High amount of systematic risk, high amount of bias, specifically over confidence, usually are good at adapting to

situations but in this case they werent

In the early 1970s NASA had devised a plan to construct an outpost to serve as a base for further space exploration,
ultimately allowing humans to travel to Mars. The plan required NASA to develop a fleet of vehicles that could
transport crew and materials between Earth and the Space Station. Ultimately, neither President Lyndon Johnson nor
his successor, Richard Nixon, approved the development of a costly space station. Nevertheless, NASA clung to the
concept of a new reusable vehicle for manned space flight. Without a space station, the vehicle needed a new
purpose. Facing budget cutbacks, NASA chose to justify the Shuttle on economic grounds. The agency argued that it
could employ a reusable vehicle to
place satellites into orbit for scientific, commercial, and national security purposes. When compared to alternative
means of transporting satellites into space, a fleet of shuttles offered the promise of substantial cost savings. To
justify the massive investment required to develop and build a fleet of shuttles, NASA used a projected rate of 50
flights per year.
On January 16, 81.7 seconds into launch, a chunk of insulating foam fell off the External Fuel Tank and struck the
Orbiters left wing. The Intercenter Photo Working Group, a team of NASA engineers charged with reviewing liftoff
imagery from tracking cameras, did not detect the strike until 9:30 a.m. the next day.
Flight Day 1
When the Intercenter Photo Working Group identified the strike on the left wing, they found that a restrictive camera
angle and a blurry image did not clarify the size, shape, or momentum of the foam or the location of impact while
the photographs were unclear, the group did have the distinct impression that the piece of foam was unusually large
larger than any they had seen.
Instead, this adhoc group became known as the Debris Assessment Team (DAT). NASA engineer Rocha and United
Space Alliance engineering manager Pam Madera chaired the DAT. CAIB member Widnall commented that the
DATs charter was very vague. It wasnt really clear who they reported to...I think they were probably unsure as to
how to make their requests to get additional data. Tetrault also stressed that the DAT did not report to the Mission
Management Team. Moreover, he pointed out that, When these issues (foam strikes) were discussed, there was
never any direct communication between the Debris Assessment Team and the Mission Management Team. It was
generally through other parties.
Flight Day 5
Early in the morning, the DAT briefed MER manager Don McCormack on the results of the Crater analysis while
pointing out that they had not completed their analysis. McCormack later relayed this information to the MMT
during its second meeting. Space Shuttle procedures directed that the MMT should meet daily during a mission.
However, during the 16-day STS-107 mission, the MMT met only five times (Flight Days 1, 5, 8, 11, and 15).
After McCormack briefed the MMT on the debris issue, Ham, the teams chairperson, reminded everyone that foam
losses had occurred often on previous flights. She also commented that foam was not really a factor during the
flight because there is not much we can do about it.
Both Ham and Dittemore, the Shuttle Program Manager, attended the meeting in which agency officials concluded
that it was safe to fly STS-113 despite the significant foam loss experienced by STS-112. After the MMT meeting on
Flight Day 5, Ham revisited the documents presented at that meeting, and she sent an e-mail to Dittemore in which
she commented that the flight rationale for STS-113 was lousy. Ham, known for her domineering management
style, knew that she was to serve as Launch Integration manager for the next shuttle mission, STS-114. She
recognized that she would have to address this flawed past rationale or face a delay of that upcoming mission.

Ham also knew that a delay in STS-114 would jeopardize a major management goalto launch Node 2 of the
International Space Station by February 19, 2004. Management considered that target date critical for two reasons.
First, Node 2 would complete the U.S. core of the Space Station. Second, NASA and the Space Station Program had
faced increased scrutiny in recent years from the White House Office of Management and Budget.

Scheduling is a massive issue with Nasa. Enormous pressure to stay on track, to stay on time, to finish the space
station made 5 launches to put it together which had never been done before.
History of foam strikes on previous flights, MER didnt classify the foam strike as an anomaly accepted risk, once
called an in flight anomaly. It was expected and accepted- never considered a flight or safety issue- it was
considered maintence concern to fix the ship.
On January 16, 81.7 seconds into launch, a chunk of insulating foam fell off the External Fuel Tank and struck the
Orbiters left wing. The Intercenter Photo Working Group, a team of NASA engineers charged with reviewing liftoff
imagery from tracking cameras, did not detect the strike until 9:30 a.m. the next day.
Instead, this adhoc group became known as the Debris Assessment Team (DAT). NASA engineer Rocha and United
Space Alliance engineering manager Pam Madera chaired the DAT. CAIB member Widnall commented that the
DATs charter was very vague. It wasnt really clear who they reported to...I think they were probably unsure as to
how to make their requests to get additional data. Tetrault also stressed that the DAT did not report to the Mission
Management Team. Moreover, he pointed out that, When these issues (foam strikes) were discussed, there was
never any direct communication between the Debris Assessment Team and the Mission Management Team. It was
generally through other parties.
Although the foam strike hit, had to continue to do everything on schedule
1.

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

This completely goes with the first reading, were managers believe in relentless execution- efficiency, timely, they
focused to narrowly on meeting goals and deadlines and didnt stop to think about what was actually happening.
People didnt feel comfortable suggesting the importance of this foam strike. This goes back to the reading of
execution as learning this was not a physcologically safe environment, people are hesitant to speak out.
Of all the behaviors that characterize this 'culture' the reluctance the part of NASA employees to speak out and
express their views was perhaps the most damming. The reciprocal of an unwillingness to speak out is the perceived
fear that doing so will have repercussions
In the past, the challenger, the one with the high school teacher- engineers and other individiauls knew that they had
not tested for cold weather, unfortunately it was freezing cold in florida the engineering staff and everyone else
who knew about the dangers didnt bring it up to there superiors as it would be a career changing move. Everyone
said it was ok, they knew of it, nasa managers would not be convinced no physcological safety if they brought
fear among everyone else then it would have cost nasa millions and millions of dollars. They ended up blowing up
30 seconds after departure as they freezing cold broke the ship and gas went up.

Perhaps the most salient characteristic of the NASA culture is that its managers act as if they are proverbial
rocket scientists.
The failure is not an option attitude breeds people that take it literally, he wrote, and think not only that its not
an option but that in reality its not a possibility. As a result, he concluded, If you NEVER consider the possibility,
youll never consider the ways to get you there. This led to an air of positiveness, a pressure to believe that a
can-do attitude could do anything.

And the hazards of being branded a whiner were severe. Unlike in other professions medicine, law, engineering
where people who wind up shunned or blacklisted in one area can find equivalent employment elsewhere, NASA
is practically the only space game in town and vindictive management often had a long reach.
There is just this one small niche, and if you spoil your reputation there, your life-long passion for space flight work
may be doomed forever. So you go along in the hopes that things may get better, while ever so slowly, as the
proverb goes, your face grows to fit the mask you must wear.
A teams atmosphere is just as important as its design. Many groups lack a climate of psychological safety; thus,
members do not feel comfortable raising tough questions, expressing dissenting views, or speaking candidly about
ambiguous threats. Team members who call attention to such threats find themselves marginalized or ostracized,
perhaps even derided as Chicken Littles. Many individuals at NASA reported that the group dynamics did not
encourage a candid discussion of threats. Meeting transcripts revealed that managers did not actively seek dissenting
views. Packed agendas inhibited thoughtful discussions of potential threats. Hierarchy and status differences made it
difficult for lower-level engineers to express their concerns.
technological uncertainty; a can do culture that minimized safety threats; severe time schedule pressures;
budgetary constraints; political uncertainty; fluctuating priorities; partially inconsistent efficiency and safety goals;
mischaracterization of the shuttle as operational rather than developmental; lack of integrated management across
program elements; political infighting; communication problems within the hierarchy; dependent and understaffed
safety agents; organizational barriers that stifled concerns about safety; and a rule- following culture that took
precedence over deference to the expertise of engineers.

Space Shuttle procedures directed that the MMT should meet daily during a mission. However, during the 16-day
STS-107 mission, the MMT met only five times (Flight Days 1, 5, 8, 11, and 15). After such anything goes wrong
there should be more meetings
NASAs hurriedly assembled, postlaunch Debris Assessment Teamthe group responsible for evaluating the foam
strikeproved to be poorly structured and had limited data with which to work. Its members had no experience
working together on critical, time-sensitive problems. The group lacked a well-defined charter, budget, reporting
structure, and formal standing within NASA. It tried to operate with an awkward cochairman leadership structure,
which left some members wondering who was in charge.
2.

How has NASA treated foam strikes historically? Why has NASA treated foam strikes in this manner?

When the foam strike occurred, the NASA officials supervising the launch did not have a clear line of sight to what
would happen as a result. Engineers had noticed the foam strike during routine reviews of videos taken at the launch
unfortunately, not from the best angle to assess the damagebut senior managers downplayed the threat, noting
that foam strikes had caused damage to shuttles in the past but had never resulted in a major accident. Some
concerned engineers described the foam strike as the largest ever and asked that additional satellite images of the
strike area be taken, but top managers rejected these requests. Management also chose not to have the astronauts
conduct a space walk, which may have enabled them to observe, and perhaps even repair, the damage.
Foam debris strikes caused damage to every mission in the history of the Space Shuttle Program. NASA originally
considered foam strikes on ascent particularly dangerous, due to the fragile nature of the TPS. NASA engineers
assumed that only small pieces of debris would strike the Orbiter. Therefore, they designed the TPS, composed of
tiles and Reinforced Carbon-Carbon (RCC) panels, to withstand minor impacts. Prior to the final Columbia flight,
debris had struck but never penetrated the RCC panels.
After the Columbias 1981 inaugural flight, NASA replaced more than 300 tiles. Foam strikes became a concern
during the investigation of the Challenger disaster as well. Despite concerns raised by the Rogers Commission
regarding NASAs safety procedures and repeated instances of foam separating from the External Tank during
ascent, the agency pushed forward with its flight schedule.
Over time, as the shuttles continued to land safely, agency engineers and managers began to focus increasingly on

the turnaround schedule implications of foam strikes rather than the flight-safety effects. According to Columbia
Accident Investigation Board member and top-ranking U.S. Department of Transportation aviation safety expert
James Hallock, [Shedding foam] became sort of expected. Not only was it expected, it eventually became
accepted. While originally considered a serious threat, foam loss eventually came to be categorized as an infamily eventa problem within NASAs experience base that was not considered a safety-of-flight issue.
stubborn attachment to existing beliefs. The human mind tends to protect itself from fear by suppressing subtle
perceptions of danger. Moreover, we are prone to noticing and emphasizing information that confirms our existing
views and hypotheses, while dismissing data that contradict them. This may explain why it was difficult for NASA
managers to believe that the foam strike during the Columbia launch was dangerous. Foam strikes, and even damage
resulting from them, were routine during shuttle launches; despite these strikes, each shuttle launched since 1986
had returned safely, helping reinforce the belief that foam shedding did not constitute a true threat. Over time,
NASA engaged in fewer efforts to seek out information that challenged this conclusion; for instance, it failed to
repair faulty cameras that recorded shuttle launches. more
The switch in risk category classification for foam shedding is an important indicator of the atrophy in shuttle safety
and marks one of several problems at NASA that can be contributed to administrative evil. The foam shedding
problem had been a problem throughout the history of the program. As each shuttle mission closed successfully
despite foam shedding, the problem became normalized and was finally categorized as in family which is a
known problem that is within the known experience base, was believed to be understood, and was not regarded as a
safety of flight issue

3. How did the history of the Space Shuttle Program shape peoples behaviour during the first 8 days of the
mission?
Foam strikes occurred regularly
Tons of succcesfull missions besides from the challenger, everyone is on a high not very alert
Nothing going wrong so everyone is just continuing

4. 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?
Astronauts on apollo 13 big problems, oxygen tanks losing pressure, power supply malfunction, moon missions
cancelled, just trying to get them home safe. The manager made all of his staff think creatively.
Obviously do not get me wrong I think that NASA one hundred percent downplayed the impact of the foam,
however
The Columbia disaster has frequently been compared to the Apollo 13 oxygen tank explosion. The thinking goes,
since NASA saved Apollo 13, they should have been able to save Columbia. But Apollo 13 is not a good analogy for
Columbia.
Apollo 13 experienced what I characterize as an objective emergency. Saving the lives of the crew was principally
dependent on measuring consumables and developing procedures to conserve them for four days. The consumables
would either be sufficient or they would not.
I characterize the Columbia disaster as a subjective emergency, dependent more on opinions and judgment calls for
critical decisions than on objective measurements.
Nasa did not realize there was an emergency, that is the difference. So it is very hard to compare because for Apollo
13- they realized they were in survival mode and carefully weighted every option.

Challenger
A group of low-level engineers at Thiokol who were involved with the O-ring problem were concerned that the
unprecedented cold temperatures on the launch pad were below the design threshold for the O-rings. The worse case
of O-ring damage and blow-by to date had occurred in a similarly strange period of very cold temperatures nearly a
year before. The engineers expressed their concerns to the upper management.
The circumstances surrounding this conference call reek of organizational failure [5]. The engineers had very little
time to assemble their presentation on why cold temperatures should be a concern for O-rings. The ground crew had
to start pumping liquid fuel into the main fuel tank by midnight that night to launch the following morning. Why
was not the launch postponed? Perhaps because the O-ring problem was not considered to be of much concern.
Perhaps because this flight had Sharon Christa McAuliffe on it, an educator and civilian. President Reagan was to
give his State of the Union address the following night and had planned on using the launch in his speech arguably
to highlight the operational nature of the Space Shuttle and the educator astronaut in a time of significant
educational spending cuts. Even though the Rogers Commission found that there was no direct evidence of an
order from the Reagan administration, the political pressure felt by upper management and political appointees
had to be huge.
Same pressures that we see in the challenger- the time, the money, the schedule etc.
Hierachy said no to these younger level ppl. For both challenger and Columbia.
Columbia = Unfortunately, it appears that the upper management in NASA shut down the imaging request in the
belief that the foam incident did not pose a flight safety risk
The report excoriates NASA management decisions during Columbia's last flight. "Perhaps most striking is the fact
that management . . . displayed no interest in understanding a problem and its implications. Because managers failed
to avail themselves to the wide range of expertise and opinion necessary to obtain the best answer to the debris strike
question . . . some space shuttle program managers failed to fulfill the implicit contract to do whatever is necessary
to ensure the safety of the crew."
5.

What differences did you perceive in the behaviour of managers versus engineers?

In a risk-management scenario similar to the Challenger disaster, NASA management failed to recognize the
relevance of engineering concerns for safety for imaging to inspect possible damage, and failed to respond to
engineer requests about the status of astronaut inspection of the left wing. Throughout the risk assessment process,
senior NASA managers were influenced by their belief that nothing could be done even if damage was detected.
This affected their stance on investigation urgency, thoroughness and possible contingency actions. The
investigation report in particular singled out NASA manager Linda Ham for exhibiting this attitude. All linda cared
about was making sure her flight rational was good. Really didnt seem like there was any good communication at
all.
At NASA, for example, a few engineers, frustrated by a paucity of data about the effects of foam strikes on shuttle
missions, had requested additional satellite imagery during Columbias final mission. The managers to whom they
made the request had already signed off, during the Flight Readiness Review, on the determination that foam strikes
did not represent a safety issue. They turned down the engineers request, and so beliefs about the harmlessness of
foam strikes went unchallenged.
6) The loss of the Soviet Union as a competitor in the human space flight arena made it difficult for NASA to obtain
budget increases through the 1990s. But rather than adjust its expectations to the new realities, the Board said,
NASA continued to push an aggressive agenda that included the development and construction of the international
space station.

With no budget increases in sight, NASA's only recourse was to try to do more with less. Enter recent NASA
Administrator Daniel Goldin and his "Faster, Better, Cheaper revolution, an era the report characterizes as "one of
continuous turmoil, to which the Space Shuttle Program was not immune."
But as the investigation continued, the report says, "it became apparent that the complexity and political mandates
surrounding the international space station program, as well as shuttle program management's responses to them,
resulted in pressure to meet an increasingly ambitious launch schedule."
Contributing to the events that led to the Columbia accident was the extraordinary pressure that NASA was placed
under to meet a strict launch schedule. As mentioned in the first article of this series, this pressure led NASA
management to downgrade the significance of previous foam strikes on the orbiter. It also affected the way NASA
management reacted to the discovery of the strike on Columbiatheir main concern was not for the safety of the
crew but the impact the incident would have on future launches.
The pressure came directly from the Bush administration, channeled through the Bush-appointed NASA
administrator, Sean OKeefe. The administration presented NASA with an ultimatum: either it had to prove that it
could complete the first phase of the International Space Station (ISS) by February 19, 2004and do this without
significant cost overrunsor it risked a sharp cut in budget financing or perhaps an elimination of the manned space
program as a whole. The number of launches that NASA needed to complete by February to meet its goal meant that
any unforeseen incidents on any of the orbiters would throw the whole schedule off.