Failure and Culture

Failure and Culture 1

Strayer University

Developing a Learning Organization

January 26, 2014

According to Smith, the National Aeronautics and Space Administration (NASA) created the

Columbia Accident Investigation Board (CAIB) and it was chaired by Admiral Harold Gehman

(Retired) to investigate the shuttle accident. The CAIB concluded that the shuttle crew died from

blunt trauma and hypoxia (lack of oxygen) after the crew cabin separated from the rest of the

disintegrating shuttle and there was no explosion. The CAIB asked NASA to evaluate two

options for returning the crew safely if the degree of damage had been understood early in the

mission (1) repairing the damage on-orbit and (2) rescuing the crew with another shuttle mission.

However, the repair option would have been logical but it relied on several uncertainties and was

rated as being an high risk and the rescue option was considered challenging, but feasible.

The CAIB recommended that NASA increase the orbiter’s ability to reenter the atmosphere

with minor leading edge damage to the extent possible; develop a better database to understand

the characteristics of Reinforced Carbon-Carbon (RCC) by destructive testing and evaluation; (1)

improve the maintenance of launch pad structures to minimize leaching of zinc primer

onto RCC, (2) obtain sufficient RCC panel spares so maintenance decisions are not subject to

external pressures relating to schedules, costs, or other considerations, (3) develop, validate, and

maintain physics-based computer models to evaluate Thermal Protection System damage from

debris impacts, (4) maintain and update the Modular Auxiliary Data System (MADS) on each

orbiter to include current sensor and data acquisition technologies can reconfigured during flight.

According to Elkekes & Phillips and the text, evaluation in a performance improvement