Case Facts

Columbia crashed on Feb 1st, 2003 CAIB report stated the cause to be a loose piece of insulating foam CAIB report also stated the organizational shortcomings that led to the crash

Case Facts
NASA was set up in 1958 in response to the soviet space programme Project Apollo was the first disaster in 1967 when an Apollo capsule caught fire and three astronauts lost their lives A second disaster was narrowly avoided in April 1970 when an oxygen tank burst during the astronauts travel to the moon

Case Facts
A Tiger Team was formed that helped avert an accident On January 28, 1986, the Challenger set out on the Space Shuttle Programs 25th mission The challenger burned 73 seconds into the mission Investigations revealed the cause to be O-Rings that did not seal at the joint below 40 F

Case Facts
Culture prevailing at NASA at that point was Prove to me that its wrong NASA Management did not heed to warnings that unusually low temperatures may prove a risk to the launch of the Challenger as ORings did not function as expected O-Rings not functioning as expected had become an accepted risk

Case Facts
Foam strikes caused damage to every mission in the history of the space shuttle programme Over a period of time, it came to be classified as an infamily event, from a serious threat As it was classified as an in-flight anomaly, it meant NASA had to resolve the problem before the next flight The cause of foam loss was not determined not were measures taken to prevent it

The Final Columbia Mission and Problems

81.7 seconds into the launch, a large piece of insulating foam fell off the External Fuel Tank and stuck to the Orbiters left wing Due to budget cuts over the years, camera images were not up to quality and the Intercentre Photo Working Group wanted better photos from NASAs spy sattelites The event was classified as an out of family event

The Final Columbia Mission and Problems

An adhoc Group, Damage Assessment Team(DAT) was formed to resolve the issue, but it was not classified as a Tiger Team DAT did not report to the Mission Management Team(MMT) and it was unsure who they would have to make their requests to for additional data No direct communication between DAT and MMT

The Final Columbia Mission and Problems

NASA Engineer Rodney Rocha wanted additional imagery to determine the extent of the damage, a request that was ultimately left unfulfilled as the request did not pass through the proper channels NASA was described as an extremely bureaucratic structure Although the MMT was supposed to be decentralized, it wasnt

The Final Columbia Mission and Problems

Damage to the shuttle was focussed on the TPS and not the RCC as it was believed that foam did not pose a threat to the RCC panels

Sources of Conflict
Goal Incompatibility - Agency engineers and managers focused on organizational efficiency and turnaround schedule, DAT focused on impact of foam strikes

Sources of Conflict
Resource Conflict - Managers were looking to minimize expenses, leading to budget cuts and poor cameras, engineers wanted better quality images, which they did not ultimately receive, something that might have helped prevent the disaster

Recommendations and Suggestions

Matrix structures are formed to give equal importance to two sets of goals, but in organizations like NASA, precedence must be allowed to change as per the situation Teams like DAT should be allowed to function more autonomously and with a clear mandate, although implementing it in an organization like NASA that depends on government funding is difficult

Recommendations and Suggestions

Communication channels must be clearly defined so that in times of crisis, precious time is not trying to get vital information

THANK YOU