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Shuttle

This is the story of the Columbia Space Shuttle accident. The story is based on the findings presented in the Columbia Accident Investigation Board Report (CAIBR), simplified in order to highlight the areas where miscommunication was pivotal in the turn of events. Relevant bibliographical sources are given at the end of the story. On 16 January 2003, NASA launched the space shuttle Columbia to carry out scientific research in orbit. The launch seemed successful, and NASA officials, engineers and the public were relieved and happy to see the shuttle exit the Earths atmosphere as planned. However, when members of the Intercenter Photo Working Group watched video footage of the launch the following day, they saw that some pieces of foam insulation became dislodged from the main tank during lift-off and struck the left wing. Immediately, they alerted senior program managers, and e-mailed a digitized film clip of the event to the Mission Management Team (the project leaders), the Mission Evaluation Room (the team monitoring engineering issues during flight), and selected engineers. This discovery led to the formation of the Debris Assessment Team (DAT), consisting of a group of experts from NASA, Boeing, and the United Space Alliance, put together to investigate the strike and present their results to the Mission Management Team. Rodney Rocha and Pam Madera co-chaired the team. Unfortunately, the available footage did not include shots taken from crucial angles of the shuttle, and therefore it did not provide information that was essential to ascertain the degree and kind of damage. The problem that needed to be solved, therefore, was how to obtain more imagery of the shuttle wing. In order to obtain more information on the impact of the strike, the Intercenter Photo Working Group requested Bob Page, their chair, to make an official request to the Department of Defense. The engineers request was that the Department would use their military technology to image the shuttle in orbit. Bob Page contacted Wayne Hale of the Kennedy Space Center to explore the possibility. Hale, in turn, contacted a representative of the Department of Defense (who was not the appropriate person for imagery requests), and asked for a plan to commence imagery of the shuttle in orbit. Neither Page nor Hale obtained authorization from the Chair of the Mission Management Team, Linda Ham, for this request. It was later found that the Department of Defense initiated action to

obtain the imagery, following Hales instructions, but did not notify the requesters or give them any information on how and when this would be done. It was therefore not possible for NASA personnel to make a timeline of further actions. Not knowing of the actions of the Department of Defense, United Space Alliance manager and DAT member, Bob White called Head of Space Shuttle Systems Integration at Johnson Space Center, Lambert Austin, to discuss how to get imagery. Austin then phoned a representative of the Department of Defense Manned Space Flight Support Office, and told him that he was asking for information on how to make a formal request, because some analysts were interested in getting imagery. Again, there does not seem to have been any follow-up by either side. On the same day, DAT held its first meeting, and it assigned Rodney Rocha the task of obtaining imagery from an external source, that is, from an engineering division outside the Department of Defense. Mission Management was not included in this decision. It turned out that, in making this decision, DAT by-passed established procedures, which entailed going through the Mission Evaluation Room to the Mission Management Team and then to the Flight Dynamics Officer. Rocha took the matter to his own division, the engineering section at Johnson Space Center (see extract E-mail A as an example of this, which also shows DATs serious concerns). The fact that no senior management was included in this, caused the Shuttle Program managers to interpret the situation as a non-critical engineering task, concerned with post-mission maintenance problems, and not as a critical operational need. After the requests were made for imagery, by both the Intercenter Photo Working Group and DAT to the Department of Defense, Lambert Austin finally notified Linda Ham. Ham tried to find out the specifics of the situation: who was making the request, and what the requirement was. In particular, she was concerned about the policy stating that requests for Department of Defense participation required evidence that there was a mandatory need for the information or services requested. Unable to find either the original source of the request or evidence that the request satisfied a mandatory need, Ham terminated the procedures that the Department of Defense had initiated to obtain imagery. Linda Ham then sent an e-mail to selected engineers in NASA and the Johnson Space Center asking if there were safety of flight risks caused by the debris strike. The replies that she got indicated that the analysis of the situation, based on the available data, did not show any serious

safety risks. Many of these replies relied on technical analyses of the situation in relation to past experiences, and did not address more global issues of risk management. An e-mail ( E-mail B ) sent by Thermal Protection System specialist Calvin Schomburg is an example of this. In their second meeting, DAT members pondered their options after their requests for imagery had been cancelled. The mandatory need policy confused them, since they interpreted the situation differently from management. When later asked by the Accident Investigation Board what they understood by the term, the DAT engineers indicated that they had no clear idea. For them, the need for imagery was obvious: without it, they could not get accurate measurements to make reliable predictions. As the Report concludes, DAT members were in the unenviable position of wanting images to more accurately assess damage while simultaneously needing to prove to Program managers, as a result of their assessment, that there was a need for images in the first place (CAIBR, 157). After this meeting, Rodney Rocha sent a series of e-mails to engineers, questioning the cancellation of the imaging request. One of these e-mails ( E-mail C ), in particular, summarizes clearly and effectively the concerns of the engineers. Ironically, Rocha did not send this e-mail, but only printed it out and shared it with a colleague. When asked by the Board why he did this, Rocha replied that he did not want to jump the chain of command or to be seen as challenging management decisions. In their third meeting, DAT members reviewed updated impact analyses, but did not reach any agreement on specific actions. They then presented their results, in a briefing meeting, to Mission Evaluation Room manager, Don McCormack. Evidently, they were so anxious that they crowded the briefing room, allowing standing room only. However, in their presentation, as with the replies to Linda Hams e-mail, the engineers concluded that their analysis did not show conclusively that a safety of flight issue existed. Management took a bottom line approach in interpreting this, and focused on the answer rather than considering the uncertainties on which this answer was based. In addition, during this important briefing session, the engineers relied on a PowerPoint presentation to communicate their results. This constrained them to squeeze a significant amount of information (some of it very important) in a few slides that were read off a screen. Subsequent analysis of their presentation revealed that the wording was vague and information

was ineffectively organized, compounding the confusion about what the recommended action was (CAIBR, 191). Don McCormack then conveyed DATs results to the Mission Management Team. The engineers concerns were mentioned during this briefing meeting, but they were not highlighted. In fact, they were so subordinated to other issues that no mention of them exists in the minutes of the meeting, and therefore they were not communicated to anyone who did not attend the meeting. After the results of DAT had been submitted, engineers remained worried about the effects of the debris strike. Carlisle Campbell, a DAT member, contacted his friend Bob Daugherty, an engineer at Langley Research Center, who specialized in landing gear design. Campbell asked Daugherty to simulate some scenarios of landing, using different degrees of damage. Since this request was not supported by Mission Management, Daugherty could only do this after hours. Having completed the simulations, Daugherty sent the most unfavourable simulation result to his peers, selected Johnson Space Center engineers, and the most favourable one to a wider NASA audience, including DAT (see Daughertys e-mail to Campbell, assessing the situation- E-mail D ). No definite action was recommended or taken as a result of DAT findings or Daughertys simulations. On 1 February 2003, Columbias scheduled landing date, the engineers fears were confirmed. Upon re-entry in the Earths atmosphere, gauges on the shuttles shattered left wing failed, temperature and pressure gauges went off the scale, and all vehicle data was lost: the shuttle broke apart piece by piece above Texas. When NASA Mission Control heard reports of the shuttles disintegration, the flight director told the ground controller, Lock the doors. The meaning of his words was clear to all involved: nobody was allowed to enter or leave the room, and all mission data was preserved for a selected Board of specialists to carry out the inevitable Accident Investigation. This investigation would find that decisions made during the Mission reflect missed

opportunities, blocked or ineffective communication channels, flawed analysis, and ineffective leadership (CAIBR, 170). In particular, the Board was alarmed to find that the Mission Management displayed no interest in understanding a problem and its implications (CAIBR, 170) actually a communication issue. The loss of Columbia was physically caused by the

damage incurred at launch when debris struck the left wing. However, faulty communication was also clearly responsible in failing to prevent the disaster.

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