great job of illustrating this principle and imparting the importance of each person's role in safety culture.

A big missing piece with manned space flight IMO is the lack of decision-making authority granted to lower staff. A junior pilot acting as first officer on their very first commercial flight with real passengers has the authority to call a go-around even if a seasoned Captain is flying the plane. AFAIK no such 'anyone can call a no-go' exists within NASA.

[1] https://en.wikipedia.org/wiki/Swiss_cheese_model

Didn't they have a crash dummy in it the last time? The data from buster should be able to tell us if the parachute worked or not.

Those astronauts don’t have anyone that loves them at home because no way in hell would any of my loved ones let me be a sacrificial turkey in a fully automated oven.

humans are so oblivious to safety

It seems that in modern times, humans focus on safety almost to the exclusion of everything else. As much as the more traditional salutations "godspeed" or "have a nice day", we're even more likely to hear "drive safe" or "have a safe trip" or "be safe".

We're very nearly paralyzed by insisting that everything must be maximally safe. Surely you've heard the mantra "...if it saves just one life...".

The optimal amount of tragedy is not zero. It's correct that we should accept some risk. We just need to be up-front and recognize what the safety margins really are.

Maybe not so much "oblivious to safety" as "oblivious to probable risk." We worry to much about low risk events (like airline flights) and don't worry enough about higher risk events (like trips-and-falls, driving a car, poor diet...)

Then explain the Apollo program, and the actual printed literature that came out of the program that summarized how they were successful.

Us humans do have difficulty with safety. Sometimes we are able to overcome that problem to an extent. Here are some the few examples where humans have done well with safety: FAA commercial airlines, Soyuz, ISS, Shinkansen trains, US Nuclear power post 3 mile island, Vaccines, and the Falcon 9.

I wouldn’t say humans are oblivious to safety. The Apollo program was very successful as long as you’re not related to Gus Grissom, Ed White or Roger Chaffee. But those three (preventable) deaths aside, Apollo was quite successful and figured out some huge problems.

If you’re interested in a heck of a good read, the Columbia Accident Investigation Report is a good place to start:

https://ehss.energy.gov/deprep/archive/documents/0308_caib_r...

It looks at the safety culture in NASA and at how that safety culture ran into budget issues, time pressure and a culture that ‘it’s always been okay’. But people were aware of the problems.

There’s a really frustrating example from Columbia where engineers on the ground badly wanted to inspect the shuttle’s left wing from the ground using ground based telescopes or even observations from telescopes or any other assets. There’s footage available was an email circulated where an engineer all but begged anyone to take a look with anything. That request was not approved - they never looked.

Realistically there’s a point to be made that NASA wasn’t capable of saving those astronauts at that point. But they had a shuttle almost ready to to, they could have jettisoned its science load and possibly had a rescue of some sort available. They never looked though but alarm bells were ringing.

It’s more accurate to say people are highly aware of safety but when you get a bunch of us together, add in cognitive biases and promotion bands we can get stuck in unsafe ruts.