Diagnosing the Needs for Change in the Aftermath
The loss of the space shuttle Columbia prompted an investigation to determine the factors that contributed to the accident. Essential to the investigation was collecting and analyzing data associated not only with the Columbia accident, but that of the 1987 loss of the space shuttle Challenger. Evidence from the investigation indicated that lessons learned from the Challenger were not necessarily applied to the shuttle program and may have been instrumental in the loss of the Columbia. It was determined that several factors outside of the technical and systemic systems were associated within the NASA organization and contributed to the loss of the shuttles. Addressed here are some of the factors that contributed to the tragedies.
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The agency centralized authority in Washington D.C. and required review of flight waivers by independent authority. However, as administrations changed in 2000, so did the leadership in NASA. While communication improved with central oversight, the decision was made to again subordinate decisions and oversight back down to units. As the oversight changed, the culture returned with reckless abandon. The differences leading up to the Columbia tragedy were that the previously experienced workforce was now significantly diminished and overworked. The central oversight was relegated to operating units that had sole responsibility for their activities. Finally, as James Oberg (2006) notes, “the disaster need never have happened if managers and workers had clung to know principles of safely operating on the edge of extreme hazards – nothing was learned by the disaster that hadn’t already been learned, and then forgotten.” The idea that risks are inherent in the pursuit of space lent itself to shoddy analysis and decision making.
Critical Contributing Factors While there were several factors that contributed to the loss of both shuttles, there are those factors that were identified with recommendations but still contributed to the tragedies. As George Santayana wrote, “those who do not learn from history are doomed to repeat it.” The following are what can be viewed as the most critical findings in the CAIB