The Nimrod Review - Official Documents

The Nimrod Review
NASA Space Shuttle “Columbia” (2003)
17.1
448
“The dwindling post Cold War Shuttle budget that launched NASA leadership on a
crusade for efficiency in the decade before Columbia’s final flight powerfully shaped the
environment in which Shuttle managers worked. The increased organisational complexity,
transitioning authority structures and ambiguous working relationships that defined the
restructured Space shuttle program in the 1990s created the turbulence that repeatedly
influenced decisions made before and during STS-107”.
(Columbia Accident Investigation Board Report, 2003)
There are uncanny, and worrying, parallels between the organisational causes of the loss of Nimrod XV230 and
the organisational causes of the loss of the NASA4 Space Shuttle “Columbia” in 2003.
17.2 Columbia was lost on 1 February 2003 as a result of a breach in the thermal protection system on the leading
edge of the left wing. This was caused by a piece of insulating foam which, after launch, separated from the left
bipod ramp section of the external tank, and struck the leading edge of the port wing in the vicinity of the lower
half of the reinforced carbon-carbon panel number 8. During re-entry to the Earth’s atmosphere this breach in
the thermal protection system proved fatal: it allowed super-heated air to penetrate through the leading edge
and progressively melt the aluminium structure of the port wing, resulting in a weakening of the structure until
increasing aerodynamic forces caused loss of control, failure of the wing, and the breakup of the orbiter.
Columbia Accident Investigation Board Report (2003)
17.3
5 The Columbia Accident Investigation Board (CAIB) emphasised the importance of identifying the fundamental
‘organisational causes’ of accidents rather than focusing merely on errors and omissions by individuals:
“Many accident investigations make the same mistakes in defining causes. They identify
the widget that broke or malfunctioned, then locate the person most closely connected
with the technical failure: the engineer who miscalculated an analysis, the operator who
missed signals or pulled the wrong switches, the supervisor who failed to listen, or the
manager who made bad decisions. When causal chains are limited to technical flaws
and individual failure, the ensuing responses aimed at preventing a similar event in the
future are equally limited: they aim to fix the technical problem and replace or retrain the
individual responsible. Such corrections lead to a misguided and potentially disastrous
belief that the underlying problem has been solved. The Board did not want to make these
errors. A central piece of our expanded cause model involves NASA as an organisational
whole.” 6
17.4 The CAIB found that the organisational causes of the loss of Columbia were rooted in the Space Shuttle’s history
and culture:
“The organisational causes of this accident are rooted in the Space Shuttle’s history and
culture, including the original compromises that were required to gain approval for the
Shuttle program, subsequent years of resource constraints, fluctuating priorities, schedule
pressures, mischaracterisations of the Shuttle as operational rather than developmental,
and lack of an agreed national vision. Cultural traits and organisational practices detrimental
to safety and reliability were allowed to develop, including: reliance on past success as a
substitute for sound engineering practices (such as testing to understand why systems
were not performing in accordance with requirements/specifications); organisational
barriers which prevented effective communication of critical safety information and stifled
professional differences of opinion; lack of integrated management across program
4 U.S. National Aeronautics and Space Administration.
5 CAIB was set up by President George W. Bush and reported in August 2003.
6 CAIB Report, Chapter 7, page 177.