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National Aeronautics and Space Administration


On January 16, 2003, there was a launching of the space shuttle Columbia by the National Aeronautics and Space Administration (NASA) on its STS-107 mission. The space shuttle Columbia broke apart on February 1, 2003 while getting back to the atmosphere. All the seven crew members who were on board died in the accident. The astronauts who died were Commander Rick Husband, Mission Specialists Michael P. Anderson, David M. Brown, Kalpana Chawla, Laurel Clark, Pilot William McCool, and Ilan Ramon, a payload specialist (Ferraris and Carveth). The disaster took place minutes after the shuttle was planned to land at the Kennedy Space Center in Florida. NASA came up to the Columbia Accident Investigation Board (CIAB), which was presided over by Adm. (Ret.) Harold Gehman, to make an investigation of the accident. On August 26, 2003, the Board released its report. The report revealed that the accident was probably not an abnormal, random event, but it was embedded to some degree in NASA’s history and culture of the human space flight program.

Problem Statement

NASA overlooked the recommendations given after the Challenger’s disaster. This resulted in the Columbia’s disaster. There were also various organizational factors that resulted in further flaws in the Columbia Shuttle Program. These factors included organizational cultures such as improper channeling of information. They also included political and budgetary compromises, considerations and changing priorities over the life of the shuttle program. Sound engineering practices were ignored. Various recommendations were given in the reports presented by the Boards. They included, among others, proper arrangement of information channeling and taking measures to save the crew on board.


One of the revelations of the report released by Columbia Accident Investigation Board (CIAB) indicated that there were organizational factors that led to the accident. The board made conclusions that the accident was entrenched in the Space Shuttle Program’s history and culture. That included the original compromises that were needed to gain approval for the shuttle, successive years of resource constraints and schedule pressures. There was also a lack of the national vision for human space flight and mischaracterization of the shuttle as operational instead of developmental.

The cultural traits and organizational practices harmful to safety were permitted to develop, comprising reliance on previous success as an alternative for sound engineering practices. This also included organizational barriers that hindered effective exchange of serious safety information. This stifled differences in professional ideologies and lack of cohesive management across program features, the development of an informal command chain, and the process of decision making that operated outside the rules of the organization (Ferraris and Carveth).

The Board also concluded that the shuttle crew died from the lack of oxygen after the crew cabin disconnected from the rest of the disintegrating shuttle. This means that the crew cabin itself disintegrated and thus there was no explosion. The Board requested NASA to make an evaluation of two options of returning the crew securely if the damage level had been comprehended early in the mission. One of the options was the repair option, which although was found logistically viable and had many uncertainties that were rated as high risk by NASA. This also included the uncertain resiliency of the repair by the use of available materials and the expected high risk of causing an additional damage to the orbiter. The second option was the rescue option which was considered feasible, though challenging. Rescue would have been viable if the NASA management had acted sooner. For instance, they could have arranged an emergency spacewalk to try to repair the left wing thermal protection.

There were various organizational barriers that resulted in the inhibition of effective communication of serious safety information. This furthered the development of diversity in professional ideologies. This also resulted in the lack of a unified management across the program features and the development of an informal command chain and decision-making procedure operating without the laws of the institution.

These factors critically affected the way the NASA institution was run and thus was bound to experience problems. The alternatives to this problem would include the legal requisition of a bureaucratic means of tendering and manufacture. Proper planning would also help in attaining a smooth flow of the processes of NASA. With organizational order, policies and management, the institution would have run properly without caving in to external pressures and resource constraints. This is because NASA would have already had a clearly laid down plan and budget, and weighed the risks against the benefits (Ferraris and Carveth).

Most important to the existence and progress of the organization, there ought to have been internal unity and order. The development of a formal chain of command and organizational management would have assisted NASA to overcome such issues as the ineffective conveyance of information, which would have resulted in a more positive way of dealing with the inherent holding of diverse professional ideologies among the personnel. The result of this would be the unified commitment towards the project (Starbuck and Farjoun).

The limitation to this is that any organization such as NASA is dependent on the views of its stakeholders. There is, therefore, not much what an organization can do against its stakeholders as that would defeat the main object of its formation. It is thus recommended that organizations do their best to balance their own interests and those of the stakeholders (Denhardt, Denhardt and Blanc).

The Board also came up with findings that a vibrant safety culture may have been an effective safety organization by encouraging the relevant personnel to deal with the issue from its onset. Investigation revealed that the crew was not wearing safety gloves, and one of them did not wear a helmet. NASA had knowledge of the foam strikes. This is the believed and confirmed cause of the Thermal Protection System breach that occurred in the left wing’s leading edge. The insulating foam piece was said to have detached from the external tank’s bipod ramp on the left, striking the wing found in the lower part of the strengthened panel of carbon-carbon. This led to a series of other breaches and malfunctions that, in turn, resulted in the overriding of the set systems and ultimately in the loss of control, the general failure, and disintegration of the orbiter.

NASA had overlooked the risks associated with the loss of foam. NASA knew about the problem linked with the foam but apparently chose to manage it. The foam problem was already in the reports of NASA’s investigations on the Challenger’s disaster. This problem was then regarded as an “Inflight Anomaly”. This meant that the problem required to be fixed and be proved to pose no dangers to the crew’s safety or to the vehicle itself before the next space flight. Despite having been so branded, the source of the foam loss was never fixed, and neither was a long-lasting amendment made. NASA should have taken the necessary measures to fix the foam flaw (Starbuck and Farjoun).

NASA, in its space exploration quest, seeks to ensure that the safety of a spacecraft and its crew is put as a priority. This is also in tandem with its aim of attaining high-quality results and furtherance of its space explorative missions. Therefore, it would appear impracticable and unfounded if NASA sent its personnel on a mission in a ‘flawed’ spacecraft. NASA, by virtue of sending its personnel out into space, must have deemed the Columbia to be fit and safe for that particular task (Ferraris and Carveth).

NASA, however, bore the ultimate responsibility for ensuring that the spacecraft and crew were safe. This means that NASA ought to have ensured that all the recommended and foreseen flaws were fixed before any further space missions. In this way, it is quite insensible that NASA let their spacecraft be used while still bearing the same risks as demonstrated and reported before. This was since the disaster of the Challenger (Denhardt, Denhardt and Blanc).

Making sure that the flaw, that is the susceptibility to foam loss, was fixed would have helped NASA in achieving the mission. This, in turn, would have resulted in a secure return of the crew. The restraint to this, however, is that NASA would not have been in an actual position to think this was in line with that particular mission. The Columbia, just like any other missions, was considered on its own merits and specific conditions.


Various reports indicated different causes of the accident. Some of them included organizational flaws such as lack of proper channeling of safety information and improper use of organizational autonomy. Various Boards were also set up to investigate the causes of the accident and make suggestions of how it could have been prevented. Some of their recommendations included rescue and repair options to save the crew members.

A rescue mission may not have been possible because of the time needed for the preparation of a shuttle for a launch and also the limited power, air and water required by an orbiting shuttle. There was uncertain resiliency of the repair by use of the available materials and the expected high risk of causing an additional damage to the orbiter. Therefore, systematic rescue of the crew would not have been possible, thus making this solution not effective. However, rescue would have been viable if the NASA management had acted sooner. For instance, they could have arranged for an emergency spacewalk to try to repair the left wing thermal protection.

The other solution that was recommended is the use of the effective vibrant safety culture by encouraging the relevant personnel to deal with the issue from its onset. As indicated in the reports, the crew was not wearing safety gloves, and one of them did not have a helmet on. Also, future space crew survival system ought not to depend on manual activation for the protection of the crew.

NASA should also take appropriate management measures such as ensuring proper communication channels, especially transfer of safety information to prevent future accidents. It should not depend on past successes but deal with each mechanical situation separately. NASA should also make a decision independently, for the safety of the crew members and the success of its missions.


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