The Space Shuttle Columbia catastrophe occurred on 1 February 2003, when the shuttle descending through the atmosphere had a piece of protective foam break off and damage the heat-resisting plating of the wing, resulting in the shuttle losing control and breaking apart. All 7 crew members perished in the crash. Although the initial statements by the commission claimed that “the foam did it,” the safety culture at NASA was deemed to be a major contributing factor to the tragedy.
The blind spots in NASA’s safety culture, according to the report, have been rooted in the system since Challenger, and have not been properly addressed despite 17 years between crashes. One of the major issues included the absence of attention to the design compromises required to get the vehicle approved. NASA frequently placed scheduling pressures and various priorities ahead of human safety and claimed the project to be operational rather than in development to answer various resource constraints. In order words, NASA placed the running of the project over the safety of individuals flying it. The board concluded that the lessons of the Challenger disasters were either not implemented or forgotten. Risk management procedures did not change – evidence-based practices were ignored and trends were not analyzed. In addition, the briefings within the organization often downplayed concerns and overlooked vital issues of the Shuttle project.
The disaster was called “Challenger all over again” because the insights brought up by the previous commission were largely ignored and abandoned. There were many signals from the reporting systems that could have prevented the tragedy from occurring. The report highlights three specific groups of issues that often occur in crashes like this one, indicating a myriad of missing signals, imagery requests that were not followed through, and the oblivious nature of the mission control team during the incident.
Some examples of poor communication and failure to obtain vital information include the failure of answering queries of engineers about the damaged wing, as well as the refusal to utilize spy satellite imagery to ascertain the damage before re-entry was approved. The former incident notes a 4-day delay between the inquiry and response, showcasing how slow vital information travels within NASA. The latter may be an indication of inter-organizational rivalry or simply a failure to care, expecting everything to be alright regardless. The report highlights that NASA showed virtually zero interest in understanding what could possibly happen and to act upon the information to prevent the tragedy. NASA could have facilitated expertise from their own employees as well as from other government agencies (such as the department of defense). Not only did they fail to do so, but also showed little interest in trying to understand what caused the debris strike.
In essence, NASA neglected to put the safety of the crew first. The videos captured 4 minutes prior to atmospheric re-entry also showcase the blatant disregard for safety protocols both in the design and the implementation of protection – some of the crew were not wearing helmets and protective gloves and were not properly fastened to their seats. Although it would not have made much difference in this incident, it could have caused issues under different circumstances. To summarize, NASA had several reporting systems readily available, and some engineers were concerned about the potential damage to the wing but refused the assistance of the ministry of defense to receive proper imagery and information, prompting a lack of action to repair and prevent the foam break-off.