The Role of RCA in the Space

Shuttle Columbia Investigation

Presented by:
Robert J. Latino
Sr. VP Strategic Development
Reliability Center, Inc.
www.reliability.com

Presentation Basis
The presentation was developed to demonstrate the
deductive logic thought process involved in the
application of Root Cause Analysis as applied by
Reliability Center, Inc. (RCI).
All verifications presented are based on literature
available through the public domain sources such
NASA, the Columbia Accident Investigation Board
(CAIB) Report, reputable newspaper articles and
associated websites.
RCI does not claim to have any information that
further validates or disproves these sources claims.
The sole purpose of this presentation is for educational
purposes on the topic of Root Cause Analysis.

The Day of
Launch
January 16, 2003
10:39 a.m.

The Launch of Columbia - 1

Debris Impact At Some 81
Seconds Into Launch

The Launch of Columbia - 2

The Launch of Columbia - 3

Originally Estimated Area of Foam Impact

Columbias Thermal Insulation

Orbiter Wing Carbon Panels

More Likely Area of

Impact

Orbiter Wing Front View

Orbiter Wing Bottom View

Re-Entry Heating and Attitude

Left Wing Sensor Triggering Sequence

The Debris Field Path

Gathering Evidence - Recovery

Gathering Evidence - Recovery

Gathering Evidence - Recovery

Notable Quotes
the Atlantis incident should have put NASA on high alert about
wing damage.
Paul C. Czysz, Parks College of
Engineering and Aviation

Im hearing a little bit of an echo here [referring to the Challenger

accident].
Dr. Sally Side, former
astronaut on CAIB

NASA had decided the occasional damage from dislodged

foam and other liftoff debris was a risk NASA had grown
comfortable with.
Ron Dittemore, Columbia
Program Manager

NASAs incremental descent into poor judgment. Prof. Diane

Vaughn, Boston College

the agency [NASA] does not have enough money to do its job
over the long run without cutting corners. Prof. Diane Vaughn, Boston College

Notable Quotes
it is clear that the space agencys decision making culture has
become as important to the Board (CAIB) as any falling foam or data
recorder.
Lawrence Mulloy, Rocket Booster
Program Leader for Challenger Mission

The no-fault approach bothers some at NASA, who say that they
believe that determining responsibility for mistakes is important.
Admiral Harold Gehman, CAIB Chairman

Unless you can point your finger at the man responsible when
something goes wrong, then you have never had anyone really
responsible
Admiral Hyman Rickover, The Father
of the Nuclear Navy

You have to look beyond the individuals and look into the situation
in which they work. Otherwise youre just going to reproduce the
problem, and that is what happened again. Prof. Diane Vaughn, Boston College

Notable Quotes
The mistake in judgment we all made was accepting deviance in the
performance from the hardware from what it was designed to do
Lawrence Mulloy, Rocket Booster Program Leader for
Challenger Mission

If the cause of the Columbia accident is the acceptance of debris falling

off the tank in ascent, and impacting on the orbiter, and causing damage
to the tiles if that turns out to be the cause of the accident, then the
lesson we learned in Challenger is forgotten, if it was ever learned.
Lawrence Mulloy, Rocket Booster Program Leader for Challenger Mission

NASA and its contractors continued to have a corporate culture of

denial that led them to soft-pedal safety problems instead of reporting
them officially
Lynda Bottos, United Space Alliance
You can change the cast of characters, and you dont change the
organizational context Prof. Diane Vaughn, Boston College

The Similarities to Challenger - 1

Columbia

Challenger

Foam Debris Impact

Physical Cause

Secondary O-Ring Erosion

Physical Cause

Foam Debris Impact Known

About for Years

Secondary O-Ring Erosion

Known About for Years

Foam Debris Impact Deemed Secondary O-Ring Erosion

an Acceptable Flight Risk in Deemed an Acceptable Flight
Flight Readiness Reviews
Risk in Flight Readiness
Reviews
Evidence that the Design was
not Performing as Expected
was Reinterpreted as
Acceptable

Evidence that the Design was

not Performing as Expected
was Reinterpreted as
Acceptable

The Similarities to Challenger - 2

Columbia
Foam Debris Impact Events
Analyzed Individually and
Not as a Trend

Challenger
Secondary O-Ring Erosion
Events Analyzed Individually
and Not as a Trend

NASA being Transformed

NASA being Transformed
from an R&D Organization to from an R&D Organization to
More of a Business
More of a Business
Communication Flow of
Information From Opposing
Views was Discouraged and
Stifled

Communication Flow of
Information From Opposing
Views was Discouraged and
Stifled

The Similarities to Challenger - 3

Columbia

Challenger

NASA Safety Systems did not

Attempt to Reverse the
Course of Events with the
Foam Debris.

NASA Safety Systems did not

Attempt to Reverse the
Course of Events with the ORing.

NASA Appeared to be
Immersed in a Culture of
Invincibility

NASA Appeared to be
Immersed in a Culture of
Invincibility

Normalization of Deviance Normalization of Deviance

Paradigm Re-Emerged
Paradigm Revealed

The Real Tragedy of Columbia