Columbia Accident 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

Damage detection of composite overwrapped pressure vessels using ARX models

After the Columbia accident, aged composite overwrapped pressure vessels (COPVs) employed for space missions are being subjected to various examination and monitoring techniques to identify different failure modes. As an innovative approach, this paper explores the capability of Auto-Regressive model with eXogenous input (ARX) model analysis method to detect damages/flaws in COPVs utilizing the pressure as the input and the corresponding strains as the response data. Different levels of pressure were applied to the instrumented COPVs; both pressure and strains were simultaneously recorded, and later were analyzed to detect anomalies. Also investigated is the possibility of obtaining indices/features related to the performance of COPVs. It was discovered that varying strain measurements were recorded of damage induced COPVs while consistent strain measurements were recorded of intact COPVs. Furthermore, a Damage Feature (DF) was identified to compare the existing conditions of COPVs. A deviation of the DF values from an established threshold level was apparent for damage-induced COPVs while other COPVs were below the threshold level.

Investigation of material response to atmospheric re-entry exposure of sub-structural Ti-6Al-4V components recovered from Space Shuttle Columbia

Aluminum and titanium char-layer deposits discovered on overhead windows recovered from the Space Shuttle Columbia accident revealed unexpected material response. It was observed that titanium melted and deposited before aluminum: behavior inconsistent with their relative melting temperatures. In close proximity to the windows, payload bay door (PLBD) latch rollers, containing Ti-6Al-4V, exhibited significant thermal damage that could not be explained by re-entry heating alone. The roller was considered a likely source of the deposition as damage was localized to the titanium region and the component was evaluated to identify features of ignition and/or combustion. A second examination was conducted on arc-jet samples obtained from a previous work that studied Ti-6Al-4V combustibility in a simulated re-entry environment. The samples were compared to the analysis of the PLBD roller and both exhibited features suggestive of titanium combustion. The PLBD roller possessed microstructural similarities to the arc-jet specimens that reacted more aggressively to the simulated environment.

Investigation of broom-straw fracture behavior of aluminum alloy 2024 debris recovered from Space Shuttle Columbia

Materials investigations of Space Shuttle Columbia debris hold great relevance for understanding materials response to atmospheric re-entry. Sections of the Xo 582 ring-frame bulkhead, recovered from the Columbia accident, exhibited highly localized thermal degradation and material loss. Unique delamination features were observed on fracture surfaces of the bulkhead, as well as on other aluminum debris. The unique nature of the fracture surfaces, termed broom-straw, is not a well described phenomenon, and takes central focus of this research. This paper presents a forensic materials characterization of the bulkhead that substantiates and expands upon the previous notions that broom-straw fracture is the result of grain boundary liquation. Observed features were consistent with material exposure to elevated temperatures and subsequent material property degradation, followed by mechanical overload. This research attempts to advance the understanding of broom-straw fracture and determine the influence of microstructure and thermo-mechanical processing on the broom-straw fracture mechanism.

Mr. Bridenstine's “To Do” List

Mr. Bridenstine's “To Do” List

Evaluating Decision-Making Modalities and Risk Acceptance Behavior after a Major Mishap: The Case of NASA and the Space Shuttle Columbia Accident

ABSTRACTThe February 2003 loss of the space shuttle Columbia on mission STS-107 was a mishap that stunned both NASA and the world. This research examines the pre-NASA and post-NASA decision-making modalities and risk acceptance behavior for the safe and reliable operation of the space shuttle through the lens of hazard analysis. Interviews with NASA administrators and senior Space Shuttle Program managers bring back to life their views from the 2003 through 2005 timeframe, during which NASA returned the space shuttle back to a flight status. Lessons from their effort have broad applicability to other organizations recovering from—and attempting to prevent—a major accident.

Columbia and Challenger: Organizational failure at NASA

The National Aeronautics and Space Administration (NASA)—as the global leader in all areas of spaceflight and space science— is a unique organization in terms of size, mission, constraints, complexity and motivations. NASA's flagship endeavor—human spaceflight—is extremely risky and one of the most complicated tasks undertaken by man. It is well accepted that the tragic destruction of the Space Shuttle Challenger on 28 January 1986 was the result of organizational failure. The surprising disintegration of the Space Shuttle Columbia in February 2003—nearly 17 years to the day after Challenger—was a shocking reminder of how seemingly innocuous details play important roles in risky systems and organizations. NASA as an organization has changed considerably over the 42 years of its existence. If it is serious about minimizing failure and promoting its mission, perhaps the most intense period of organizational change lies in its immediate future. This paper outlines some of the critical features of NASA's organization and organizational change, namely path dependence and “normalization of deviance”. Subsequently, it reviews the rationale behind calling the Challenger tragedy an organizational failure. Finally, it argues that the recent Columbia accident displays characteristics of organizational failure and proposes recommendations for the future.

Organizational Oscillation Between Learning and Forgetting: The Dual Role of Serious Errors

We know that organizations change over time as a result of their ability to learn and their tendency to forget. What we know less about, however, is why they might change back, despite evidence suggesting that this occurs. In this paper, we develop and test a model of organizational oscillation that explains why firms cycle through periods of learning and periods of forgetting. In particular, we identify a dual role for serious errors, which push firms toward a focus on safety while also pulling them away from other foci, such as efficiency or innovation. Although existing learning research recognizes errors as disruptive, this dual effect has not been theorized. We also demonstrate that, over time, the effect of a serious error on safety weakens, allowing alternative activities to emerge that lead to subsequent errors. We draw on qualitative data from the National Aeronautics and Space Administration’s Challenger and Columbia accidents to build theory about why organizations oscillate between safety and other foci, and how serious errors trigger these shifts. We then test this theory using a data set of all pharmaceutical firms that introduced Food and Drug Administration-approved drugs in the United States from 1997 to 2004. Results confirm our theory, which contributes to our understanding of complex learning processes by identifying a mechanism by which organizations learn, then forget; then learn, then forget again.

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.

Organizational learning at NASA: the Challenger and Columbia accidents

Preface Part 1: Recognizing the Value of Organizational Learning1. Uncanny Similarities: The Challenger and Columbia Accidents2. Identifying Organizational Learning Part 2. Analyzing the Causes of the Shuttle Accidents 3. Structures for Processing Information4. Contractor Relations5. Political and Budgetary Pressures6. Organizational Culture Part 3: Institutionalizing Lessons about Public Organizational Learning7. The Challenges of Learning in Public Organizations8. Lessons from NASA about Organizational Learning References Index

極超音速衝撃波・境界層干渉におけるCrackの空力加熱率への影響

A small crack on body surface led to a tragic accident in 2003, which is the Columbia accident. During the shuttle's re-entry, high temperature gas penetrated crack on leading-edge of the left wing and melted the aluminum structure, finally the Columbia blew up. Since early times, there are many fundamental studies about simple cavity-flow formed on body surface in hypersonic speeds. However, an investigation of Shock/Boundary-Layer Interaction (SBLI) on crack has not been researched. For multistage space transportation vehicle such as TSTO, SBLI is an inevitable problem, and then SBLI on crack becomes a critical issue for TSTO development. In this study, the effects of crack, where SBLI occurs, were investigated for TSTO hypersonic speed (M∞ = 8.1). A square crack locates at SBLI point on the TSTO booster. Results show that a crack and its depth strongly effect on peak heat flux and aerodynamic interaction flow-field. In the cases of shallow crack (d/C ≤ 0.10), there exist two high heat flux regions on crack floor, which locates at a flow reattachment region and a back end wall of crack. In this case, a peak heat flux at flow reattachment region becomes about 2 times as large as the stagnation point heat flux, which value becomes larger compared with a peak heat flux in the case of No-Crack TSTO. While in the case of deep crack (d/C = 0.20), overall heat flux on crack floor decreases to below the stagnation point heat flux. These results provide useful data for a development of TSTO thermal protection system (TPS) such as thermal protection tile.

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.