Health and Safety Specialist

Lessons We Can Learn From the Columbia Shuttle Accident

On February 1, 2003, the Columbia Space Shuttle broke apart upon reentry. As you probably recall, a piece of foam separated from the external fuel tank upon lift-off, breaching the Thermal Protection System on the leading edge of the left wing of the shuttle. The extent of damage was not fully investigated prior to reentry, at which time superheated air entered the wing, destroying the aluminum infrastructure. This ultimately resulted in the break up of the shuttle and the deaths of all seven crew members.

Some general observations of the Columbia accident investigation board were:

- "Flying with flaws became routine and acceptable." Foam had fallen off of the external tank on 80% of previous shuttle flights with no consequence.

- The NASA hierarchy blocked the flow of critical information. People with important safety information were either discouraged from reporting it, or were ignored when they did.

- Time pressures to meet a launch schedule dictated many decisions and prevented more careful review of information from previous flights.

- Serious problems became hidden in the 'noise.' Many 'abnormal' events were observed during each flight making it harder for NASA engineers to notice the significant or risky ones. Unacceptable risks became acceptable in this environment.

During the fourteen days that the Columbia was in orbit there were at least eight opportunities to evaluate the extent of damage on the shuttle wing. On each of these occasions NASA personnel discussed getting additional images of the shuttle wing so a better damage assessment could be performed. Tragically, no one followed up on these discussions. The shuttle crew attempted to return to earth without information that could have saved their lives.

The investigation board observed that NASA suffered from "blind spots" in their safety culture. Project managers made erroneous assumptions about how "robust" their systems were based on prior success rather than data and testing. Hard questions about safety risks were no longer asked.

While the work we do at may not be "rocket science," it can be complex and hazardous. We can also easily fall prey to the same mistakes made by NASA if we are not diligent to maintain