A Critical Analysis of The Challenger and Columbia Incidents

Introduction

The sky is not the limit for safety amongst space-faring organizations. As exemplified through the Challenger and Columbia failures, in the early days of NASA the operational requirements of this organization far outweighed their safety priorities. Although they believed their safety framework was satisfactory, retrospective analysis has shown this did not translate into an effective safety culture within the organization. This essay will critically analyze the systemic factors leading to these two disasters and thenceforth demonstrate how a modern integrated safety management system (ISMS) if effectively implemented, could have prevented these losses. Critical analysis will initially focus on the technical chain of the accident sequence, however, soon proceed beyond this into the root organizational environment that enabled this to occur. By comparing this organizational snapshot against that of an ideal generative safety culture, significant shortfalls will be identified which might have negated these tragedies.

Challenger

The Challenger accident occurred on January 28, 1986. A failure of the aft field joint on the shuttle’s solid rocket booster (SRB) ultimately resulted in an explosion that destroyed both the booster ensemble and the shuttle, killing all seven crew members. It was determined that the launch vehicle was exposed to three abnormally cold nights, resulting in the thermal expansion of the joint’s O-rings and consequently making them brittle. In-flight this allowed hot gases to escape, pierce the primary fuel tank and subsequently cause the fatal explosion.

Although this technical failure was the immediate cause of the accident, it was merely the end result of an extensive chain of organizational safety failures which allowed “an incremental descent into poor judgment, supported by a culture of high-risk technology”. Vaughan argues that NASA’s cultural environment was plagued by normalization of deviance and evidence of managerial neglect. For example, concerns were raised by Thiokol, manufacturer of the SRBs, the day prior to the launch specifically about previously observed ‘significant blow-by’ effect caused by cold temperatures impacting SRB O-rings. Despite the predicted morning launch temperatures being approximately twenty degrees lower than those at which problems were already detected, Thiokol’s position was challenged during two teleconferences and eventually withdrawn due to the fact that there were no Launch Commit Criteria for SRB joint temperature. This example was cited in the Presidential Report and investigations noted that no safety representative or reliability and quality assurance engineer was present. This means that not only despite clearly disregarding the indication of safety risks but it was also done so without the perception of breaking any organizational safety or policy requirements. Of the five communication or organizational failures stated by Mr. Aldrich, Space Shuttle Program Manager, four related directly to the safety program. They included lackluster reporting requirements, poor trend analysis, and misunderstanding of critical safety requirements. In the case of the O-ring failure it was even suggested, prior to the disaster, that the fact nothing had happened previously meant that the risk was already mitigated. Such glaring holes in NASA safety management indicate the likelihood that a systemic failure, not a technical one, was the root cause and the Challenger incident was in fact ‘an organizational failure of tragic proportion’.

Columbia

In a high-performance, high-risk organization it can be expected that identified mistakes of similar nature are not repeated. In the case of Columbia, this scarcely holds true in the technical domain and falls catastrophically flat in terms of managerial safety considerations. Separated by only seventeen years, many lessons learned from Challenger appeared to have already been forgotten. Exactly as in the Challengers' case, the cause of this disaster was documented on numerous occasions prior to and during, yet once again risk was downplayed to achieve operational outcomes. Upon re-entry, Columbia suffered a critical integrity failure in the left wing resulting in swift loss of control, wing failure, and the rapid breakup of the orbiter. It was determined that a large piece of foam from the external tank-shuttle attachment had broken off and struck the leading edge of the left wing during take-off. Despite being light-weight, the velocities involved meant the impact force was able to disrupt the integrity of one of the reinforced Carbon-Carbon plates which covered this edge. Thus, the superheated air of re-entry was able to enter the wing and ultimately destroy the orbiter. The relationship between these two disasters was so strikingly similar that board member and astronaut Sally Ride stated, “I think I’m hearing an echo here”.

At the time of this incident, the broken safety culture of NASA displayed chronic overconfidence, groupthink, and tolerance of abnormal events. Coupled with the oppressive intimidation of concerned engineers, a ‘silent safety culture' was created and maintained. Despite the cultural reforms promised as a result of stark criticism of the Challenger accident, the organization was highly resistant to change and slipped back into its traditional cultural norms. It is this degeneration of cultural improvement that likely allowed NASA to repeat the same mistakes of their past. Increasing budget cuts and decreasing political gains in the build-up to the Columbia accident served to amplify performance pressure, the organization even adopted the philosophy “Faster, Better, Cheaper”. However, in an organization still bolstered by the successes of the Apollo missions and for the most part, whether by luck or otherwise, the shuttle program, it is understandable to see how past success could lead the development of this pseudo-safety culture. Regardless, it is still confounding that the dangers of foam strikes were able to be disregarded so many times and not be further examined until catastrophe had occurred.

Preventative Impact of an Effective ISMS

The introduction of an integrated safety management system (ISMS) within NASA prior to either of the previously discussed failures would likely have drastically minimized losses, if not prevented these accidents entirely. An effective ISMS blends safety-oriented work practices, beliefs, attitudes, and procedures seamlessly into all aspects of everyday operation. A common criticism is that ‘NASA’s culture is one of dedication to mission’. Nonetheless, this is not an inherently negative bias provided that the organization understands that safety is a key enabler of critical mission capability. NASA’s safety framework, despite being excellent in theory, appeared to have been notionally ignored and NASA as an organization had ‘simply stopped following and enforcing its own rules. The four key components of an SMS are safety policy and objectives, risk management, assurance, and promotion. NASA as an organization failed holistically across all of these despite having extensive mechanisms in place which fore fill many of the key requirements of the aforementioned components. NASA had in place a safety legislative framework, safety responsibilities and accountabilities, accident investigation, enforcement policies, data collection and analysis, oversight, and agreement on safety performance. What NASA lacked at the most fundamental level was an effective safety culture, the proponents of which are flexible, learning, informed, just, and reporting sub-cultures. These sub-cultures are intrinsically linked to creating a feedback loop which enhances a safety culture.

As demonstrated in the Challenger and Columbia incidents, it has been directly evidenced that poor safety culture contributed significantly in both situations. The ability to adapt decision-informing processes in unusual situations is a key enabler of high-tempo safety reporting. NASA failed in adaptability, demonstrating rigidity in launch timings and re-entry plans through the low-level quashing of Thiokols O-ring concerns and the stringent data requirements that inhibited information on Columbia’s debris danger from being passed up the chain. Indicators of a learning culture are open communication, management support, employee empowerment, and collaboration. NASA demonstrated its lack of learning culture through the failure to learn from the mistakes of Challenger and its ineffectual reforms. A just culture is one which discourages blaming of individuals for honest mistakes, thus encouraging employees to speak up about them. In reference to just culture, NASA arguably displayed too much tolerance for mistakes and risky decisions. Coupled with an anti-reporting subculture that oppressed the raising of concerns by engineers, this actually worsened the safety culture of the organization. As exemplified by the assumptive decision-making regarding foam strike to Columbia’s RCC panels, NASA had an information culture that was content to operate with uncertainties. This may have proved beneficial in the uncertain days of the Apollo missions, yet was a historical remnant that had no place in the more contemporary shuttle program. Thus, despite a tolerable safety framework, the lacking of proponents to an effective safety culture crippled NASA’s safety organization.

Conclusion

Had an effective ISMS been introduced in NASA prior to these incidents, it is likely that the chain of events that led to both Challenger's and Columbia’s demise would have been stopped long before either voyage reached its launch date. In an ideal ISMS, concerns regarding both O-rings and foam strike would have been raised, acknowledged, considered, and rectified years prior to either incident. Chien coherently argues that although difficult to accept, ‘once the foam hit Columbia’s wing the crew was doomed’ and that there simply wasn’t enough information to conclusively determine that Columbia was fatally damaged. This view, however, as demonstrated in this essay, is fundamentally short-sighted in that it considers only what was, and not what should have existed in terms of NASA's safety culture and effective ISMS.

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