On February1, 2003, after 16 days in space, the Space Shuttle Orbiter Columbia on its STS-107 mission with a seven-member crew on the board during entering the Earth's atmosphere broke apart. The investigation of the disaster has shown how NASA's culture had influenced the process of handling the problems that occurred before and during Columbia's final mission.
The concept of the shuttle as a reusable vehicle was created in 1970s as a result of NASA's budget cutback. The implemented technologies were experimental, revolutionary and innovative, but there was pressure to make it look routine to buy-in customers. NASA's promises of the reliability, efficiency, and safety of the shuttle had provided substantial funding for the program, but funding still was not enough for the complex design specification. So, some important safety features like an escape system for the crew were not part of the design. Driven by the schedule demand, the final steps of the Columbia's development, including tiles mounting, were not done in the manufacturing facility in California but at the Kennedy Space Center in Florida by engineers. The testing regiments were deviated and analytic models were used to verify the entire system. That was not a normal procedure. Only after the disaster proper tests did identify the technical problem of the Columbia's final flight.
A variation of this problem occurred in the very first of Columbia's flight in 1981 and repeated in every flight since then. It was the foam debris strike during the liftoff that would lightly damage Shuttle's tiles. For all these 22 years this damage became systematic and was not treated by NASA as a serious issue requiring an immediate resolution. Over the time, the defect turned into an accepted risk and a maintenance item after every flight and was treated as a routine. I think this was one of the reasons that it was so hard to hold anyone accountable for the tragedy.
The disaster of another Shuttle, Challenger, in 1986 was caused by a similar constructional issue. The shuttle with 7 crew members aboard perished. The lesson still was not enough for NASA to prevent Columbia's tragedy. NASA's cultural practices of playing “Russian roulette” and the cultural approach of “prove to me that there's something wrong,” instead of “prove to me that it is right” became a crucial barrier for any action to handle the existing foam debris strike damage risk as an elevated severity issue. In the 2002 Atlantis's flight, the foam damage was the “most severe of any mission yet flown”. This didn't strike NASA's management attention and didn't lead it to conduct some serious investigation or at least to install better tracking video cameras to observe and document the damaging events as a source for engineers to better understand the impact of the damage. The pressure to follow the schedule for subsequent mission flights has prevailed over any safety concerns when the Shuttle Program decided to fly Columbia. Sad enough is the fact that the values of the mission's scientific experiments was not high or critical and even was criticized by describing as “childish and elementary”.
The better images of Columbia's left wing taken from the military satellites could have help significantly in assessments of the damages happened during the liftoff. Unfortunately, requests for these images had not followed official procedures and were canceled because of miscommunication. Even from looking at the not very clear existing NASA's own images, engineer Rodney Rocha was very alarmed and concerned about the possible consequences. Despite the fact that event was classified as “out of family”, i.e. not previously experienced, it ended up in the log documented by Mission Evaluation Room managers as a “low concern”. The written guidelines for the “out of family” events were to form the high efficient, well trained Tiger Team to work with agency contractors to analyze the situation. Instead of that ad-hoc group, Derbies Assessment Team (DAT), was formed. This group had a very vague charter and was not familiar with the established procedures of escalation to handle the situation and in particular to make requests for additional data. DAT did not report to the Mission Management Team (MMT), who was making all important decisions, and there was no direct contact between these two teams. Unfortunately, the analysis of possible damages provided by Boeing after using a mathematical tool called Crater had a historical exaggeration in prediction and was discounted by the DAT. The MMT didn't follow the Space Shuttle procedure of meeting daily during the mission. I think this fact is important in the puzzle of all organizational issues NASA experienced. Management's adherence to the schedule for the upcoming flights, the lack of communication, and lack of Shuttle's crew involvement to analyze the situation were the biggest factors in making the wrong decisions. NASA's defensive reaction that there was nothing that they could do is very disturbing and is proof of culture of ineffectiveness and negligence created in the agency.
Refernces; Richard M.j Bohmer, Amy C. Edmonson, Michael A. Roberto. Columbia's Final Mission. Harward Business School.
