Columbia disaster

Ocasio, W. (2005) The opacity of risk Language and the culture of safely in NASA s space shuttle program , in W. H. Starbuck and M. Farjoun (eds.) Organization at the Limit Lessons from the Columbia Disaster. Blackwell Malden, p. 103-115. 

Since the space shuttle returned to flight after the Columbia disaster in 2003, such diagnostics are performed using ground-based telescope cameras or from chase planes during the upper portions of the liftoff and during orbital passes in order to alert mission controllers if repairs are needed in orbit. 

This book enlists a diverse group of experts to review the Columbia disaster and to extract organizational lessons from it. Thanks to the documentation compiled by the CAIB, as well as other NASA studies, this endeavor involves a rich and multifaceted exploration of a real organization. Because disasters are (thankfully) very unusual, we need to use multiple observers, interpretations, and evaluation criteria to experience history more richly (March et al., 1991). Some contributors to this book draw conclusions very different from the CAIB s. 

In chapter 6, William Ocasio examines the interplay between language and culture in the Columbia disaster. Using historical and archival analysis, Ocasio examines how... 

Chapter 17 was written by Henry McDonald, who served as a center director at NASA and who headed the Shuttle Independent Assessment Team (SIAT) that was formed to study increases in shuttle failures around 1999. The SIAT report anticipated many of the contributing factors of the Columbia disaster. Based on his review of all the other chapters in this volume, Henry McDonald offers his observations on NASA and on the lessons it should draw from this volume. He offers a view of the events preceding the disaster, and he particularly discusses the extent to which NASA has implemented the SIAT report. He comments on how the different chapters in this book reinforce or deviate from the CAIB report, and discusses potential lessons NASA could and should have drawn from organization and management theoiy. 

SYNOPSIS NASA, THE CAIB REPORT, AND THE COLUMBIA DISASTER... 

Chapter 6 of the CAIB report, titled Decision Making at NASA, focuses on the decisions that led to the STS-107 accident. Section 6.1 reveals that the shedding of foam from the external tank - the physical cause of the Columbia accident - had a long history. It illustrates how foam debris losses that violated design requirements came to be defined by NASA management as an acceptable aspect of shuttle missions - a maintenance turnaround problem rather than a safety of flight concern. Table Al, adapted from figure 6.1-7 of the CAIB report, provides the histoiy of foam debris losses up to the Columbia disaster. 

March S7HT report, investigating the recent increases in mission failures, anticipates the Columbia disaster with great accuracy... 

February 1 STS-107 Columbia disaster. NASA finds other accidents waiting to happen ... 

The new vision, the related policy, and the technological decisions negotiated and drafted in the 1970-2 period placed the space shuttle program on a long-term trajectory that culminated in the Columbia disaster and will continue to affect NASA for years... 

The Columbia disaster occurred on February 1, 2003. While tracing the causes of the accident, the CAIB investigation revealed several other accidents waiting to happen. More recently, it was found that the shuttles have flown for decades with a potentially fatal flaw in the speed brakes (Leary, 2004). 

Chapter 4 of this volume focuses specifically on the recent years prior to the Columbia disaster. 

The Columbia disaster occurred on February 1, 2003. The final benchmarking team report of July 2003 put a new emphasis on recognizing creep or erosion of technical requirements and safety procedures and on the need to understand when and how to push back against budgets and schedules. Table 4.1 summarizes key developments over the period and shows the abundance of suggestive shadows and warning signs. 

O Keefe shifts money from the space iaunch initiative to the space shuttle and ISS programs. Cancelled safety upgrades. STS-107 - Columbia disaster. Findings of other accidents waiting to happen. ... 

Shutde program Challenger Disaster STS 93 Mishaps Columbia Disaster ... 

Our reading of the CAIB report disclosed a number of coordination neglect issues, some of which probably contributed to the demise of the Columbia. However, for the remainder of this chapter, we will focus on another relational issue - dependence -that has received considerably less attention than coordination neglect in the literature, but probably played a much greater role in the Columbia disaster. 

Although NASA and its contractors utilize several redundant safety and mission assurance organizations and groups, the Columbia disaster and CAIB investigation provide considerable evidence that dependence among these different safety components eliminates much of the benefit of redundancy. 

The analysis is, and will remain, preliminaiy. A more systematic analysis of the vocabulaiy would require a more comprehensive examination of a more complete corpus of written documents, memos, and emails. One of the difficulties of a retrospective analysis is that of sampling on the dependent variable. Using internet search engines, I searched for documents containing key terms in NASA s vocabulaiy, including safety of flight and acceptable risks, i also searched for documents on foam debris, tiles, and reinforced carbon carbon (RCC), paying particular attention to documents produced prior to the Columbia disaster. 

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