Human Factors Quiz

The Columbia Space Shuttle Disaster: Causes and Organizational Failures

• On February 1, 2003, the space shuttle Columbia disintegrated during re-entry into the Earth's atmosphere, resulting in the loss of its seven-member crew.
• A piece of insulating foam had struck the leading edge of Columbia's left wing during launch, causing damage that ultimately led to the disaster.
• NASA management failed to perceive the significance of the damage and did not inspect the thermal protection system or make contingency plans.
• Engineers who voiced concerns were marginalized, and dissenting views were often ignored.
• NASA's culture and organizational structure were found to be as responsible for the disaster as the foam strike.
• The workforce was reduced by 25%, leading to a skill imbalance and increased workload that impacted operations and safety.
• Discussions about the damage to Columbia often revolved around the fact that previous strikes had never been classified as flight safety issues, leading to missed opportunities to address the problem.
• The pressure to meet an increasingly ambitious launch schedule, particularly the delivery of a section of the International Space Station, resulted in a culture of accepting more and more risk to stay on schedule, leading to a gradual degradation in safety.
• The Challenger disaster in 1986 was caused by similar engineering, organizational, and cultural deficiencies.
• High-reliability organizations prioritize both technical and safety functions equally with schedule and cost functions.
• The investigation reports, including the Columbia Accident Investigation Board and the Roger's Commission, provide comprehensive discussions of organizational and management issues leading to the disaster.
• Hindsight bias should be avoided in analyzing the disaster as it can overlook similar issues in other organizations.