Columbia Accident Investigation Board Research Articles

Normal Accident Theory and Learning from Major Accidents at the National Aeronautics and Space Administration (NASA).

A review of NASA’s accident history through the lens of Normal Accident Theory (NAT) offers insights into the prospects for safety during the Artemis Program. NAT is applied to NASA’s four major human spaceflight accidents: the Apollo launch pad fire, Apollo 13, Challenger and Columbia. NAT predicts that in the complex and tightly coupled systems used for human spaceflight, an accident type known as the “normal accident”, is inevitable. These accidents are attributable to hidden system interactions that overwhelm the cognitive abilities of human operators and, thereby, escape detection. A review of the four official accident reports and supporting secondary analyses suggests NASA has had one such accident: Apollo 13. It was also the only major accident without injury and a successful recovery effort. NAT would categorize the other three as component failure accidents. Unlike normal accidents, component failure accidents are not inevitable. They stem from an organization’s failure to appropriately monitor, assess and mitigate the risk associated with a faulty component. In such cases, NAT would ask if production pressures, often rooted in scheduling and resource constraints, were a factor.Production pressures are ultimately imposed on organizations through the exercise of power. These pressures impede an organization’s ability to adequately assess risk and increase the likelihood of component failure accidents. The substantial organizational literature on NASA’s human spaceflight accidents has yielded potential remedies to help mitigate the risks associated with production pressure. This paper discusses these remedies and their potential safety benefits. It also proposes a modification to a safety governance mechanism recommended by the Columbia Accident Investigation Board (CAIB). The resulting changes could help NASA, and other organizations administering high risk technologies, further improve safety.

Lock the Doors: The Myocarditis Disaster and a call for the broad examination of the CDC and FDA

“Lock the doors.” uttered by LeRoy Cain, the flight director of STS-107, meant the complete loss of Space Shuttle Columbia. Locking the doors initiated the protocol to preserve data and logs for the impending investigation. Some hard lessons were learned from the Space Shuttle Challenger disaster 17 years earlier, one of which was that the National Aeronautics and Space Administration (NASA) should not be put in a position to investigate itself. The interagency Columbia Accident Investigation Board (CAIB) was formed to learn what we could from the fate of Columbia. Had NASA been the investigating agency, given the culture, it is possible the concluding cause would have been a random event such as bird strike after takeoff or micrometeoroid in orbit. “We are convinced that the management practices overseeing the Space Shuttle Program were as much a cause of the accident as the foam that struck the left wing.”[1] Those management practices point to lock-stepping, where dissenting opinions are discouraged or suppressed. NASA’s opinion was that foam is safe. When Bob Page, chair of NASA’s Intercenter Photo Working Group, saw foam strike the wing he raised an alarm that the heat shield may be compromised. He and two members of the Debris Assessment Team made a total of three requests to the Department of Defense (DoD) to obtain high-resolution images of Columbia’s left wing. A request that, by all accounts, the DoD was willing and able to fulfill. Those requests were subsequently canceled by the shuttle program managers. The CAIB report went on to say, “[t]he Board was also influenced by discussions with members of Congress, who suggested that this nation needed a broad examination of NASAʼs Human Space Flight Program, rather than just an investigation into what physical fault caused Columbia to break up during re-entry.” There are two vitally important lessons we have learned from NASA. The first is that a government agency should not be able to investigate itself. The second is that lock-stepping is lethal. The most advanced population health surveillance in the United States couldn’t find a single healthy child who died of COVID-19. Zero is a powerful number. Zero is also the number of vaccines that impart superior immunity over that of natural immunity. If we could choose one feature that the emergent 5th endemic cold virus could have, it would unequivocally be a minimal effect on children – safeguarding our future and allowing the progression of natural immunity. There is nothing mild about pediatric myocarditis. Even with the best medical management, 1/3rd of all patients never completely recovers, and will live with dilated cardiomyopathy. If untreated, 80% of children will develop chronic heart disease. These children are subject to a high risk of sudden death and may require an urgent heart transplant[2].

Growing the NASA safety and mission assurance (SMA) workforce of tomorrow

The NASA Safety Center (NSC) was established in 2006 in response to Columbia Accident Investigation Board (CAIB) recommendations to strengthen NASA's safety program. The NSC supports all NASA centers and facilities. The NSC fosters world-class Safety and Mission Assurance (SMA) support for NASA programs and projects through professional development activities and the advancement of the following SMA technical disciplines:•Aviation Safety•Operational Safety•Quality Engineering•Reliability and Maintainability•SMA Technical Leadership•Software Assurance•System Safety

Mr. Bridenstine's “To Do” List

Mr. Bridenstine's “To Do” List

NASA Standard for Models and Simulations: Philosophy and Requirements Overview

Following the Columbia Accident Investigation Board report, the NASA Administrator chartered an executive team (known as the Diaz Team) to identify those report elements with NASA-wide applicability and to develop corrective measures to address each element. One such measure was the development of a standard for the development, documentation, and operation of models and simulations. The resulting standard attempts to develop a general framework for communicating information to decision makers by including programmatic, documentation, and reporting requirements. It also includes a scale intended to measure the credibility associated with model and simulation results. This report describes the philosophy and requirements overview of the resulting NASA Standard for Models and Simulations.

Shuttle diplomacy

This article analyzes the decisions and technological challenges that drove the Space Shuttle’s development. The goal of the Shuttle program was to create a reusable vehicle that could reduce the cost of delivering humans and large payloads into space. Although the Shuttle was a remarkable flying machine, it never lived up to the goals of an airline-style operation with low operating costs. In January 2004, a year after the Columbia accident, President George W. Bush unveiled the “Vision for U.S. Space Exploration” to guide the U.S. space effort for the next two decades. A major component of the new vision, driven by the recommendations of the Columbia Accident Investigation Board, was to retire the Space Shuttle fleet as soon as the International Space Station assembly was completed. With cancellation of the Constellation program in 2010, the planned successor to the Shuttle, the U.S. space program is now in an era of uncertainty.

The importance of failure theories in assessing crisis management: The Columbia space shuttle disaster revisited

An adequate assessment of crisis management failure (and success) requires a validated causal theory. Without such a theory, any assessment of crisis management performance amounts to little more than a “just so” story. This is the key argument of this paper, which describes how hindsight biases and selective use of social science theory gave rise to a suggestive and convincing – but not necessarily correct – assessment of NASA's role in the Columbia space shuttle disaster (1 February 2003). The Columbia Accident Investigation Board (CAIB) identified NASA's organizational culture and safety system as a primary source of failure. The CAIB report reads as a stunning indictment of organizational incompetence: the organization that thrilled the world with the Apollo project had “lost” its safety culture and failed to prevent a preventable disaster. This paper examines the CAIB findings in light of the two dominant theoretical schools that address organizational disasters (normal accident and high reliability theory). It revisits the Columbia shuttle disaster and concludes that the CAIB findings do not sit well with the insights of these schools.

The Importance of Failure Theories in Assessing Crisis Management: The Columbia Space Shuttle Disaster Revisited

An adequate assessment of crisis management failure (and success) requires a validated causal theory. Without such a theory, any assessment of crisis management performance amounts to little more than a ‘‘just so’’ story. This is the key argument of this paper, which describes how hindsight biases and elective use of social science theory gave rise to a suggestive and convincing – but not necessarily correct – assessment of NASA’s role in the Columbia space shuttle disaster (1 February 2003). The Columbia Accident Investigation Board (CAIB) identified NASA’s organizational culture and safety system as a primary source of failure. The CAIB report reads as a stunning indictment of organizational incompetence: the organization that thrilled the world with the Apollo project had ‘‘lost’’ its safety culture and failed to prevent a preventable disaster. This paper examines the CAIB findings in light of the two dominant theoretical schools that address organizational disasters (normal accident and high reliability theory). It revisits the Columbia shuttle disaster and concludes that the CAIB findings do not sit well with the insights of these schools.

Studying decision processes via a knowledge management lens: The Columbia space shuttle case

While the role of knowledge management (KM) for decision support is well acknowledged, there is a gap between existing KM theory and actual KM practice in real-life decision-making. This paper aims to illustrate this gap by studying the report of the Columbia Accident Investigation Board, focusing on diagnosed pre-explosion problems in decision-making processes, and prescribed post-explosion recommendations. The paper's research contribution is two-fold: 1) consolidating two KM frameworks to one research tool, to serve as lens for studying decision-making processes and 2) providing convincing evidence regarding the role of the KM perspective in organizational decision-making processes.

Shuttle Debris Impact Analysis: Postreturn to Flight Real-Time Mission Support

Prior to the Columbia accident, quantitative impact assessment tools were not available to analyze debris impacts onto the Shuttle’s thermal protection system. Following the accident, the Columbia Accident Investigation Board recommended changes to increase the safety of future shuttle flights; one component was the development of physics-based analytical capabilities to evaluate damage due to debris impacts. This paper will present an overview of real time debris assessment impact analysis conducted by the Boeing Philadelphia Advanced Structural Analysis Impact Analysis Team in support of Space Shuttle missions since Return to Flight, the first mission after the Columbia accident. Specifically, analyses performed in support of missions STS-114, 121 and 117 will be presented. For each of these cases, an overview of the structural and material model development will be provided, and results of each analysis will be presented followed by a discussion of how the results lead into real time mission decisions....

The Loss of the Space Shuttle Columbia: Portaging Leadership Lessons with a Critical Thinking Model

:Business schools have long valued case studies as a tool for both broadening a student's perspective, and provoking them to deeper consideration of complex situations. The challenge with case studies is assuring the portability of the lessons; we don't expect students to see situations imitating those they've studied, hence the goal must instead be habits of mind and principles of action that the student can portage to the circumstances of their professional lives. This article evaluates the suitability of Richard Paul's Critical Thinking model as a template for evaluating engineering enterprise thinking habits and organizational behavior, using the Columbia Accident Investigation Board (CAIB) report as a case study. With minor refinement, Paul's model provides a powerful vocabulary for complicated case study analysis; familiarity with the model provides participants with both a mechanism for analysis and a means for portaging lessons to other professional situations and organizations.

Assessing NASA’s Safety Culture: The Limits and Possibilities of High‐Reliability Theory

After the demise of the space shuttle Columbia on February 1, 2003, the Columbia Accident Investigation Board sharply criticized NASA’s safety culture. Adopting the high‐reliability organization as a benchmark, the board concluded that NASA did not possess the organizational characteristics that could have prevented this disaster. Furthermore, the board determined that high‐reliability theory is “extremely useful in describing the culture that should exist in the human spaceflight organization.” In this article, we argue that this conclusion is based on a misreading and misapplication of high‐reliability research. We conclude that in its human spaceflight programs, NASA has never been, nor could it be, a high‐reliability organization. We propose an alternative framework to assess reliability and safety in what we refer to as reliability‐seeking organizations.

The Evolving Face of Ethics in Technical and Professional Communication: Challenger to Columbia

Our view of ethics in professional and technical communication has evolved, paralleling developments throughout society. Earlier views on ethics and values have grown into a broad perspective of complex gradations with people at many levels affecting eventual practical outcomes. This newer perspective includes not only persons but social forces and organizations. The organizational culture of NASA, for example, was specifically identified by the Columbia Accident Investigation Board (CAIB) as one of the causes of faulty communication leading to a terribly tragic event. The Challenger investigations of 20 years earlier, on the other hand, focused primarily on physical events, secondarily on professional judgments, and only little on the social and cultural context of the disaster. We learn by failures but also by self-examination. As we see how ethics and values impact technical events, we understand that technological progress is ultimately a human endeavor in which reflection and judgment is as important as measurement and observation.

Telling the Columbia Story

This content analysis of newspaper stories seeks to answer three questions about the Columbia space shuttle disaster: What sources did journalists cite in telling the Columbia story? What did those sources say? Which sources were heard most often? Stories analyzed were published by the New York Times, Washington Post, and Houston Chronicle in the 217-day period following the accident. News reporters most frequently used elected and appointed government leaders and NASA administrators, engineers, and other agency employees as sources. Those sources most often communicated “neutral” facts and observations while not placing blame for the accident or evaluating the shuttle program's progress. Astronauts and their relatives, NASA contractors who built and maintained the shuttle fleet, and government accident investigators from agencies other than NASA or the Columbia Accident Investigation Board rarely appeared in the stories. Journalistic routines call for reporters to balance their story narratives with sources representing different viewpoints. In the Columbia story, however, this was not necessarily the case.

Masters of the Universe? Resource Dependency and Interorganizational Power Relationships at NASA

On February 1, 2003, the space shuttle Columbia broke apart as it re-entered the atmosphere. Months later, the Columbia Accident Investigation Board determined the immediate cause of the crash, but it also alluded to relationships NASA has with other organizations as being problematic, suggesting that Columbia was a painful symptom of a deeper disease. This paper uses resource dependency theory and structuration theory together to examine NASA's interorganizational network, illustrating that NASA is involved in multiple toxic relationships and that a pattern has developed through NASA miscues in the last 20 years. This case study demonstrates the advantages of using these two theories together, how such integration provides a useful perspective for understanding power and change in interorganizational relationships. The paper also discusses practical suggestions for NASA specifically, but also for others as organizations become more dependent on external stakeholders and interorganizational relationships.

Application of the Cost – Risk Network method to the thermal protection system of the Space Shuttle

This paper discusses the application of the Cost – Risk Network (CRN) to a real world problem. The case study involves the thermal protection system (TPS) of the Space Shuttle's Orbiter used by the National Aeronautics and Space Administration. The CRN for the TPS focuses on decisions affecting the operation and maintenance of the components of the TPS. The decisions and data needed to construct the CRN for the TPS was gathered from a variety of sources including previous studies regarding the TPS, the Columbia Accident Investigation Board reports, NASA documents, and published articles, as well as knowledgeable estimates where necessary. Using the CRN method to analyse the decisions, both the cost and risk associated with the TPS were reduced.

Studying organisational cultures and their effects on safety

How do organisational cultures influence safety? To answer this question requires a strategy for investigating organisational culture. By far the most widely used research strategy is the perception survey. An alternative is for researchers is to immerse themselves in one or more organisations, making detailed observations about activities and drawing inferences about the nature of the organisation’s culture (the ethnographic method). A third technique makes use of the wealth of material that is assembled by inquiries into major accidents. This paper describes how this material can be used to provide insights into organisational cultures. It draws on specific examples from the author’s own work as well as the cultural analysis carried out by the Columbia Accident Investigation Board. It concludes with some additional suggestions for carrying out research on safety-relevant aspects of organisational culture.

<p>The Epistemic Value of Cautionary Tales</p>

Twice in NASA history, the agency embarked on a slippery slope that resulted in catastrophe. Each decision, taken by itself, seemed correct, routine, and indeed, insignificant and unremarkable. Yet in retrospect, the cumulative effect was stunning. In both pre-accident periods, events unfolded over a long time and in small increments rather than in sudden and dramatic occurrences. NASA’s challenge is to design systems that maximize the clarity of signals, amplify weak signals so they can be tracked, and account for missing signals. For both accidents there were moments when management definitions of risk might have been reversed were it not for the many missing signals – an absence of trend analysis, imagery data not obtained, concerns not voiced, information overlooked or dropped from briefings. A safety team must have equal and independent representation so that managers are not again lulled into complacency by shifting definitions of risk . . . Because ill-structured problems are less visible and therefore invite the normalization of deviance, they may be the most risky of all. – Vol. I, Section 8.5, Report of the Columbia Accident Investigation Board (August 2003).

Columbia accident investigation board (CAIB) pathfinder analysis of item 33767

Early in the shuttle Columbia crash investigation, item 33767 was one of several “Pathfinder” components selected from the Columbia debris that exhibited damage patterns similar to those observed on the left wing airframe components, the components in which initial failure was thought to have occurred. “Pathfinder Analysis” sought to answer academic questions regarding the maximum heat attained and heating direction/duration and identify debris imposed on this fuselage section during Columbia breakup and re-entry. Traditional failure analysis techniques provided useful information on debris constituents and damage sequence and were successful in identifying heat effects, such as the presence of large thermal gradients across the component, and the existence of several failure modes that included hot tensile failure, hot bending failure, and rapid overload fracture.

A review of the findings and recommendations of the Columbia accident investigation board

A review of the findings and recommendations of the Columbia accident investigation board