The interaction between technological challenges, uncertainty, and cultural components culminated within the STS-107 Columbia Area Shuttle catastrophe on February 1, 2003. Seven astronauts’ lives had been misplaced because the Columbia disintegrated over Texas upon re-entry in what President George W. Bush referred to as a “nice disappointment to our nation.”[1]

Technological Challenges and Uncertainty[edit]

Just like the Challenger shuttle catastrophe earlier than it, the Columbia area shuttle incident was attributable to a seemingly insignificant technological flaw that proved to be extraordinarily consequential for the seven passengers aboard the shuttle in the course of the return flight to Earth. Roughly sixty seconds after liftoff, a bit of froth insulation from the Exterior Tank struck the high-strength thermal tile on the forefront of the left shuttle wing, creating a big gash within the tile floor.[2] Overseas object harm and tile harm had been quite common in earlier missions, however the extent of this tile harm was posthumously decided to be unprecedented. Through the the rest of the flight, engineers and managers at NASA investigated the issue however weren’t utterly knowledgeable of the extent of injury.[3] This uncertainty brought on the Particles Evaluation Staff, the group answerable for analyzing affect harm on the shuttle, and Mission Management to make improper judgments on the security of the flight.

The Particles Evaluation Staff, headed by Rodney Rocha, spent a number of days watching the video proof of the affect and performing case evaluation as a way to decide the potential penalties of the particles strike. To conduct this evaluation, engineers used a mannequin to establish tile penetration depth after affect; it was later discovered that this mannequin was not acceptable to be used on this context. Nonetheless, the mannequin predicted full tile penetration, however the engineers discounted these outcomes primarily based on their earlier information of tile harm.[3] The assumptions on this evaluation, in addition to the danger or uncertainty related to the outcomes of the analyses, weren’t made public inside NASA, and no effort was made to acquire these estimates. In the long run, the engineers decided that prime decision imaging from the Division of Protection could be useful and mandatory in making any conclusive choices on the security of the mission. The group was not granted these pictures after three successive tries. Thus, the group was left solely with a considerable amount of uncertainty of their unique fashions and experiential studying from earlier shuttle missions.[3]

Cultural Challenges[edit]

Uncertainty and failed communication plagued the Columbia mission. Through the flight, engineers’ and managers’ opinions of the results of the tile harm diverse broadly, and this led to confusion and an obfuscation of the complexity of the issue. Within the years previous to this flight, NASA management started stressing effectivity over security in what turned an deterioration of the preliminary emphases positioned on security and well being. The mixed results of complexity and turpitude resulted in a dire scenario for the mission.

Skilled Tradition[edit]

For a few years earlier than the Columbia catastrophe, NASA operated below the security slogan of “If it isn’t secure, say so.” In April of 1992, Dan Goldin was appointed because the chief Administrator of NASA. He held this place till November of 2001, and NASA underwent many important modifications throughout his tenure. Stress from the federal authorities on NASA to chop prices pushed Goldin to introduce a brand new tradition.[4] In a speech to his workers throughout his first 12 months, Goldin challenged them by asking, “Inform us how we are able to implement our missions in a less expensive method. How can we do every part higher, sooner, cheaper, with out compromising security?”[5] This perspective threatened the success of “If it isn’t secure, say so.”

The brand new, “higher, sooner, cheaper” (FBC) mantra was criticized by the media and members of congress for its potential to neglect security in favor of upper danger, decrease price methods. Senator Kay Hutchinson (R-Texas) bluntly acknowledged, “FBC must be thrown within the waste basket.”[6] Goldin repeatedly rejected such criticism, telling an viewers on the Jet Propulsion Laboratory in 1994, “After I ask for the price range to be lower, I am informed it will affect security on the Area Shuttle … I believe that is a bunch of crap.” Nonetheless, prices had been lower considerably within the space of security assurance, as a result of notion within the 1980s and early 1990s that NASA’s security packages had been overly redundant and expensive.[3] Criticism of Goldin’s administration methods continued all through the 1990s. Between 1996 and 2000, six out of NASA’s twenty-five complete launched missions failed, confirming the fears of the critics. These failures included the lack of 4 spacecrafts.[3] Though no lives had been misplaced, it’s clear that mission high quality was being sacrificed in favor of upper output and decrease price.

In March of 2000, Goldin accepted accountability for the current failures, telling workers and reporters, “I requested these folks to do extremely powerful issues, to push the boundaries… and we hit a boundary. They did terrific issues and I pushed it too exhausting.”[7] NASA within the 1990s failed to realize all three of Goldin’s targets. Although mission frequency elevated whereas working prices had been lower, mission failures indicated a neglect of the “higher” prong of his mantra. The “higher, sooner, cheaper” perspective could also be intrinsically flawed and harmful. It shares similarities with a generally mentioned situation in public healthcare immediately. The three most essential targets or desired qualities of healthcare are high quality, low price, and accessibility. These three qualities lie on the vertices of the “iron triangle of healthcare.” When the directors in a healthcare system try to enhance one in every of these attributes, there are all the time sacrifices made in both one or each of the others. By shifting in the direction of one vertex of the triangle, the system distances itself from a minimum of one of many others. NASA within the 1990s was subjected to an identical iron triangle, with higher, sooner, and cheaper on the vertices, because of Dan Goldin’s administration. Sadly, the company appeared to perform furthest from the “higher” vertex, favoring low-cost, excessive amount operation as a substitute.

Organizational Construction[edit]

Technical points had been a significant motive for the crash, however they weren’t the one motive. The tradition at NASA within the early 2000s was lower than best, and the command construction of the company lended itself to flawed communication and organizational silence. Following the catastrophe, a lot focus was positioned on Rodney Rocha and his resolution to not ship an e mail that expressed his concern. Whereas this was an element within the crash, the issue was a lot larger than him–it concerned all the organizational construction of NASA.

Issues at NASA[edit]

At NASA, particularly a decade in the past, there was a single chain of command in place. Engineers may solely report back to their group managers, who would then report back to their venture managers. This led to 2 main issues:

  1. Data was diluted because it went up the chain—it may very well be distorted, silenced, or misplaced relying on the opinion of the supervisor relaying the knowledge
  2. The engineers had no actual energy themselves—they’d report back to their superiors to get something completed.

Results on Columbia Mission[edit]

Columbia lifting off on its last mission.

So what went unsuitable in the course of the Columbia mission? The primary drawback was with the chain of command. There have been three foremost teams concerned within the evaluation of the froth strike:

  1. Particles Evaluation Staff—a bunch of engineers headed by Rodney Rocha and Pam Madera that was created after the froth strike to evaluate the harm
  2. Mission Analysis Room– the group tasked with evaluating all the flight from an engineering perspective; liaison between the Particles Evaluation Staff and the Mission Administration Staff
  3. Mission Administration Staff– the group, headed by Linda Ham, that was answerable for the making the important thing choices all through the mission [8]

After analyzing the preliminary pictures of the froth collision, the engineers of the Particles Evaluation Staff decided that they wanted extra pictures; they couldn’t make correct calculations and assessments with out extra data. As co-chair of the Particles Evaluation Staff, Rodney Rocha had severe doubts in regards to the security of the flight, and notified a number of others about his issues. Nonetheless, with out adequate information to show that his issues had been legit, he skilled problem in validating his fears to his superiors. His managers, together with Linda Ham and Ron Dittemore, Shuttle Program Supervisor, discovered earlier shuttle affect harm historical past to be a extra compelling benchmark to evaluate the severity of the present drawback at hand[3]. Moreover, with the frequency with which tile harm occurred previously, these managers turned normalized to the scenario and rapidly deemed this foam strike an “in-family situation.” This meant that it was one thing NASA had seen earlier than and knew the way to cope with, and they didn’t take into account it to be a urgent situation. The tile harm was subsequently categorised a upkeep situation slightly than a “security of flight” situation. The difficulty was dismissed by program leaders, and the flight continued with out restore to the vessel[3].

Engineers within the Particles Evaluation Staff did not have the facility themselves to demand images–they needed to get permission from their superiors. And when the Mission Administration Staff confirmed little curiosity in serving to them, Rocha tried to get pictures by way of casual chains of command, requests had been denied for failing to undergo the correct channels. The engineers had been confused by these choices[9], however as a result of administration construction at NASA, they had been left with no place to show.

Issues could have turned out otherwise if Rocha had despatched an e mail he drafted voicing his issues in regards to the mission. On this e mail, he outlined his issues with the selections being made by administration and harassed the necessity for extra pictures.[10] However Rocha did not ship the e-mail as a result of he did not need to bounce the chain of command. At NASA, the boss had the ultimate say; since he’d introduced this issues to his boss, he referred to administration’s judgment of the case. Moreover, whereas engineers packed the room in the course of the Mission Analysis Room presentation to the Mission Administration Staff in regards to the situation, not a single one spoke up when the presenter, Don McCormack, mentioned there was no safety-of-flight concern. Not one of the engineers needed to lose their jobs by talking out towards their superiors.[8] Thus, this single chain of command was a significant contributing issue within the Columbia catastrophe.

Security Reporting System[edit]

NASAs implementation of its “If it isn’t secure, say so” mantra includes a posh sequence of reporting steps. An worker who turns into conscious of a security danger is required to abide by the NASA Security/Hazard Reporting Hierarchy. These pointers instruct the worker to first report the difficulty to their instant supervisor. They include a collection of difficult contingencies relying on whether or not or not the difficulty is resolved at every step. The system requires that the worker progress up by means of the chain of command, sustaining private accountability for reporting the issue till it’s resolved.

This method is contrasted by the Aviation Security Reporting System (ASRS), which permits airline workers to report questions of safety on to a central company. The system’s house web page incorporates a hyperlink to an nameless report kind, which may be filed electronically. The worker has the choice to supply both contact data in case questions come up or utterly anonymize their report.

NASA’s system requires {that a} reporter preserve private accountability, thus doubtlessly leading to a sacrifice of social capital within the office. The method itself could dissuade an worker from really reporting a problem. Nonetheless, the ASRS permits reporters to take care of anonymity, encouraging open reporting of all potential issues.

DuPont Case Examine[edit]

Though there are some who blame Rodney Rocha for not voicing his qualms in regards to the foam hit to forestall the Columbia catastrophe, it’s clear that there have been many different components concerned on this case {of professional} ethics. This begs the query of whether or not the group and tradition of an organization can have an effect on the selections made and the moral guidelines adopted by professionals. One different case research helps to make clear the issues at NASA in 2003 and lends some justification to Rocha’s final resolution to stay quiet.

Pierre S. du Pont[edit]

Pierre S. du Pont was the president of chemical engineering firm, DuPont, from 1915 to 1919. In these years, he developed a novel administration construction that challenged the normal mannequin of firm tradition and group at DuPont. With this contemporary system, rationality and effectivity had been most popular over custom. This mannequin was later termed rational administration. As president, du Pont was influenced by the concepts of the Enlightenment, which sought to advertise reality by way of sincere and open debate. Pierre du Pont hoped to use these beliefs and trendy administration practices to his household’s firm.Walter S. Carpenter was the president of DuPont from 1940 to 1948, and in his time there, he additional promoted this concept of rational administration. Beneath the management of those people and presidents to observe, DuPont developed into the world’s third largest chemical firm serving 16 totally different industries starting from agriculture to well being care and medication.[11]

Rational Administration[edit]

At its core, the mannequin of rational administration emphasised that good concepts slightly than private empires are the important thing to continued success.[12] This required leaders and managers to ask for, and in reality encourage, constructive criticism from workers. In essence, this created a tradition throughout the firm that promoted “satan’s advocates” at each stage of group. This ensured that issues had been all the time examined from a spread of views, and that the chain of reasoning was all the time logical and constant. By way of the event of this working surroundings, any concepts or issues at DuPont may get a good listening to, even when senior managers didn’t favor them.

Organizational Construction[edit]

As DuPont grew, the corporate additionally carried out a novel organizational method to help their administration beliefs. Every time new divisions or departments had been added, the organizational construction was altered such that there have been semi-autonomous working departments, every with its personal manufacturing, gross sales, and analysis divisions. Every division’s common supervisor was held accountable to the Govt Committee for the division’s efficiency.[13] This flattened hierarchy of group labored properly with the present tradition of constructive criticism. DuPont was a pioneer in this sort of enterprise group, which was quickly copied by firms around the globe. DuPont is now thought of the most effective EHS organizations in business, and their structural group, together with a tradition that believes adverse suggestions is on the coronary heart of sound decision-making, has contributed to this success.[14]


Instantly following the crash of the Columbia, many NASA executives and workers confronted directed criticism for his or her actions or inactions, as within the case of Rodney Rocha. Though the people concerned within the chain of command and decision-making course of actually affected the tragic end result of this case, there have been two main flaws inside NASA on the time that performed a a crucial function in shaping their choices. First, NASA was embedded in a tradition that inspired effectivity on the expense of dissent and second, its organizational hierarchy made dissent from decrease ranks exceedingly troublesome. Thus, though Rodney Rocha was blamed for his function as a person skilled confronted with a troublesome resolution, we suggest that the cultural and hierarchical surroundings at NASA was the main contributor to this tragedy.


  1. [1], Bush, G. W. (2003, February 1). Area shuttle Columbia tragedy speech to the nation. Tackle introduced on the White Home Cupboard Room.
  2. [2], Dunn, M. (2003, February 1). Columbia’s issues started on left wing. Retrieved Could 6, 2012, from The Baltimore Solar web site:
  3. abcdefg [3], Gehrman, H. W. Nationwide Aeronautics and Area Administration, (2003). Columbia accident investigation board report. Washington, D.C.: Authorities Printing Workplace.
  4. [4], Lambright, Henry (2007). Main Change at NASA: The case of Dan Goldin. Area Coverage Vol. 29(1) 33.43.
  5. [5], Mars Program Impartial Evaluation Staff (2000). Mars Program Impartial Evaluation Staff Report.
  6. [6], Cowing, Keith (2003). Farewell to Sooner-Higher-Cheaper. SpaceRef.
  7. [7], Goldin D. Remarks, at Jet Propulsion Laboratory, March 29, 2000,, March 29, 2000.
  8. ab [8], Marsen, S. (n.d.). Evaluation of case research.
  9. [9], Rocha, R. (2011, January 27). Unintended case research of organizational silence & communication breakdown: Shuttle Columbia, mission STS-107. [PDF Document]
  10. [10] Rocha, R. (2003, January 22). RE: STS-107 wing particles affect, request for outdoor photo-imaging assist.
  11. DuPont.
  12. [11], Smith, John. DuPont: The Enlightened Group.
  13. DuPont: The Enlightened Group
  14. [12], MacLean, Richard. (2004). EHS Organizational High quality: A DuPont Case Examine. Environmental High quality Administration.

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