At NASA, once again, the problem is its culture -- a habit of dismissing the concerns of know-ledgeable underlings.
Four years ago, it involved higher-ups ignoring engineers who feared possible catastrophic damage to the shuttle Columbia. The engineers were right.
This time, it is NASA doctors and even astronauts getting the brushoff when voicing worries that some astronauts have drunk too much alcohol before flying.
"I think things have changed, but some things remain the same," said Douglas Osheroff, a Nobel Prize-winning physicist who investigated the Columbia disaster in 2003.
An independent health panel disclosed on Friday that, at least twice, astronauts were cleared to fly despite warnings from flight surgeons and other astronauts about their heavy drinking. One intoxicated astronaut flew into orbit on a Russian spacecraft; the other ended up with a shuttle launch delay for mechanical reasons but later tried to take off in a training jet while still under the influence.
In both cases, the doctors and other astronauts were ignored by higher-ranking officials. Flight surgeons feel so disregarded, in general, that they told the panel they are demoralized and less likely to report concerns of impaired performance.
All NASA's leadership wants, several senior flight surgeons told the panel, is to hear that all medical systems are "go" for space flight operations.
It always seems to come down to schedule pressure, which contributed in large part to the demise of Columbia, Osheroff noted.
"I think part of it is still this pressure to launch and launch on time," he said. "I don't know what it costs NASA to delay a launch. But there are two costs. One is a political cost and the other is an economic cost."
Besides tales of drunken astronauts, the health panel heard anecdotes about other risky behavior -- unspecified in the report -- that was well known to their colleagues, who were too afraid to speak up for fear of ostracism.
With no formal code of astronaut conduct in place and no official, written ban on alcohol within 12 hours of a space launch -- two things that are quickly changing -- poor behavior was simply overlooked.
That won't be the case for NASA's next shuttle launch, set for Aug. 7. The commander, Scott Kelly, and the crew's lead flight surgeon have already been notified of the space agency's expectations for their behavior on launch day. They have also been urged to bring up any safety concerns.
As for overindulging in liquor, Osheroff finds it mind-boggling that NASA could have cleared intoxicated astronauts for flight.
"Launch and re-entry are the two times when the astronauts have to really be sharp because that is when most of the danger is," he said. "So the idea of being drunk when you're going up, you might as well go up in a casket."
NASA is up against almost 50 years of tradition when it comes to astronaut hijinks. Ever since the seven original Mercury astronauts were selected in 1959, the stereotype has been a cocky but competent pilot who works and lives hard -- a flyboy.
"Cultural changes such as these will and must disrupt the status quo," the panel concluded. "While cultural changes are the most difficult to achieve, they are also the most significant and pose the highest risk of human failure if not adequately addressed."
Osheroff notes that in the corporate world, complete culture change often comes only after enough new people are hired and the old guard is gone.
At NASA, that could take a while.
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