[IP] The Columbia space shuttle accident report

[Dave Farber <dave@farber.net>]

Delivered-To: dfarber+@ux13.sp.cs.cmu.edu
Date: Sun, 19 Oct 2003 13:51:30 -0700
From: Andreas Ramos <andreas@andreas.com>
Subject: The Columbia space shuttle accident report
To: dave@farber.net

Dave,A

I sent you this about the Columbia space shuttle last week. You didn't send
it out to the IP list, and I don't know whether you oversaw it or you didn't
want to send it out. The accident board's report is a remarkable document
about the impact of management's decision making process on large
organizations. It's really worth reading.

yrs,
andreas
www.andreas.com


Dave,

Here's a summary of the report on the Columbia space shuttle accident.

yrs,
andreas
www.andreas.com


Back in February, the space shuttle Columbia came in for a landing. It would
pass over Northern California, so I was outside in the early dawn to watch
it go overhead. But Palo Alto was cloudy that day.

I came in and a few minutes, the radio news reported that the space shuttle
had been lost during re-entry. All seven astronauts died.

An accident review board, the CAIB, was created and they released their
report a few weeks ago. Yesterday, I read the CAIB report. Here are a few
notes and a summary of the report, along with links to the report.

The day after takeoff, NASA engineers were reviewing the various videos of
the takeoff. They noticed that a piece of foam hit the shuttle's wing. This
started a discussion among NASA engineers as to whether the foam had caused
damage. They estimated the foam was traveling at about 500 miles per hour
when it struck the wing.

However, NASA management had a tight schedule for a number of missions.
There was no time for delays. In previous takeoffs, pieces of foam had hit
the shuttles and nothing had happened, so management, who weren't engineers,
concluded there was no need to look into this.

NASA engineers, using personal contacts, asked the US military and
intelligence agencies to use their spy satellites to look at the shuttle's
wing. There were three separate attempts to ask for spy photos and each
time, NASA management found out about these requests and ordered the
military NOT to look at the shuttle. Managers warned the engineers to follow
procedures.

If the NASA engineers had gotten the images, they would have seen the hole,
the astronauts could have stayed in the space station, another shuttle
(Atlantis) could be sent up, and the astronauts could return on the second
shuttle.

At page 140 in the CAIB report, there is a description of these actions and
decisions, with a list of three requests for images at p. 166 and a list of
eight missed opportunities at p. 167, with a summary at p. 170. At p. 177,
the CAIB looks into NASA's decision-making process.

The piece of foam stuck the wing, creating a hole in the wing's leading
edge. During re-entry, superheated air entered through the hole, melted the
wing's aluminum internal structure, and the wing collapsed and fell off the
shuttle as it was moving at 12,000 miles per hour.

NASA managers, with their demand to stick to the schedule, their refusal to
listen to the engineers, and using threats of reprimands against engineers
who spoke up, caused the loss of the shuttle and the deaths of the
astronauts.

In the early 80s, the shuttle Challenger took off in cold weather. The
Challenger accident review showed that engineers warned NASA before launch
that the O-rings might fail and they asked for a launch delay. NASA managers
overrode the engineers and went ahead with the launch. Challenger exploded
and all seven astronauts were killed (summary of the Challenger event at p.
199-200.)

From the CAIB's summary: ".NASA's management system is unsafe to manage the
shuttle system."

In contrast, the US Navy has a decision system that actively seeks minority
or dissenting opinions. If there are no dissenting opinions, the officers
are obligated to actively look for dissenting opinions. At NASA, the
opposite was done: management suppressed dissent and did not seek it out.

The CAIB report should be read by anyone who works in large organizations.
It uncovers the blindness in organizational decision making, shows how this
occurs, and how this can be remedied.

The Columbia Accident Investigation Board (CAIB at www.caib.us) 248-page
report is at www.caib.us/news/report/default.html (PDF, 10 MB file). I
suggest that you fetch this file; the CAIB website will close in early 2004.

yrs,
andreas
www.andreas.com

-------------------------------------
To manage your subscription, go to
 http://v2.listbox.com/member/?listname=ip

Archives at: http://www.interesting-people.org/archives/interesting-people/