Space Shuttle Columbia Disaster: What Happened and Lessons
The Space Shuttle Columbia (Columbia) disaster occurred on the 1st of February, 2003. On its return journey from space following its 28th mission, Columbia disintegrated after re-entering the earth's atmosphere, killing the entire crew.[footnoteRef:1] Whereas technical failures were responsible for the disasters, investigations have extensively faulted deficiencies in NASA's organisational culture, especially in terms of organisational structure, communication, and decision making processes.[footnoteRef:2],[footnoteRef:3] This paper delves into these issues, clearly highlighting why the disaster occurred and how it might have been prevented. [1: S.J. McDanels, B.M. Mayeaux, T.E. Collins, G.A. Jerman, R.S. Piascik, R.W. Russell, and S.R. Shah. "An Overview of the Space Shuttle Columbia Accident from Recovery Through Reconstruction," Journal of Failure Analysis and Prevention 6, no. 1 (February 2006): 82-91.] [2: Julianne G. Mahler, Organization Learning at NASA: The Challenger and Columbia Accidents (Washington D.C: Georgetown University Press, 2009).] [3: Ruth Guthrie and Conrad Shayo, "The Columbia Disaster: Culture, Communications & Change." Journal of Cases on Information Technology 7, no. 3 (July 2005): 57-76.]
The Disaster
The National Aeronautics and Space Administration (NASA) launched Space Shuttle Columbia on April 12, 1981. The shuttle was the first orbiter in NASA's Space Shuttle Program. Initiated in 1972, the aim of the program was to have regular missions to and from space. More importantly, the program was intended to lower the cost of space missions.[footnoteRef:4] Previous spacecrafts would be destroyed upon re-entering the earth, meaning that NASA had to develop a new spacecraft for every mission. With the Shuttle Program, NASA wanted to build reusable orbiters in an effort to reduce space exploration costs. [4: Ibid, 59.]
Columbia conducted 28 missions in total, an equivalent of 300.7 days in space, 4,808 orbits, and 201,497,772 km. Columbia's last mission, however, ended badly. Shortly after re-entry into the earth's atmosphere, the shuttle split up, killing all seven crew members. The debris was recovered in various parts of Texas and Louisiana.[footnoteRef:5] The disaster became the second catastrophe in the Space Shuttle Program after the 1986 Space Shuttle Challenger (Challenger) disaster. In the aftermath of the disaster, the Space Shuttle Program was temporarily halted. The development of the International Space Station (ISS) was also delayed. [5: S.J. McDanels, B.M. Mayeaux, T.E. Collins, G.A. Jerman, R.S. Piascik, R.W. Russell, and S.R. Shah. "An Overview of the Space Shuttle Columbia Accident from Recovery Through Reconstruction," Journal of Failure Analysis and Prevention 6, no. 1 (February 2006): 82-91.]
Technical Failures
In the months following the disaster, a wide-ranging investigation was mounted to uncover the causes of the accident. Based on failure analysis techniques, video footages taken during takeoff, and interrogation of NASA personnel, the investigation revealed startling findings.[footnoteRef:6] During launch, at about 66,000 feet above the surface of the earth, a bit of foam was shed from the shuttle's external fuel tank.[footnoteRef:7] A spacecraft's external fuel tank is the major fuel tank. The tank is insulated with foam to prevent the formation of ice when it is filled with liquid oxygen and hydrogen. If shed during takeoff, such ice could inflict damage on the spacecraft. In this case, the shed foam struck the shuttle's left wing, creating a hole. During re-entry into the earth's atmosphere, the damage created by foam shedding permitted the penetration of atmospheric air into the shuttle's internal wing. As a result, the spacecraft became unstable and disintegrated. [6: S.J. McDanels and Richard W. Russell, "The Space Shuttle Columbia Accident Investigation and Reconstruction: Two Years Later." Microscopy Society of America (2005): 1-2.] [7: McDanels et al. n 5. ]
The 28th launch was not the first-time foam shedding had been observed -- similar occurrences had been noticed in previous launches.[footnoteRef:8] Nonetheless, no substantial measures were undertaken to rectify the problem in large part because all previous occurrences did not result in any accident. In all preceding launches in which foam shedding occurred, the missions were accomplished successfully. In essence, NASA had become accustomed to the phenomenon, consistently maintaining that it did not pose any serious risks. [8: Ruth Guthrie and Conrad Shayo, "The Columbia Disaster: Culture, Communications & Change." Journal of Cases on Information Technology 7, no. 3 (July 2005): 57-76.]
During the investigation, an important question was to determine exactly why foam shedding affected Columbia only during re-entry. In other words, given that the shedding occurred during takeoff, how come the spacecraft completed its mission successfully, but disintegrated while re-entering the earth's atmosphere? During re-entry, a spacecraft relies on its thermal protection system to safeguard its aluminium structure.[footnoteRef:9] This protection is enabled by heat-resistant elements (e.g. tile surfaces) in the thermal protection system. During the launch, the thermal protection system experienced significant damage. More specifically, the tiles were heavily damaged, hindering the thermal protection system from carrying out its insulation function.[footnoteRef:10] Unable to withstand the pressure of atmospheric gases and the heat, the spacecraft exploded. [9: Katie Boyles, Michael Gallis, and Gerald Lebeau. "DSMC...
M. Capece, R. Kinmonth, M. Chumakov, R. M. Deacon, and A. R. Marder. "Failure analysis of a thermal tile on the space shuttle Columbia." Journal of Failure Analysis and Prevention 6, no. 1 (2006): 55-60.]
Organisational Issues
Technical failure without a doubt caused Columbia to disintegrate upon re-entering the earth's atmosphere. Nonetheless, independent investigations revealed that the technical failure did not just happen -- it was an outcome of serious organizational failures at NASA.[footnoteRef:11],[footnoteRef:12] First, the
management of NASA failed to address a problem that had been identified long before the Columbia disaster. Judging from previous experiences, NASA had come to view the occurrence of foam shedding as normal. In her book Challenger Launch Decision Process, Diane Vaughan describes this phenomenon as the "normalisation of deviance."[footnoteRef:13] It was normal for NASA to proceed with shuttle missions even after the
observation of foam shedding during lift-off. [11: Joseph Lorenzo Hall, "Columbia and Challenger: organizational failure at NASA." Space Policy 19, no. 4 (November 2003): 239-247.] [12: Ruth Guthrie and Conrad Shayo, "The Columbia Disaster: Culture, Communications & Change." Journal of Cases on Information Technology 7, no. 3 (July 2005): 57-76.] [13: Diane Vaughan, The challenger launch decision: risky technology, culture, and
deviance at NASA (Chicago: The University of Chicago Press, 1996), 119.]
NASA's behaviour reveals serious underestimation of
risk on the part of the organisation. Any prudent organisation, especially one involved with highly technical operations, would hesitate to proceed with an operation if a technical abnormality is noted in the beginning of the operation. The fact that technical abnormalities observed in the past did not result in serious
consequences does not necessarily mean that future occurrences of the abnormality will not lead to disastrous consequences. NASA was fully aware that foam shedding altered the functioning of the shuttle's wing structure. Riding on the
success of past experiences, however, the organisation remained reluctant in addressing the problem -- it failed to undertake extensive investigations to determine the root cause of the shedding of foam during takeoff and consequently take measures to prevent the recurrence of the problem.
For Dombrowski, failure to rectify a technical problem it was fully aware of exemplifies serious ethical deficiencies on the part of NASA.[footnoteRef:14] As a public organisation, NASA has crucial ethical obligations. The organisation's
ethical responsibilities are even greater given the
nature of its operations. Space missions are critical
operations -- right from the development and
testing of spacecrafts to the termination of missions. Every stage poses serious risks to not only personnel, but also the general public and the
environment. For example, an explosion of a spacecraft during takeoff or re-entry endangers the life of the crew as well as the public. Accordingly, all relevant risks must be carefully identified and robust measures put in
place to mitigate them. More importantly, any technical anomaly cannot be ignored even if previous occurrences have not generated serious consequences. For NASA not to rectify the problem of foam shedding as early as it was noticed, it put the life of the crew and the public at risk, an indication of poor professional and ethical judgement. [14: Paul M. Dombrowski, "The Evolving Face of Ethics in Technical and Professional Communication: Challenger to Columbia," IEEE (December 2007): Section 3.]
NASA's behaviour also embodies a disturbing organisational culture. Organisational
culture essentially denotes the values, beliefs, traditions, standards, systems and procedures common to a given organisation or group of people.[footnoteRef:15] These norms dictate several aspects of the organisation -- from organisational
structure to reporting lines, decision making processes, management-staff relationships, as well as relationships with outsiders. In essence, organisational culture influences how things are done in an organisation, meaning that organisational culture often has a
significant impact on organisational productivity and
performance. [15: Ruth Guthrie and Conrad Shayo, "The Columbia Disaster: Culture, Communications & Change." Journal…
