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Team 5 Columbia's final mission

1. How would you characterize the culture of NASA? What are its strengths
and weaknesses?
STRENGTH:
> bureaucratic = very organized, clear structure, easy to find responsible
one
> evidence based = no to rash decisions
WEAKNESS:
> bureaucratic = time consuming, too many hierarchical levels, a lot of
paperwork
> evidence based = very time consuming , hard to prove some important
issues > Seen as an anomaly
> Common occurrence = considered it as normal
> considered maintenance problem > Foams strikes occurred regularly
> lead to be seen normal occurrence
> many successful missions = less alert
> to much waiting/trust another will do the job
2. How did the history of the Space Shuttle Program shape people`s behavior
during the first 8 days of the mission?

3. How would you characterize NASA`s response to the foam strike, in


comparison with its response to the Apollo 13 incident?

Putting yourself in the shoes of the manager or engineer whose actions you have
followed in the multi-media case, consider the following questions:
4. How does the Columbia mission compare to the Challenge accident in
1986? What differences did you perceive in the behavior of managers
versus engineers?

5. What prior assumptions and beliefs shaped the way that you thought and
behaved during the Columbia mission?
- Corporate culture its very bureaucratic
- Evidence based
- Finding proofs
- No one wants to be responsibility
- Chain of command was complicated
- Success orientated -> would harm my career
*
6.

What pressures affected your behavior?

- foam strike not considered as dangerous


- Missing pictures and data
- Chicken Little behaviour > Overconfident compared to before
> Apollo 13 = serious problem = not solved = dead
> Columbia = common occurrence = outcome is unsure
> Budget problems = budget was cut
> Could have lead to a delay in the time table = huge expensese >
Underestimated the problem in both cases
> Danger that is there but not prove = bearable risk
> Engineers opinion was not valued enough
> Engineers = no time to prove danger

> The engineers afraid of being little chicken > Managers =


focused on goals and success
task orientated
communicate with managers
> Engineers =
focused on the orbiter
knowledge orientated
communicate with engineers
7. Why has NASA treated foam strikes in this manner?
> Did not know origin
> To find out why it happens = time consuming = missing deadlines
> No real danger so far
> Considered a bearable risk Continued > Where did these pressures originate?
- Corporate culture
- Time pressure
- My own success
> In what ways did the culture impact your actions?
- Many obstacles/red tapes --> hinder good performing
- Miss-communication = de-motivation and confusion
- High competition with other countries
- Time limits and plans
8. If you were in that person`s shoes during the Columbia mission, would have
you behaved differently? Why or why not?

- No we guess = because we were lacking information


- Yes by knowing more now - we would have been more persistent on getting the
picture

1. How would you characterize the culture of NASA? What are its strengths and
weaknesses?

NASA:Created in 1958 by US Congress and President Eisenhower in


response to the launch of Sputnik by Soviet Union. Some looked to the new
and exciting discoveries, while others were challenged to transform man
beyond scarcely dreamed frontiers.
Complex matrix organisation employing over 24000 people.
Most employees were either managers or engineers.
Managers helped with running the space programs within timelines and under
the budget while Engineers dealt with the complex rocket science and built
vehicles for space travel.
NASAs culture was characterized by Prove to me that theres something
wrong rather than prove to me that its right. Its culture was hard to
navigate and extremely bureaucratic and going against the norm was
extremely difficult for someone like an engineer.
Moreover, the problems there were conveniently ignored unless they were
perceived to be big enough to be noticed. This could be seen from the
example of O-Rings which was used in the shuttle even when it was known
that they were not fully functional at low temperatures because there was no
evidence against it to be rejected which ultimately led to the crash of a space
orbiter called Challenger.

The following were NASAs strengths and weaknesses:


Strengths:
technical competency and its focus of expertise in Space exploration
Cost optimization: service at low cost since cost was reduced due to low latency.
Strong sense of pride and teamwork:The engineers could think creatively and come
up with ingenious solutions that enabled them to excel in their field.
Bureeaucratic=very organized,clear structure,easy to find responsible one
Evidence based decision making
Weaknesses:
Complex,hazy organizational structure.
Safety at risk due to complacent nature of the managers in the organization.
The critical ratings of components which were required immediately in the processes
were downgraded at will which reduced the credibility of those components and this
eventually led to the destruction of two space orbiters namely Challenger and
Columbia.
Managers were valued more than Engineers as they helped the system run in time
with budget constraints

2. How did the history of the space shuttle program shape peoples behaviour during
the first eight days of the mission?

Organisation emphasis on the turnaround time between missions


The Space Shuttle Program (SSP) as described by CAIB member Sheila Widnall
was badly oversold. NASA to justify the high investment in SSP over promised on the
deliverables, with projected rate of 50 flights per year. This made the organisation emphasis
on the turnaround time between missions. This can be seen when the program decided to fly
two mission STS-13 and STS-107 without resolution of the foam problem. This could have
led to hesitation in looking into the foam problem much deeper with an impending major
management goal- to launch Node 2 for international space station was scheduled.
Downgrading the severity of foam strike and its implications
Even though NASA originally considered foam strikes as dangerous, the frequency of its
occurrence, photographic evidence of foam loss existed for 65 of the 79 mission, led to
downgrading the severity of foam strike and its implications. This belief was further
strengthened when the Atlantis (STS-112) returned sustaining the severe damage.

Attention on the TPS tiles and not the RCC panels on the wings leading edge
Prior to the final Columbia flight, debris had struck and had damaged only the tiles but never
penetrated the RCC panels. This led to SSP not considering the possibility of RCC damage
in Columbia fight during Crater simulation of the damage. The DAT focused their attention
on the TPS tiles and not the RCC panels on the wings leading edge due to a long-standing
belief that foam did not pose a danger to the RCC panels.
One could say, On a macro level, the structure of the organisation, the wait times and the
nature of the missions led to an expectation that the issue would be taken care of and
handled by someone else.Also,NASA had the internal and external credibility of leaving no
problem unsolvable.This disaster was a rude awakening and a clear demonstration of
underlying unresolved problems.
3. How would you characterize NASAs response to the foam strike in comparison
with its response to the Apollo 13 incident? How does the Columbia mission compare
to the Challenger accident in 1986?

In April 1970, a primary oxygen tank burst while astronauts were travelling to the
moon. Flight director Gene Kranz quickly assembled a Tiger Team consisting of
members who had the capability and expertise to work towards resolving this
scenario.The team successfully defused the scenario, working around the
clock for three days, under the direct guidance of Kranz who supported the
creativity, differing opinions of the team and encouraged rapid analysis of
alternatives.

In stark contrast to this is the story of recurring foam strikes that caused damage to
every mission undoubtedly an issue deserving importance. The management often
decided to ignore concerns about this accepted risk and preferred to move ahead
with schedules, their apparently higher priority. The agency incrementally lessened
the severity of its classification of this threat, making this an accepted factor which
they could get away with, analogous to the attitude towards O-rings. In the case of
Apollo 13 incident, the effectiveness of the organisation and its preparedness,
especially of the management, is evident and it is this control and leading that
averted a disaster.

While in the scenario of foam strikes, we are presented with an explicit instance of deviation
from set standards and principles with tragic results. Here we see the organisational

structure failing to perform and individuals and teams cutting across standards, and thus that
becoming the new norm across the passage of time. Specifically in the case of Columbia,
the realisation of failing to give more importance to the voice of engineers and experts cost
them dearly and this is a failure majorly in the part of management.
Columbia mission comparision to the Challenger accident in 1986
Two missions of NASA that ended tragically, that were separated by a span of nearly
two decades, were marked by intriguing background factors pertaining to the working of the
parent organisation. Primarily, the identified root cause behind the failure of these missions
have been at least somewhat highlighted as a risk by engineers and the management at that
point failed to give them their due importance. Roger Boisjoly and Rodney Rocha,
respectively for Challenger and Columbia, had been successfully able to identify the
potential risk- but they from their position as engineers failed to be heard strongly across the
management. The organisational standards of NASA, or at least its application, comes under
the scanner when we see that both O-rings and foam strikes were deemed as an
acceptable risk. NASA as an organisation needs to be evaluated as to why two separate
incidents, two decades between them, have happened owing to similar reasons along the
lines of organisation structural deficiencies. The issue of the voice of technical experts,
engineers failing to reach appropriate levels of management needs to be considered with
utmost seriousness and the situation needs to improve. The actions of different strata of
management need to come under extreme scrutiny, since we have multiple shortcomings
from their end in terms of ensuring safety standards. The time gap between the incidents is a
great source of concern, since it might point to the fact that compromising safety norms and
ignoring self-classified accepted risks so as to ensure good score on business productivity
and performance metrics might be the organisation level theme. Thus the Columbia mission
and the Challenger incident have many similarities in terms of how it was the deficiency in
the organisational structure of NASA that contributed to the situation indirectly. As an line of
thought to consider all dimensions, this alone does not necessary direct us to conclude
negatively about the NASA as an organisation, since they also have successfully defused
scenarios such as Apollo 13. But again this calls for a revaluation of relevant factors since it
is the utmost priority to prevent another tragedy, as quoted by the tribunal.

4. What differences did you perceive in the behavior of managers and engineers?
The managers and engineers, as is evident from multiple instances in the case, did not look
eye to eye in regard to critical issues pertaining to the shuttle and the various missions. In
the Challenger Disaster case regarding long-standing unresolved problems with the rubber
O-rings, including leakage and erosion, we observe that although engineers had not
resolved the problem, the managers had downgraded its criticality rating in a Flight
Readiness Review. It was not even defined as a problem in the review.
On the launch day of Columbia, when a chunk of insulating foam fell off the External Fuel
Tank and struck the orbiter's left wing, it raised the issue of the need of higher-resolution
images to analyse the impact better. Due to the significant debris size, analysts at JSC
classified the event as out of family which according to NASA standards required
immediate attention and teaming up with the NASA engineers to evaluate the matter.
Regardless, the MER managers entered in their log that the strike was of low concern and
the group that should have become Tiger Team reporting directly to Mission Management

Team, came to be just known as Debris Assessment Team(DAT) for which the reporting
structure was not clear.
In another incident we see that Rocha, co-chair of the DAT, e-mailed a JSC manager to
determine whether Columbias crew could perform a spacewalk to inspect the wing but did
not receive an answer. In another separate incident, Ham and Dittemore concluded that it
was safe to fly STS-113 despite the significant foam loss suffered by STS-112 because Ham
knew that a delay in STS-114 would jeopardize a major management goal of launching
Node-2 of the International Space Station within the deadline. The engineers, through this
instance, come out to be more practical and meticulous, managers are more concerned
about the macro situation i.e. their deadlines and hence risk overlooking crucial data.
On Flight Day 6, Rocha wrote a scathing email expressing his reservations regarding the re
entry capability of Columbia as the imagery he requested were not made available and
hence the danger of overlooking a potential threat remained. However, Rocha did not send
the mail to his superiors or to the Shuttle Program Managers instead he simply showed it to
his colleagues. He later explained that engineers were often told not to send messages
much higher in their own rung in the ladder.
Hence we also notice a gap in terms of communication and perceived status between the
engineers and the managers. This is also evident in the case when the Columbia Accident
Investigation Board (CAIB) concluded that organizational communication barriers stifled the
flow of critical information, such as Rochas concerns and requests for imagery, Dittemore
disagreed saying that NASA encouraged people to speak freely and openly. Dittemore
effectively put the blame on the engineers to have failed to bring the serious issue to his
attention. Even Ham noted that she was not alerted to the concerns that were expressed by
the engineers working on the issue. Rocha lamented that he couldn't speak up more
forcefully because he is too low down and Ham is way up here.
In another incident involving request proposal for imagery sent to Ham, two members of
MMT were unaware of such a request even being made. The Mission Management Team
was very rule and protocol oriented with a very centralized operation and bureaucratic setup.
It is evident from the fact that Ham did not contact the DAT directly to determine if its
members wanted additional imagery. Also on the issue of maneuvering Columbia for
valuable imagery, Ham told that it was not being pursued and that even if they saw
something, they could not have done anything about it.

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