Space Shuttle Program
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.
Here
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
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.
Here
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