COLUMBIA SPACE DIASASTER

Nissan Motor Company Ltd.: Building Operational Resiliency

Name of Student
Name of University
Name of Course/Section
Professors Name
Date of Submission

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Description of the system and its working environment

The space shuttle is a part of the Space Transportation System and it comprises of an
orbiter that is similar to an airplane, a large External tank that hold the fuel for the main engines
of the orbiter and two Solid Rocket Boosters. Columbia a bright white coloured space shuttle
roared into the deep blue sky on April 12, 1981 as nations first reusable Space Shuttle. This
Space Shuttle was named after the first American vessel to encircle the globe and it continued the
legacy of intrepid exploration. Columbia Space Shuttle was the heaviest of the NASAs orbiters;
however, it lacked the essential equipments to support the assembly of the international Space
Station. The 28th space mission of Columbia was named as STS-107 and it was planned to
commence on 11th January 2001; however, due to a variety of reasons, the mission was delayed
for two years. On 16th January 2003, finally the Columbia was launched along with its crew of 7
persons. The primary purpose for sending the Space shuttle was to carry out a scientific research.
A research program involving 59 separate investigations was conducted by the crew on this
mission. After the return of the shuttle, some research work required analysis of the data sets and
the specimen; however majority of the data was lost with the orbiter and the crew
After 80sec of the launch, a piece of the foam insulation was parted off from the
propellant tank of the space shuttle which hit the edge of the left wing of the space shuttle. This
foam collision was located by the Camera that centered the launch sequence; however, the
engineers were not able to locate the exact location as well as the extent of damage. Despite the
fact that comparable events took place on three space shuttles, which were launched before
without resulting critical damages, few engineers still believed that any harm to the wing could
lead to catastrophic failures. The concerns of these engineers were not taken into consideration
during the whole period, the Columbia spent in the orbit for the reason that the management of

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NASA presumed that even if the major damage has caused, nothing much can be done to correct
the situation.
Description of the top event
Following the Challenger disaster, Nasa took nearly 32 months prior to it was prepared
and confident enough to launch its next Space Shuttle mission. STS-107 was finally launched in
16th January and it was the 28th flight of Columbia following a delay of more than 2 years. It is
general practice of NASA to observe the launch with the help of tracking cameras and the same
was done following the Columbia launch.

Figure 1 STS-107 being launched from KSC

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After few seconds of the launch of Columbia, it was observed through the cameras that a
large object from the ET collided with the orbiter and caused harmed to the left wing of the
shuttle. It was concluded by the Debris Assessment Team that during the re-entry some localized
heating damage might have occurred. Consequently no significant attention was placed to the
damage observed. After finishing its research mission of 16 days, Columbia began to return to
Earth on the morning of 1st February 2003. Everything was going according to the plan; even the
sensors did not display any signs of problem. However, when the shuttle was located over
California, the observers present on the land noticed the signs of debris. The debris was a result
of superheated air that surrounded the shuttle and was observed over the next 23 seconds by the
observers. The primary sign at Mission Control that something may be turning out wrong was
when four hydraulic driven sensors in the left wing had fizzled. The last correspondence with the
group of STS-107 was a broken reaction at 8:59, and recordings by eyewitnesses on the ground
shot at 9:00 a.m. demonstrated that the Orbiter was deteriorating. At 9:16 a.m. EST, NASA
executed the Contingency Action Plan that had been set up after the Challenger mishap. With
this, the crisis reaction was started, and a trash seek recuperation exertion was begun. At the
point when all was said and done 25,000 individuals from 270 associations were included in the
debris recuperation operations, bringing about the finding of more than 84,900 pounds of debris,
representing only 38 percent of the dry weight of the Orbiter.

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A fault tree diagram

Problem

What

Problem(s)

Lost Columbia/ crew, foam struck wing

When

Date

February 1, 2003

Time

~8:59 AM EST

Different, unusual, unique

Foam strike on ascent

State, city

Cape Canaveral

Facility, site

Columbia (ST-107)

Task being performed

Disintegration upon re-entry

Safety

Loss of 7 astronauts (entire crew)

Vehicle

Total loss of shuttle

Mission

Major impact to shuttle flight schedule

Equipment

Damage from foam strike

Labor, Time

Investigation, clean up

Where

Impact to the Goals

$3,000,000,000

$400,000,000
$3,400,000,000

Frequency

2nd loss of crew & orbiter

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Cause Analysis

Fm o a eD g i rs a i nt i t o Or r b i t e Ls o sf GS a o f a e l t y
s tru c n b ro k e n 7 Im p a c t
k
3

Solutions

No.

Action Item

Cause

Reinforce panels on wing

Hole in left wing

Remove foam pieces from

Foam fell off external tank

external tank

during ascent

Conduct visual of shuttle

Extent of damage unknown

during orbit

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Primary event
Secondary event
Intermediate event
And function
Or function

An event tree diagram

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ah

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10

Cause-and-Effect Diagram
Materials

Management
ynt

Ignored warnings from

engineers

Loss of materials due to

Relaunch urgency

Columbia Space.
Diasater

Still in design phase

Expensive Maintence
andrefittingh

Method

Inadequate communication

Not fail safe

Machine

Failures and their causes which contributed to the Columbia Accident

The causes of the Columbia Space Shuttle Accident were broadly classified into two
types: physical cause and organizational cause. The physical cause of the failure of Columbia on
its return was the breakage in the Thermal Protection System on the leading edge of the left
wing. This breach was caused when a insulating foam that got detached at 81.7 seconds after the
launch from the left bipod ramp section of the External Tank and collided with the wing in the
lower half region of the reinforced carbon-carbon panel. While the Columbia was re-entering the
Earth, the breakage in the Thermal Protection System permitted the air that was superheated to
penetrate via the leading edge insulation. This superheated air caused the aluminum structure of
the left wing to melt, which in turn weakened the entire structure and resulted in loss of control,
failure of the wing and fragmentation of the Orbiter. Since the breakage manifested in the flight
regime, it was impossible for the squad to stay alive. On the other hand, there were few
organizational aspects that resulted in this accident. The organizational causes of the failure of
Columbia are embedded in the history and culture of the Space Shuttle Program. These include

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11

scheduled pressures, fluctuating priorities, mischaracterization of the Shuttle as operational

instead of developmental, subsequent years of resource allocation and the actual comprises that
were needed to attain the approval for the Shuttle. It has been also observed that the development
of the organizational practices as well as cultural traits that were detrimental to safety was
encouraged. These included the initiation of in-formal decision making processes and evolution
of casual chain of command, high dependence on past success measures instead of efficient
engineering practices such conducting various test to comprehend why the systems are not
working as per the requirements, absence of an integrated management across the program
elements and the organizational barriers that stifled professional differences of opinions and
prevented effective communication of safety information.
Similar Catastrophic Events
Similar to the Columbia incident, the United States has suffered from two other space
shuttle accidents that resulted in the fatalities of the crew. The crew of the first Apollo mission on
27th January 1967 lost their lives when the fire was breakout due to electrical arcing in spacecraft
wiring. After this incident, it took nearly 21 months to resume the Apollo flights. Another
similar spaceflight incident took placed on 27th January 1967 when the space shuttle named as
Challenger was exploded after 73 seconds of its launch. This incident in the loss of 7 astronauts
named as Ellison Onizuka, Ronald McNair, Michael Smith, Francis Dick Scobee, Judith Resnik,
Gregory Jarvis and Christa McAuliffe. William Rogers who was a former secretary of the State
formed a commission to investigate the causes of the Challenger accident. The report released by
the commission showed that the climate at site of launch was relative cold that resulted in the
failure of the rubber O-ring in one of the SRBs that allowed the gases to escape leading to a
catastrophic explosion.

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Recommendations for preventing the recurring of the events

According to the board member who investigated the Columbia accident, a good
leadership can direct a culture of adapting new realities. Therefore, the culture of NASA should
be changed and the following recommendations should be adopted.

Commence a program specifically designed to increase the ability of the Orbiter to

sustain diminutive debris damage by employing measures such as enhanced acreage and

impact-resistant Reinforced Carbon-Carbon tiles.

A comprehensive inspection plan should be developed and implemented to determine the
structural integrity of all Reinforced Carbon-Carbon system components. The benefit of

non-description technology must be taken into consideration while designing this plan.
Increase the ability of the Orbiter to the extent possible so that it can re-enter Earths

atmosphere with diminutive damage to the leading edge structural sub-system

Endow with the capacity to attain and downlink high-resolution images of the External

Tank after it get detached.

It is essential to maintain and update the sensor suite as well as the Modular Auxiliary
Data System instrumentation on each Orbiter to include current sensor and data

acquisition technologies.
Implement and sustain a shuttle flight schedule that is in line with the resources available.
Even though schedule deadlines are a significant management tool, it is essential to
evaluate those deadlines for ensuring that any supplementary risk incurred to meet the

schedule I identified, comprehended and within the acceptance limit

Design and implement an extensive training programs
An independent Technical Engineering Authority should be established that is responsible
for technical requirements and all waivers to them as well as construct a systematic,
disciplined approach to identify, analyze and control the hazards all through the lifecycle
of the shuttle system

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Design an extensive plan for establishing, defining, implementing and transitioning an

independent safety programs, Technical Engineering Authority and a recognized Space
Shuttle Integration Office

Management Issues Raised

The Columbia space disaster raised several management issues among which few are
listed below:

NASA was unable to comprehend the mechanisms that led to foam loss on nearly all the

flights from larger areas of foam coverage

No certified non-destructive evaluation techniques are present to find out the

characteristics of the foam prior to the flight.

Nearly 38 % of the missions lacked adequate imagery to spot the loss of foam
The inspection techniques currently being employed are not sufficient to evaluate the

structural integrity of the RCC components.

The long-range camera assets that are presently deployed on Eastern Range and Kennedy
Space Center do not provide best possible engineering data during the departure of the

Space Shuttle.
Lack of high speed and high resolution cameras hampered the assessment of the impact

of STS-107 debris
It was observed that NASA did not followed its own defined rules and requirements on

foam shedding.
Even though the team clearly reported its plans and the final outcomes to the Mission

management, no Mission manager took the responsibility of the actions of the team.
The members of the team never realized that the decision of the management no in favor

of seeking imagery was not intended as a final or direct response to their request.
The damage assessments entailed several substantial uncertainties because of a range of
reasons including flawed engineering judgments, inadequate utilization of assessment
tools, improper imagery, communication breakdowns and management failures

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There were lapses in the communication as well as leadership that made it complicated
for the engineers to understand the decisions and raise the concerns. Management failed
to actively engage in the analysis of potential damage caused by the foam strike.