Columbias Final Mission

By Group 3

NASA

High Interactive complexity or tight coupling

Multiple Interdependencies

Lot of focus on Research with large amount of uncertainties Excessive focus on efficiency(deadlines) rather than collaboration and communication Subtle change in working environment from organic to mechanistic

What caused the disaster?

Technical

Cognition

Group Level

Organizational

Technical
Foam Issue Crater software not up to date Cameras not sufficient

Cognitive
Confirmatory bias Overconfidence on initial assessments Assumption that only TPS tiles affected, no effect on RCC tiles

Group Level

Poor team design

Ad-hoc group with poorly defined lines of authority Limited access to resources No tiger team implying that Foam issue is not very serious Other teams not co-located

Team climate
Interpersonal climate was not conducive to dissent or questioning especially when power distance was high

Organizational

Organization Structure
Strict reporting relationships Information flow is not rapid/Rigid Communication protocols

Organization Culture Lots of hard data needed as culture was of proving something does not work rather than vice versa

If NASA fixes the foam problem, would this be effective in preventing future accidents? Why not? NO

Complex and Unstable Environment requires

Hierarchy
Formalization

Organic Structure Specialization: Centralization:

Reasons that led to downplay of foam strikes

Environment attributes leading to downplay Budget cuts Aggressive competition with other space agencies Deadlines Schedules

Reasons that led to downplay of foam strikes

Debris Assessment Team (DAT) was formed with people from diversified background to work together and give an answer in 3 days No definite structure defined in DAT for reporting/working DATs requests were all shutdown by managers of SSP (Space shuttle program) No support given to DATs request for imagery from the management Led to DATs flawed and uncertain analysis submitted within deadline

Reasons that led to downplay of foam strikes

Management Level Issues

Preoccupied with success and Arrogance of Optimism

Management tended to wait for dissent rather than seek it, which is likely to shut off reports of failure and other tendencies to speak up

Reluctance to Change

The Columbia disaster is an unfortunate illustration of how NASAs strong cultural bias and optimistic organizational thinking undermined effective decision-making. Over the course of 22 years, foam insulation strikes were normalized to the point that they were simply a maintenance issue - a concern that did not threaten a missions success

Resilience
To bounce back from the ambiguity of blurred images, NASA could, for example, have expanded data collection to include asking astronauts to download all of their film of the launch and to see if they could improvise some means to get an in-flight view of the damaged area. Although both actions were suggested, neither was done.

Recommendations to avoid future mistakes

Need High Responsiveness Organic Structure

Technical Complexity High Flexibility High

Efficiency Low

Recommendations to avoid future mistakes

Focus on schedules and deadlines is incorrect approach in a research environment Structure: Direct teams in problemsolving efforts with clear reporting lines, responsibilities and authority DAT Structure with SSP & Mgt. should have been Pooled Interdependence

Recommendations on how NASA can avoid such mistakes in future Culture: Challenging and testing
existing assumptions and experimenting with new behaviors and possibilities. Exaggerate threats Acting rather than waiting A mindset of openness Promoting Experimentation Encouraging constructive conflict and dissent

Thank you
Group 3