Organizational Causes of the STS-107 Mishap

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Rudolph Owen
8 years ago
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1 Organizational Causes of the STS-107 Mishap ORGANIZATIONAL CAUSES: The organizational causes of this accident are rooted in the Space Shuttle Program s history and culture, including the original compromises that were required to gain approval for the shuttle program, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human spaceflight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision making processes that operated outside the organization's rules.

operational rather than developmental, and lack of an agreed national vision for human spaceflight.

2 Organizational Causes of the STS-107 Mishap ORGANIZATIONAL CAUSES: The organizational causes of this accident are rooted in the Space Shuttle Program s history and culture, including the original compromises that were required to gain approval for the shuttle program, subsequent years of resource constraints, fluctuating priorities, schedule pressures, mischaracterization of the Shuttle as operational rather than developmental, and lack of an agreed national vision for human spaceflight. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision making processes that operated outside the organization's rules.

3 The foam did it The institution allowed it.

4 History From Challenger to Columbia The Shuttle Program flew 87 successful missions between Challenger and Columbia However, the Shuttle Program had been operating too close to too many margins Shuttle budget and workforce reduced by 40% 3,233 waivers on Columbia 36% not reviewed in 10 years Little margin for addressing unexpected technical problems or to make upgrades Shuttle mischaracterized in 1995 as a mature and reliable system NASA thus believed it could continue to outsource more functions By treating the Shuttle as operational, NASA reduced engineering functions normally associated with a flight development vehicle

addressing unexpected technical problems or to make upgrades Shuttle mischaracterized in 1995 as a mature and reliable system NASA thus believed it could

5 History: From Challenger to Columbia Since the early 1970s, NASA has received 20% or less of the funding available to it during the Apollo Program Apollo Post-Challenger

6 History: From Challenger to Columbia During the 1990s, while other areas of federal spending grew, NASA lost 13% in purchasing power--even though building the ISS

7 History: From Challenger to Columbia NASA continued to pursue an ambitious agenda on a level budget; adopted a Faster, Better, Cheaper approach, various managerial changes, and budget and workforce cuts As the largest single NASA program, the Space Shuttle bore more than its share of these cuts

approach, various managerial changes, and budget and workforce cuts As

8 History: From Challenger to Columbia Shuttle replacement NASA attempted to develop Single Stage to Orbit (SSTO) vehicle in partnership with private sector; no strong government commitment Space Launch Initiative did not result in breakthrough technologies 2002 shift to new Integrated Space Transportation Plan introduced concept of of Orbital Space Plane Date for Shuttle replacement extended from 2006, to 2012, to 2020 or beyond (now back to ~2010) Fluctuating attitude toward investing in Shuttle upgrades, SLEP, and infrastructure revitalization

new Integrated Space Transportation Plan introduced concept of of Orbital Space Plane Date for Shuttle replacement extended from 2006, to

9 A glimpse of the future?

WikiLeaks Document Release

WikiLeaks Document Release February 2, 2009 Congressional Research Service Report RS21606 NASAs Space Shuttle Columbia: Synopsis of the Report of the Columbia Accident Investigation Board Marcia S. Smith,