Columbia Accident Investigation Board

Technical Authority (ITA) recommended in the report of the Columbia Accident Investigation Board. The risk analysis itself is described in the chapter on the new hazard analysis technique called STPA (chapter 8). But the first step in the safety or risk analysis is the same as for technical systems to identify the system hazards to be avoided, to generate a set of requirements for the new management structure, and to design the control structure. 

CAIB (2003). Report of the Columbia Accident Investigation Board. Volume 1. Columbia Accident Investigation Board. 

Columbia Accident Investigation Board Report, 2003. Available at http //caib.nasa.gov/news/report/default.html (accessed September 28, 2009). 

NASA convened the Columbia Accident Investigation Board (CAIB). It looked at many aspects of this mission and its flight. It considered other organizational and cultural factors. 

Reference is made several times in this book to an organization s safety culture and how it impacts on the injury experience attained, favorable or unfavorable. Since causal factors for incidents resulting in serious injury are largely systemic and their accumulation is a reflection of the organization s safety culture, that subject must be explored. Comments made on organizational culture in the August 2003 Report of the Columbia Accident Investigation Board on the Columbia space ship disaster are pertinent here. They follow. 

Comments made about incident investigation in the previously mentioned August 2003 Report of the Columbia Accident Investigation Board are identical to the conclusions I drew as a result of that research. As the following excerpts from that report are read, I suggest that safety professionals think about how they relate to the quality of the incident investigation systems in the entities with which they are involved. 

Columbia Accident Investigation Board Report, Vol. 1. Washington, DC NASA, August 2003. Also available at http //www.nasa.gov/columbia/home/AIB Voll.html. 

If a safety professional undertakes to improve the quality of incident investigation, I propose that the following comments about incident investigation as excerpted from the August 2003 Report of the Columbia Accident Investigation Board be kept in mind as a base for reflection throughout the endeavor. The Report pertains to the Columbia Space Shuttle disaster. It is accessed at http //caib.nasa. go v/news/press releases/pr031028.html) ... 

CAIB (Columbia Accident Investigation Board). 2003. Report, 6 vols. Government Printing Office, Washington, DC. www.caib.us/news/report/default.html. 

The Columbia Accident Investigation Board s view of oiganizational causes of the accident ... 

Vaughan, D. 2003. History as cause Columbia and Challenger. In Columbia Accident Investigation Board. Report, vol. 1, chapter 8. Washington DC US Government Printing Office. 

A key finding of the Columbia Accident Investigation Board (CAIB) report is that the lack of an adequate safety culture in NASA s space shuttle programs was a causal factor in the catastrophic loss of the Columbia orbiter and crew. While safety is not directly defined by the CAIB, the report suggests that (1) the culture of the program led to inadequate safety practices (2) this breakdown of safety culture led to the toleration of a pattern of problems with the foam debris (3) foam debris was the... 

The Columbia Accident Investigation Board fingered the issue of a lack of deference to expertise as a key contributor to the Columbia accident. NASA s culture of bureaucratic accountability emphasized chain of command, procedure, following the rules, and going by the book. While rules and procedures were essential for coordination, they had an unintended negative effect. Allegiance to hierarchy and procedure had replaced deference to NASA engineer s technical expertise (CAIB, 2003 200). 

Our analysis - which draws from the Columbia Accident Investigation Board (CAIB) report, newspaper accounts, and original data from interviews with three CAIB members, a former shuttle astronaut, a former NASA engineer, and a sociologist who studied NASA extensively (see table 12.1) - characterizes the Columbia recovery window as systematically under-responsive. In the aftermath of foam debris... 

The interpretation process begins when a stimulus event occurs that is in need of processing (Louis and Sutton, 1991). In this case, the relevant event is described well in the official report by the Columbia Accident Investigation Board (CAIB), chaired by retired US Navy Admiral Harold Gehman, Jr. (we have characterized the event below) ... 

CAIB [Columbia Accident Investigation Board). 2003. Report, 6 vols. vol. 1. Government Printing Office, Washington, DC. www.caib.us/news/report/default.htmL Cohen, W., and Levinthal, D. 1990. Absorptive capacity a new perspective on learning and innovation. Administrative Science Quarterly 35, 128-52. 

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