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Space Shuttle Disaster

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On the 1st February 2003, a critical systems failure on the space shuttle Columbia on its re-entry to the earth’s atmosphere. This caused the disintegration of the shuttle leading to the death of all seven crew members.

1. Describe NASA's apparent approach to risk management after Challenger but before Columbia.

On January 28, 1986, the space shuttle Challenger broke apart in 76 seconds after launch, killing all of its 7 crew members. On the day of launch engineers were concerned that the temperature was too low to launch (-2.2 C lowest launch temperatures recorded) and that there was too much ice on the shuttle. O-rings would not perform correctly at this temperature. NASA management was told of this issue but it was deemed an acceptable risk and launch went ahead. After the incident, a new safety office was created to allow better communication and risk assessment. NASA’s apparent approach to risk management at this time was probable risk management1. For the space shuttle, linear analysis might be sufficient between probability, impact, and frequency2, with probability addressing how likely the risk event or condition is to occur, impact detailing the extent of what could happen if the risk materialized, and frequency meaning likelihood of occurrence of an event whose values lie between zero and one.

2. What additional risk measures would you recommend to NASA? Justify your recommendations?

Firstly, NASA may need to change the organizational attitude to approach to risks. They are more preoccupied with success by asking “Prove that it is unsafe” rather than being preoccupied with failure by asking “Prove that it is safe.” This kind of optimistic approach to risks is very dangerous because some risk with low probability and medium level of consequence might be overlooked. Secondly, NASA may need to concern the risk from management level. Even though this risk is not directly related to the risk impact, it can be very dangerous due to several reasons; Lack of technical knowledge from higher management level, Overconfidence, Position or job pressure to make the timeline, and low budget.

3. What lessons learned are common between the Columbia Disaster and the Challenger Disaster?

a. Communication Failure within the reporting structure: For both cases, engineers reported problems to their intermediate managers and this was supposed to be reported to the top-level management group to decide either launch or delay after engineers found technical faults. However, it didn’t happen.
b. Risks can very complex: Many variables such as weather, weight, speed, and dimensions are involved in the risk function. More study on risk needs to be developed and managers must recognize the risk management concepts as complex impact functions.

4. If these are common lessons learned, why weren't they sufficient to prevent the Columbia Disaster?

NASA’s optimistic culture and overconfidence of management made it difficult to look at failure or even acknowledge that it was a possibility. Failure was not an option for them even they had experienced. Management tended to wait for dissent rather than seek it, which was likely to shut off reports of failure and other tendencies to speak up. Furthermore, because NASA’s “can-do” bureaucracy was preoccupied with success, it was even more difficult for people to bring up possible issues. Secondly, safety had never been number one priority due to many aspects NASA had faced; sever time schedule pressure, budgetary constraints, personnel downsizing, communication problems within the hierarchy, and so forth. Lastly, at the organizational level, NASA was a very complex organization that maintained strict reporting systems, which constrained information flow to defined channels of communication. Especially, NASA’s structure did not facilitate fast information flow concerning unexpected events or possible critical issues.…...

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