Case Write Up

Group 9
Columbias Final Mission
1. How would you characterize the culture of NASA?
What are its Strengths and Weaknesses?
NASA was created in 1958 as a response by the United States to the
Soviet Union who launched Sputnik into orbit. The primary objective of
the organisation was to make space travel almost commonplace. NASA
functioned like any other organization with its own shares of goals,
deadlines, cost minimization targets and so on, however this was
escalated to a level of national pride and importance.
It has a very bureaucratic system which worked as one of its primary
advantages as it gave a clear structure to the organisation as well as fix
accountability at various levels. NASAs greatest strength is the technical
expertise available to them. The ability of their engineers to create and to
think on their feet allowed them to accomplish great things and solve the
most complex problems. NASAs regimented approach and problem
solving skills is what makes them successful in most of their missions.
However, the same hierarchical structure acts as a barrier also as
implementation takes time due to multiple levels and lot of paperwork.
Secondly, NASA's success leads to their greatest weaknessescomplacency. It places more trust in its business managers than in its
engineers, who are the backbone of the organisation. The emphasis shifts
from technical expertise and quality to meeting steep deadlines. Over
time, NASA has grown to accept too much risk, they did not have an
effective safety and inspection plan in place, they had a tight budget from
the government, and the organization was driven by a tight schedule.
These are the attributes which led to the second shuttle disaster.

2. How did the history of the space shuttle program

shape peoples behaviour during the eight days of the
mission?
NASA established the space shuttle program in January 1972. Despite
NASAs budget constraints and complex design specifications, it believed
that the shuttle would be safer than any other spacecraft-thus did not
develop an escape system in the orbiter for the crew. NASA had 24
successful launches in-spite of facing failures like the Challenger; the team
working on Columbia oversaw the STS-107 mission with calm demeanour.
Foam debris foam strikes were considered common occurrences and the
management did not consider them a safety issue anymore. The Thermal
Protection System was made of tiles and Reinforced Carbon-Carbon (RCC)
panels which could withstand minor impacts. The agency had started

focusing on the turnaround schedule implications rather than the safety

effects of foam debris strikes. This can be classified as illusion of control
cognitive bias of the management.
On the very launch day, 81.7 secs into the launch, a chunk of insulating
foam fell off the External Fuel Tank and struck the Orbiters left wing. This
was not detected till the next day at the base centre by the Interceptor
Photo Working Group. The blurry images from the restrictive camera (with
poorly maintained lenses) angle on the left wing did not clarify the size,
shape and momentum of the foam or the location of impact. The group
did not have the distinct impression of how unusually large the piece of
foam was-larger than any they have seen. The Debris Assessment Team
that formed as per the written guidelines did not inform the Mission
Management Team. All the communication regarding the debris strike
between DAT and MMT was never direct but through different parties. This
shows to the complacency towards the safety issue that should have been
resolved long ago as well as the overall dismissal of the Debris
Assessment team.
The best way to describe peoples behavior on this mission was being too
business minded and casual. Space travel was supposed to be a ride to
the Disney world and that was the sales pitch. NASA appeared to take
pride in possessing a calm outlook, giving the impression that no problem
was too big or complex for them to solve. They were mainly targeting to
increase the number of missions per year, to catch up their schedule and
deliver the payload; unfortunately, although they enjoyed great
successes, they had not achieved the required speed and were many
years behind schedule. Also, foam strikes had become a common problem
occurring on many missions. This led to the complacency towards an issue
that should have considered as a serious threat and been resolved long
ago as well as the overall disappointment of the work by the Debris
Assessment Team.

3. How would you characterize NASAs response to the

foam strike in comparison to its response to Apollo 13
incident? How does the Columbia mission compare to
the Challenger accident in 1986?
In the case of Apollo 13, NASAs response was completely different from
its response to the foam strike. Responses in these situations can be
categorized to be active in the first one and ignorant & avoiding in the
second one. In case of Apollo 13, as soon as primary oxygen tank busted,
flight director Gene Kranz moved to analyse the problem. He did not
ignore the problem, and formed a Tiger Team to seek a way in order to
save astronauts and ensure safe return of Apollo 13 to the earth. The
team was not passive and they had performed drills during preparations
to handle possible crisis during the mission. It pushed the team to come
up with creative ideas and analyse different situations quickly. The team

was always thinking of survival rather than surrendering, which ultimately

helped them to save the mission.
While in the case of Columbia, the decision makers gave more value to
the history rather than the facts & alerts. They believed that it was a
trivial incident and would not have any major impact like the other foam
strikes in past. Though the technical team had information about foam
strikes during take-off and they wanted to raise an alert, but these alerts
could never be communicated to those, who were the decision makers.
Secondly, as soon as a foam strike had happened no Tiger team was
formed, rather an ad-hoc team, Debris Assessment Team was formed.
There was no communication between this team and mission
management team, which was the ultimate decision maker. The
management remained passive and kept itself in hard mold of
bureaucratic communication rather than taking quick actions. The
management ignored the doubtful finding, as it was not enough to prove
that there is something wrong indeed. Such alarms were ignored
completely in the case of Columbia and eventually it met something which
could have been avoided. These two cases are completely different in
terms of responses to crisis, in one case it was considered that a crisis
could happen and the team had practiced how to respond while in the
other no such drills or practice happened. It was also the burden of history
which overpowered the rationality.
Comparison of Columbia and Challenger accident:
Both of these two missions had met the same fate, the only difference
being that for one it happened while taking off and for the other while
landing. The two missions failed and caused casualties not because of
unexpected technical failures but due to poor communication and
response to crisis in time. We have drawn following similarities and
differences between these two failures.
For both the cases, some doubts over the safety were raised but because
of being inconclusive there was no action. Both the missions had been
given a green signal ignoring the concerns raised by technical staff. Also,
the managers have downgraded the criticality of technical faults in both
cases to get a positive flight readiness review from flight safety authority.
In case of Challenger mission, manager downgraded criticality of o-ring at
low temperatures while in case of Columbia, increasing impact of foam
strikes on various flights was not paid attention. It has been described as
usual flight risk rather than looking for solutions actively. The only
difference which was there in these cases was the response time. In the
case of challenger there was no response time for NASA after flight took
off, while in that of Columbia, they had a response time of two weeks,
though even this could not save them.

4. What differences did you perceive in the behaviour of

managers versus engineers?

From the start, Columbias shuttle mission organizational team of

managers and engineers experienced tremendous pressure. The entire
team had huge task responsibilitys that not only affected their work in the
way they performed their jobs but also in their ability to make tough
decisions. The entire management team of Columbias mission had to
analyse each individual system of flight and respectively assess the
engineers. Engineers were divided into teams of specific expertise. All
engineering teams were running into specific challenges that needed to
be corrected in time for flight. Managers heavily depended on all
engineers to provide good data that could then be prioritized in order of
acceptance. On the same token, management was pressured by NASA to
stay on course and stick to schedule. In the end it was really up to the
management team to decide what was crucial to the mission, and this is
where mistakes were made because certain engineering concerns were
overlooked and unfortunately eventually accepted. The absence of a
communication bridge between the engineers and the managers resulted
in the catastrophe.