![]() Lesson #7: When the Fox Guards the Chicken Coop. Effective risk evaluation processes typically involve “give and take” exchanges with various interested parties, but provide protections against the excessive influence of purely financial pressures. This was done to accommodate a major customer of the contractor. A primary contractor reversed its opinion and recommended the shuttle launch, contrary to the strenuous safety concerns of its engineers. Lesson #6: Yielding to Pressure Rarely Works Out. This was justified, according to the commission, “because we got away with it the last time.” Effective project leaders recognize that the ability to “get away with” something is never an acceptable basis for assuming material risk. The response of NASA and a key shuttle contractor to early indications of a design flaw was to increase the amount of damage considered to be an acceptable risk. Lesson #5: Increasing Levels of Acceptable Risks. ![]() Basic principles of risk oversight make it imperative that both the establishment of project compliance checks and balances, and decisions to override them, are subject to review by higher levels of management. At some point in the launch process, NASA management made an independent decision to waive previously established launch constraints designed to assure flight safety. Lesson #4: Protecting Checks and Balances. Project information flow must provide decision-makers with access to the perspectives of all meaningful project participants. Senior launch officials were unaware of key warnings expressed by others: the most recent problem with the O-Rings a contractor’s recommendation not to launch below 53 degrees the similar warnings of project engineers and the manufacturer’s concerns with launchpad ice. Want to see more NASA-related cause maps? Check out our root cause analysis of the fire aboard Apollo 1 or the 1986 Challenger explosion.Lesson #3: Those Right Hand, Left Hand Problems. The shuttle’s external tank was redesigned, more camera views were placed on the shuttle during launch to better monitor the foam shedding, and in 2005 astronauts tested a new procedure to scan the shuttle for broken tiles using cameras and a robotic arm.įinally, in memory of the crew, seven asteroids orbiting the sun between Mars and Jupiter now bear their names. The Columbia Accident Investigation Board (CAIB) released a multi-volume incident report that included a searing criticism of the minimization of safety issues at NASA over the years, citing “reliance on past success as a substitute for sound engineering practices.”Īside from the shift in perspective, the Columbia disaster also provoked changes in design and procedure. The disaster also shook NASA out of the complacency it had fallen into, prompting a serious reevaluation of their notions of acceptable levels of risk. The Columbia disaster held far-reaching consequences for NASA and the future of space travel, beginning with the suspension of the space shuttle program in Columbia’s aftermath. We’ve compiled our root cause analysis of the Columbia disaster into a step by step cause map PDF.ĭownload the Cause Map PDF Space Shuttle Columbia Aftermath As with any incident, root cause analysis involves three steps: The disintegration and loss of the space shuttle Columbia on re-entry serves as an example of how root cause analysis can be applied to a specific incident. During launch, a briefcase-sized piece of foam insulation broke off from the shuttle’s external tank and struck the left wing, damaging its thermal protection system, which protects the vehicle from the intense heat generated upon reentry.Īfter spending 16 days in space, Columbia broke apart when reentering Earth’s atmosphere on February 1, 2003, resulting in the total destruction of the orbiter and killing all seven astronauts aboard. This notion came to a sudden end during the shuttle’s 28th mission (STS-107). Colombia’s long running success, especially in the wake of the 1986 Challenger explosion signaled to some that human space travel was approaching the point at which it might be considered routine. The first space-worthy space shuttle in NASA’s orbital fleet, Columbia was first launched in April of 1981, and had successfully completed 27 missions by 2003. The Columbia space shuttle was a seasoned veteran of space travel.
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