Risk Management: Space Shuttle Columbia Tragedy

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The tragedy of space shuttle Columbia occurred on February 1, 2003 following the disintegration of the space shuttle Columbia over Texas when it was entering into the earth’s atmosphere (Barling, Louglin & Kelloway 2002). The disaster lead the death of a seven crew member just when it was about to complete its twenty eighth mission. After the tragic disaster, an investigation to determine the cause of the accident was established by the Columbia Accident Investigation Board (CAIB). The purpose of the paper is to evaluate the report of the investigation of the accident.

Initial planning

Since the accident was the first of its kind, there was need for adequate planning for the investigation on what caused the accident. The initial planning for the investigation focused on identifying a team of experienced persons to carry out the truth finding about the crash of the space shuttle. The government was required to identify the best team of investigators who would provide reliable reports within the shortest time possible. NASA space shuttle program was the first team to carry out an initial investigation about the accident.

Aspects of the investigation

Various aspects had to be considered in order to establish the truth about the accident. This was because such an accident had not occurred before and there fore there was the possibility of many causes of the accident. NASA, being the first investigating organ established all the likely possible causes of the disaster by examining multiple choices. It was later decided that an independent board to be assigned the task of investigation. This task was therefore assigned to the Columbia Accident Investigation Board (CAIB). CAIB was preferred as the independent investigating organ since it was comprised of people from different backgrounds and therefore their decisions would be neutral. This board consisted of military experts and civil analyst who were tasked to make a deep investigation into the tragedy (Barling, Louglin & Kelloway 2002). CAIB was therefore made up of professional from different professionals implying that it would provide some reliable report.

Adequacy of the initiation and planning

CAIB had to start it investigation immediately after it was proposed to carry out the investigation. This was particularly an immediate practice because immediately after the accident, reliable data was available. For instance, debris could be easily available at the scenes of the accident and also people who witnessed the accident were also available. The public was warned from collecting the debris. However, there were instances whereby the public ignored the warnings issued by the search team. For instance, there were some residents of Texas who collected some debris and planned to sell them using eBay, an online auction website (Barling, Louglin & Kelloway 2002). This auction was completely removed. There was a three day amnesty that provided an opportunity for the looted shuttle debris to be brought in large quantities after it was realized that the possession of the debris was illegal and was associated with a prosecution. However, there was close to forty thousand pieces of the debris that were recovered and which could not be recognized.

Data collection

The investigation majorly depended on primary data. During the initial period preceding the investigation, it was realized that there was a lot of hazardous material scattered in the areas of the accident. In addition, the public was advised to report the location of any hazardous chemicals to the local emergency services or any other government agency that would attend o the situation. The public was also warned that any individual who could be found in possession of debris related to the accident would automatically be prosecuted. Since the area being investigated was large, the search teams received support from amateur radio operators who went along with them in order to assist them in communication process (Barling, Louglin & Kelloway 2002).

OEX recorder was used by CAIB to record information during the interviews. The OEX is intended to create awareness to the engineers so that they can have a better understating of a vehicle before it can go for its first test (Barling, Louglin & Kelloway 2002). However, the recorder of the space shuttle was still operational even after the first test. The recorder was meant to record several parameters as the space shuttle was moving in the air. As a result, the recorder helped the investigators to gather the information about the events that led to the crashing. Signals lost from the sensors located on the wings were used by the investigators to determine the tract of the damage. The operation dealt with an analysis of forensic debris which was undertaken by Lehigh University. In addition, there was need to conduct other test so as to determine the likelihood of other probable events associated with the tragedy (Barling, Louglin & Kelloway 2002).

The Southwest Research Institute was assigned the responsibility of performing foam impacts tests. The SRI used a compressed-air-gun in firing a foam block which had same characteristics as the one that struck Columbia. Roughton (2002) found out that “the tests clearly demonstrated that a foam impact of the type Columbia sustained could seriously breach the thermal protection system on the wing leading edge” (p. 29).

By the end of the data collection process, the investigators had collected over 2000 debris fields. The debris which comprised of human remains were scattered in southwest Dallas from east Texas which was a sparsely populated area. There was also large debris that was gathered at Louisiana and in some parts of the Southwestern countries like Arkanas. The data contained in the disk drive was also useful. Despite the disk drive sustaining several damages, the data in it was not affected and was therefore left unharmed. In addition to the debris, interviews conducted by CAIB found out the status of the area of the accident before and after the accident. Such interviews were important since they provided the investigators with first hand information relating to the accident.

Accident causal analysis


The Columbia Accident Investigation Board provided its report about the accident after a long period of investigation. The report indicated that there were several technical errors during the manufacture of the space shuttle. According to the report issued by CAIB, it was evident that the most potential likely source of the disaster was the breaching of the leading-edge situated at the periphery of the left-wing. It was therefore clear that this came up from insulating-foam that was shed on the time of the launch (Roughton 2002). On the other hand, the report critiqued the processes that were used by NASA in decision making and risk assessment. As noted out by Clarke (1999) “it concluded the organizational structure and processes were sufficiently flawed and that compromise of safety was expected no matter who was in the key decision-making positions” (p. 190).

According to the CAIB report, an instance of such case was the case of the shuttle program manager whereby, the manager had several tasks to perform individually. In reference to the CAIB report, these duties cannot be allocated to an individual since they are all meant to achieve different goals and therefore such roles can conflict on one another. In addition, it could easily be established that CAIB reported that NASA had agreed that there were deviations from the set design consideration that had occasionally resulted to other similar problems. Several design specification accepted by NASA were not effective. For instance, the thermal protection system did not have ability to withstand some dangerous impacts and any happening as a result of an impact in the course of its flight. The Columbia Accident Investigation Board was therefore in a better position to make specific recommendations that would provide changes required to be considered in the manufacturing processes and organizational culture (Clarke 1999).

Spacecraft Crew Survival Integrated Investigation Team (SCSIIT) produced a report titled as ‘Columbia Crew Survival Investigation Report’. As indicated by Roughton (2002) this group was commissioned by NASA to carry out a detailed analysis of the events leading to the accident. This group therefore focused on the factors and events that affected the survival of the crew. Finally, the group was tasked to come up with recommendations that would help improve the survival of people using space vehicles in future so as to avoid similar incidents. This report found out that the Columbia event occurred so fast that the members of the crew were not able to configure the suit in order to ensure maximum protection as a result of loss of cabin pressure. According to the report, it could be concluded that although the circulatory-systems were functional for a short period of time, the impacts of the de-pressurization were so serious that the crew was not in a position to gain consciousness again (Roughton 2002).

Accident causation theoretical models

There are many theories that explain about the movement of objects into the atmosphere (Etkin 2002). Causes of accidents can not be determined since can only be determined after an accident has occurred (Fay & Riddell 2008). On such theory use the la of gravity that explains what restricts the movement of objects in the atmosphere. Gravity is known to force everything in the air back to the ground. As explained by Fay & Riddell (2008) “in cases, temporal displacement causes nose bleeds, headaches, forgetfulness, and in the worst cases, death by apparent brain aneurysm” (p. 81). However, there are instances whereby travelling physically through time can cause someone to lose consciousness (Fay & Riddell 2008). This theory can be used to explain how the space shuttle crashed since the pilot lacked control on realizing that the space shuttle had lost control.

Comparison of the accident and theoretical models

Travelling in the air is risky and therefore space shuttles should be assessed for their safety while in the air. As a result, people argue that what has already happened is past, what is presently happen is viewed as now, and what has not happened is considered to be future or untouched (Fay & Riddell 2008). It is therefore impossible to view time from a non-linear perspective without making a paradox. Fay & Riddell (2008) defined temporal paradox as “paradoxical situation in which a time traveler causes, through actions in the past, the exclusion of the possibility of the time travel that allowed those actions to be taken” (p. 80). Paradoxes are explained by such philosophies as externalism. From this perspective, it can be concluded that events happening in the course are time should be considered to take place in fixed positions (Barling, Louglin & Kelloway 2002). This theory considers the impacts of time- travel on anyone travelling to be same irrespective the kind of travel.

Evaluation of the output of the investigation

Extent of the actions

CAIB presented a detailed and comprehensive report based on the evidence it gathered at the scene of the accident. The report relied on physical data and also interviews conducted to the witnesses of the tragedy. The report indicated that there were many actors that should have played their roles in order to avoid such an accident. The shuttle design company failed to manufacture the shuttle with all the required parts thereby leading to some parts of the shuttle malfunctioning. Secondly, NASA management failed to assess the effectiveness of the shuttle before it took off. If the space shuttle was assessed for readiness to start its flight, there was a possibility of realizing that three were some parts that were not in order. As a recommendation by CAIB, any space shuttle should undergo an assessment process in order to identify if space a space moving vehicle is worth to travel in the air.

However, there are possibilities of a space shuttle crashing in the air due to factors like bad weather or other errors that are non-human. In such circumstances, rescue mission is required by NASA management to take prompt actions immediately. Such rescue missions involve space walks that enable the management of space vehicles to repair a shuttle in the air; like for the scenario of the Columbia space shuttle a rescue mission would have been space walk to repair its left wing. CAIB also identified that a rescue-mission could not occur easily since a lot of time is required to launch a shuttle. The mission of rescuing a shuttle is also heavily influenced by the consumable goods like water and fuel in an orbiting shuttle. The Columbia Accident Investigation Board identified that the space shuttle had carried a lot of consumables as a result of the existence of an extended duration orbiter. In order to avoid such accidents in future, CAIB recommended all space shuttles to undergo a safety management assessment before they are allowed to take off into the air.

Impacts of the accident

The tragedy was associated with major impacts on all the stakeholders. The community was highly affected a result of losing their lovely ones in a very fatal accident. The company that owned the space shuttle also suffered a great loss after the accident. Additionally the company that owned the space shuttle was faced with the charges of death of the members of the crew who died. This would be a serious case for the company as it seemed that, the company did not have an emphasis on risk management. The space shuttle situation had therefore not been assessed for any risk that would come as a result of it being faulty. On the other hand, the government also suffered in the process of carrying out the investigation. The Columbia Accident Investigation Board required adequate resources in order to determine the cause of the accident and draw recommendations. Resources were required in order to hire the personnel and also to purchase equipment to collect and analyze the data.

Investigation verses the terms of reference

The report by CAIB established that the shuttle design company and the NASA management failed to address matters of risk and safety management of the Columbia space shuttle. The initial investigation was to assess the several possibilities of the cause of the accident. Through a detailed and comprehensive process of investigation, CAIB was in apposition to determine the real cause of the space shuttle accident. However, though there were terms of reference, CAIB membership comprised of professionals from different background but with different skills who would provide the truth concerning the accident without any imbalance on any side. CAIB therefore worked hard to provide the investigation report within the shortest time possible. This was achieved through professionalism, hard work and determination by the members of CAIB.


The investigation carried out by CAIB found several factors that failed to address risk management. It was found out the space shuttle was not fully assessed before it started travelling in the air. The recommendations made by CAIB indicated that any space vehicle should undergo check ups before being permitted to travel in the air. Risk management is important because, when an organization is able to manage the risks, it can minimize the likelihood of incurring big losses (Etkin 2002). Such losses do not only affect an organization but also other stakeholders. This can be illustrated by the tragedy of the Columbia space shuttle whereby the community, government and the company suffered as a result of the accident.

Reference List

Barling, J., Louglin, C., & Kelloway, E. 2002. Development and Test of a Model Linking Safety-Specific Transformational Leadership and Occupational Safety, Journal of Applied Psychology, 87, (3): 488-496.

Clarke, S. 1999. Perceptions of Organizational safety: implications for the development of safety culture. Journal of Organizational Behaviour, 5 (20) 185 – 198.

Etkin, B. 2002. Dynamics of Atmospheric Flight. New York: John Wiley & Sons, Inc.

Fay, J. & Riddell, F. 2008. “Theory of Stagnation Point Heat Transfer in Dissociated Air”. Journal of the Aeronautical Sciences, 25 (2): 73–85.

Roughton, J. 2002. Developing an Effective Safety Culture: A Leadership Approach (1st Edition). New York: Butterworth-Heinemann.

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