This is important. A satement on why NASA managment failed. Sound familiar?
Back in February, the space shuttle Columbia came in for a landing. It would pass over Northern California, so I was outside in the early dawn to watch it go overhead. But Palo Alto was cloudy that day.
I came in and a few minutes, the radio news reported that the space shuttle had been lost during re-entry. All seven astronauts died.
An accident review board, the CAIB, was created and they released their report a few weeks ago. Yesterday, I read the CAIB report. Here are a few notes and a summary of the report, along with links to the report.
The day after takeoff, NASA engineers were reviewing the various videos of the takeoff. They noticed that a piece of foam hit the shuttle's wing. This started a discussion among NASA engineers as to whether the foam had caused damage. They estimated the foam was traveling at about 500 miles per hour when it struck the wing.
However, NASA management had a tight schedule for a number of missions.
There was no time for delays. In previous takeoffs, pieces of foam had hit the shuttles and nothing had happened, so management, who weren't engineers, concluded there was no need to look into this.
NASA engineers, using personal contacts, asked the US military and intelligence agencies to use their spy satellites to look at the shuttle's wing. There were three separate attempts to ask for spy photos and each time, NASA management found out about these requests and ordered the military NOT to look at the shuttle. Managers warned the engineers to follow procedures.
If the NASA engineers had gotten the images, they would have seen the hole, the astronauts could have stayed in the space station, another shuttle
(Atlantis) could be sent up, and the astronauts could return on the second shuttle.
At page 140 in the CAIB report, there is a description of these actions and decisions, with a list of three requests for images at p. 166 and a list of eight missed opportunities at p. 167, with a summary at p. 170. At p. 177, the CAIB looks into NASA's decision-making process.
The piece of foam stuck the wing, creating a hole in the wing's leading edge. During re-entry, superheated air entered through the hole, melted the wing's aluminum internal structure, and the wing collapsed and fell off the shuttle as it was moving at 12,000 miles per hour.
NASA managers, with their demand to stick to the schedule, their refusal to listen to the engineers, and using threats of reprimands against engineers who spoke up, caused the loss of the shuttle and the deaths of the astronauts.
In the early 80s, the shuttle Challenger took off in cold weather. The Challenger accident review showed that engineers warned NASA before launch that the O-rings might fail and they asked for a launch delay. NASA managers overrode the engineers and went ahead with the launch. Challenger exploded and all seven astronauts were killed (summary of the Challenger event at p.
199-200.)
From the CAIB's summary: ".NASA's management system is unsafe to manage the shuttle system."
In contrast, the US Navy has a decision system that actively seeks minority or dissenting opinions. If there are no dissenting opinions, the officers are obligated to actively look for dissenting opinions. At NASA, the opposite was done: management suppressed dissent and did not seek it out.
The CAIB report should be read by anyone who works in large organizations.
It uncovers the blindness in organizational decision making, shows how this occurs, and how this can be remedied.
The Columbia Accident Investigation Board (CAIB at www.caib.us) 248-page report is at www.caib.us/news/report/default.html (PDF, 10 MB file). I suggest that you fetch this file; the CAIB website will close in early 2004.
yrs,
andreas
www.andreas.com
