Columbia shuttle accident

City and, in particular, the Columbia Shuttle accident in 2003. He espoused the adoption of Four Key Principles ... 

Read the very good commentary by Dave Woods on hindsight bias in the enquiry on the Columbia shuttle accident http //researchnews.osu.edu/archive/hindbias.htm. 

Our understanding of how the events preceding a disaster unfold has been greatly expanded in the last 20 years by the careful examination of a number of high profile accidents (Boxes 7.1 and 7.2). The brief summaries of major accidents, and the account of the Columbia Space Shuttle accident, allow us to reflect on the many ways in which failure can occur and the complexity of the story that may unfold during a serious investigation. Human beings have the opportunity to contribute to an accident at many different points in the... 

As the Columbia Space Shuttle Accident Investigation Board reported, Causal factors for accidents that result in severe injuries are multiple and complex, and relate to several levels of responsibility (p. 124). 

Again, it is very eerie to compare the similarities of the Challenger (1986) and Columba (2003) Space Shuttle accidents, especially with a focus on safety management. Like the previous example and the list of accidents in the Table 4.2, we must all be humble in recognizing that though we may understand the causes of accidents, we don t always know how to not repeat them. Some of the causes of the Columbia accident, which were similar to Challenger, are the following ... 

Columbia Space Shuttle Accident and Davis-Besse Reactor Pressure-Vessel Head Corrosion... 

In the Columbia accident The machine was talking to us, but nobody was listening. Deviations from requirements had become normal business for NASA. The Columbia Accident Investigation Board (CAIB) report referred to this as the normalization of deviations (Columbia Space Shuttle Accident and Davis-Besse Reactor Pressure-Vessel Head Corrosion Event, 2005). 

US DOE. (2005). Columbia space shuttle accident and Davis-Besse reactor pressure-vessel head corrosion event. (2005). US Department of Energy Action Plan Lessons Learned, Pubhc Domain. Retrieved from http //l.usa.gov/YOWYft... 

Twenty years later, another Space Shuttle was lost. While the proximate cause for the Columbia accident (foam hitting the wing of the orbiter) was very different than that for Challenger, many of the systemic causal factors were similar and reflected either inadequate fixes of these factors after the Challenger accident or their reemergence in the years between these losses [117]. 

The desire to predict the future often leads to collecting a large amount of information based on the hope that something useful will be obtained and noticed. The NASA Space Shuttle program was collecting six hundred metrics a month before the loss of Columbia. Companies often collect data on occupational safety, such as days without a lost time accident, and they assume that these data reflect on system safety [17], which of course it does not. Not only is this misuse of data potentially misleading, but collecting information that may not be indicative of real risk diverts limited resources and attention from more effective risk-reduction efforts. 

When working at such elevated levels of risk, the only question is which of many potential events will trigger the loss. The fact that it was the foam and not one of the other serious problems identified both before and after the loss was the only random part of the accident. At the time of the Columbia accident, NASA was regularly flying the Shuttle with many uncontrolled hazards the foam was just one of them. 

After the Columbia accident, safety standards in the Space Shuttle program (and the rest of NASA) were effectively anchored and protected from dilution over time by moving responsibility for them outside the projects. 

Major organizational accidents such as the destruction of the space shuttle Challenger in 1986, the explosion of the Chemobyl s nuclear power plant in 1987, the accident with off-shore platform Piper Alpha in 1988 or the destmction of the space shuttle Columbia in 2003, highlighted the relevance of hmnan contributions to organizational safety. Investigations traditionally considered technical and human factors in the development and prevention of these negative events but, in spite of such operational perspective, statistics have revealed the preponderance of human factors in up to 60-70 percent of the situations (e.g., Deldcer, 2002). 

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) ... 

Flexible tailored elastic airfoil section (Sheila Widnall) Widnall applies for a patent for this device, which addresses the problem of being able to measure fluctuations in pressure under unsteady conditions. She serves as secretary of the Air Force (the first woman to lead a branch of the military) and also serves on the board investigating the space shuttle Columbia accident of 2003. 

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. 

Smith, M.S. 2003. NASA s space shuttle Columbia synopsis of the report of the Columbia Accident Investigation Board. Congressional Research Service, Library of Congress, Order Code RS21606. 

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