Topics: Space Shuttle Columbia disaster, Space Shuttle Columbia, NASA Pages: 5 (1577 words) Published: April 5, 2014
Columbia and Tenerife Case study
Decision Making Analysis Report

Mengjie Chen
Instructor, Peter G. Dominick

Columbia and Tenerife Case study
The Tenerife crash, recently referred as the biggest air disaster in history, seems to have little connection with the tragedy of Space Shuttle Columbia. However, there are similarities, especially some decisions made by two people from the two cases respectively. When they made certain decisions, they did fall into similar cognitive traps which, if identified in time, would prevent the two tragedies from happening. The two people are Rodney Rocha, a NASA engineer, and Klass Muers, the First Officer of KLM plane. Rodney Rocha chaired the Debris Assessment Team to analyze the foam strike happened during Columbia’s launching. Klass Muers, was on his first co-pilot flight with Captain Van Zanten, who was also the head of KLM’s Training Department. 1. Individual-level Decisions

a. Columbia Case
During the first five eight flight days, Rodney Rocha had made the following decisions. Day 1
Rocha concerned about the foam strike due to the unusual size of debris. Day 2-4
Rocha asked a JSC manager for conducting space walk to check the wing with no reply. Day 5
Rocha begged Paul Shack for images about the wing.
Day 6
Rocha angrily wrote an email in belief that management team was wrong in withdrawing the imagery requiring. However, Rocha did not send the email. Day 7
Rocha discussed his concern but was ended by “there’s not a damn thing we can do about it!” Day 8
Rocha believed that MMT did not realize the limitation and uncertainty in the DAT analysis.

Clearly, Rocha made good decisions when dealing with complex technical problems. First of all, he realized the unusual size of debris could have serious and complicated effects, despite the previous harmless strikes. He conducted successful self-awareness in identifying the difference between Columbia and previous strikes; He foresaw of the possible serious consequences of the; what’s more important, he concerned the lack of information or clarity about the problem and put great effort to gather more information. In summary, Rocha successfully avoided his own confirmation trap and availability heuristic. However, on the side, Rocha made poor decision in management side. Rocha knew there was a misunderstanding among MMT managers about the foam strike. After he tried but failed to persuade the management team, Rocha gave up trying with discontent. Here, Rocha fell into his own bias about the hierarchy system. For one thing, he followed the regular rules to report rather than bringing critical concerns directly to MMT. For another, he failed to clarify the severity of consequences to managers who bounded their own awareness of Columbia’s foam strike with previous anchors and turned their attention to other short-term emergency. b. Tenerife Case

The First Officer of KLM flight, Klass Muers’s duty was mostly to assist Captain Van Zanten during the flight. During the crucial last minutes, Muers made the following decisions. 1
Muers stopped Captain’s take-off.
" Wait a minute, we do not have a [Air Traffic Control] clearance " 2
Muers saw Captain nudged the throttles forward without take-off clearance. He said, " We are now - eh - taking off ", to the control tower. 3
After the tower controller said  “Okay, stand by for takeoff - I will call you ..." Muers silently followed Captain’s idea to take-off.
When Second Officer questioned Captain about the tower direction, Muers chose to be silent.

Similarly, at first, Klass Muers made correct decision to stop Captain from a hurry take-off. However, when the Captain escalated to his false decision, Muers, turned to control tower in hope the tower could clarify whether they should take-off. Muers was under pressure to challenge the take-off decision and after struggling, he chose to believe the Captain was right, all because of the hierarchy...
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