Columbia Accident Case Study
This is an edited version of the Columbia Accident Investigation Board report released in August, 2003. It provides a comprehensive and often sobering example of management lapses that have severe consequences. The original report was over 280 pages. This edited version eliminates the much of the technical discussion and focuses instead on the organizational factors that lead to the accident. You may obtain the entire report from http://www.caib.us/news/report/default.html I have included some sections for background. Read these sections to gain an overview of the accident and the report. I have included some pages simply to provide context for sections that relate to questions below. I have placed arrows in the text to indicate those sections that are most important.
Questions to Consider:
1. According to the report, what were the causes of the Columbia accident? 2. What were the essential features of the culture at NASA? 3. Which factors played the greatest role in the events leading up to the accident: logical factors, such as schedule, technicalities of the shuttle design, testing, or psychological, such as politics, the perspective of deadlines? 4. What was the meaning of February 19, 2004? 5. How did February 19, 2004 contribute to the Columbia accident? 6. How did management and workforce differ in their perspective on the pressure to meet 2/19/04? Why did they differ? 7. What types of schedule management tools did NASA use? Were they effective? 8. What were the de facto priorities of the shuttle program leading up to the accident? 9. How did these priorities shape management’s perspective on “facts” presented by engineering after the launch of ST-107? 10. Which perspective on communication best explains the findings in the report: communication as information flow or communication as influence? 11. Which was most important in explaining the cultural factors leading up to the accident: a lack of management or a lack of leadership? Why? 12. What role did the management’s perception of NASA’s history play in the events leading up to the accident? 13. What role did a willingness to learn from mistakes play in the events leading up to the accident? 14. Given the example of the Navy’s reactor safety program, how could NASA correct these organizational deficiencies? 15. Could NASA managers have done a better job if they had followed Descartes’ four rules for thinking? Why? 16. What role did PowerPoint play in management’s failures? 17. How do the reports conclusions about leadership, culture, change, structure and risk apply to the management of everyday projects?
ACCIDENT INVESTIGATION BOARD
Report Volume I August 2003
ACCIDENT INVESTIGATION BOARD
On the Front Cover
This was the crew patch for STS-107. The central element of the patch was the microgravity symbol, µg, flowing into the rays of the Astronaut symbol. The orbital inclination was portrayed by the 39-degree angle of the Earthʼs horizon to the Astronaut symbol. The sunrise was representative of the numerous science experiments that were the dawn of a new era for continued microgravity research on the International Space Station and beyond. The breadth of science conducted on this mission had widespread benefits to life on Earth and the continued exploration of space, illustrated by the Earth and stars. The constellation Columba (the dove) was chosen to symbolize peace on Earth and the Space Shuttle Columbia. In addition, the seven stars represent the STS-107 crew members, as well as honoring the original Mercury 7 astronauts who paved the way to make research in space possible. The Israeli flag represented the first person from that country to fly on the Space Shuttle.
On the Back Cover
This emblem memorializes the three U.S. human space flight accidents – Apollo 1, Challenger, and Columbia. The words across the top translate to: “To The Stars, Despite Adversity – Always Explore“...
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