This is the story of the Columbia Space Shuttle accident. The story is based on the findings presented in the Columbia Accident Investigation Board Report (CAIBR), simplified in order to highlight the areas where miscommunication was pivotal in the turn of events. Relevant bibliographical sources are given at the end of the story. On 16 January 2003, NASA launched the space shuttle Columbia to carry out scientific research in orbit. The launch seemed successful, and NASA officials, engineers and the public were relieved and happy to see the shuttle exit the Earth¶s atmosphere as planned. However, when members of the Intercenter Photo Working Group watched video footage of the launch the following day, they saw that some pieces of foam insulation became dislodged from the main tank during lift-off and struck the left wing. Immediately, they alerted senior program managers, and e-mailed a digitized film clip of the event to the Mission Management Team (the project leaders), the Mission Evaluation Room (the team monitoring engineering issues during flight), and selected engineers. This discovery led to the formation of the Debris Assessment Team (DAT), consisting of a group of experts from NASA, Boeing, and the United Space Alliance, put together to investigate the strike and present their results to the Mission Management Team. Rodney Rocha and Pam Madera co-chaired the team. Unfortunately, the available footage did not include shots taken from crucial angles of the shuttle, and therefore it did not provide information that was essential to ascertain the degree and kind of damage. The problem that needed to be solved, therefore, was how to obtain more imagery of the shuttle wing. In order to obtain more information on the impact of the strike, the Intercenter Photo Working Group requested Bob Page, their chair, to make an official request to the Department of Defense. The engineers¶ request was that the Department would use their military technology to image the shuttle in orbit. Bob Page contacted Wayne Hale of the Kennedy Space Center to explore the possibility. Hale, in turn, contacted a representative of the Department of Defense (who was not the appropriate person for imagery requests), and asked for a plan to commence imagery of the shuttle in orbit. Neither Page nor Hale obtained authorization from the Chair of the Mission Management Team, Linda Ham, for this request. It was later found that the Department of Defense initiated action to

and what the requirement was. Again. It was therefore not possible for NASA personnel to make a timeline of further actions. Bob White called Head of Space Shuttle Systems Integration at Johnson Space Center. did not show any serious . in making this decision.obtain the imagery. In particular. It turned out that. caused the Shuttle Program managers to interpret the situation as a non-critical engineering task. based on the available data. but did not notify the requesters or give them any information on how and when this would be done. Ham terminated the procedures that the Department of Defense had initiated to obtain imagery. there does not seem to have been any follow-up by either side. which entailed going through the Mission Evaluation Room to the Mission Management Team and then to the Flight Dynamics Officer. because some analysts were interested in getting imagery. Rocha took the matter to his own division. Unable to find either the original source of the request or evidence that the request satisfied a ³mandatory need´. Not knowing of the actions of the Department of Defense. from an engineering division outside the Department of Defense. DAT held its first meeting. and not as a critical operational need. by both the Intercenter Photo Working Group and DAT to the Department of Defense. Austin then phoned a representative of the Department of Defense Manned Space Flight Support Office. Lambert Austin. The replies that she got indicated that the analysis of the situation. she was concerned about the policy stating that requests for Department of Defense participation required evidence that there was a ³mandatory need´ for the information or services requested. Ham tried to find out the specifics of the situation: who was making the request. following Hale¶s instructions. Mission Management was not included in this decision. DAT by-passed established procedures. to discuss how to get imagery. The fact that no senior management was included in this. After the requests were made for imagery. the engineering section at Johnson Space Center (see extract E-mail A as an example of this. concerned with post-mission maintenance problems. and it assigned Rodney Rocha the task of obtaining imagery from an external source. On the same day. and told him that he was asking for information on how to make a formal request. United Space Alliance manager and DAT member. that is. which also shows DAT¶s serious concerns). Lambert Austin finally notified Linda Ham. Linda Ham then sent an e-mail to selected engineers in NASA and the Johnson Space Center asking if there were safety of flight risks caused by the debris strike.

Don McCormack. but only printed it out and shared it with a colleague. the engineers concluded that their analysis did not show conclusively that a safety of flight issue existed. in particular. and did not address more global issues of risk management. They then presented their results. that there was a need for images in the first place¶ (CAIBR. When asked by the Board why he did this. the need for imagery was obvious: without it. the engineers relied on a PowerPoint presentation to communicate their results. summarizes clearly and effectively the concerns of the engineers. in a briefing meeting. Evidently. DAT members µwere in the unenviable position of wanting images to more accurately assess damage while simultaneously needing to prove to Program managers. as with the replies to Linda Ham¶s e-mail. Many of these replies relied on technical analyses of the situation in relation to past experiences. For risks. Subsequent analysis of their presentation revealed that the wording was vague and information . Management took a ³bottom line´ approach in interpreting this. in their presentation. Rocha did not send this e-mail. Rodney Rocha sent a series of e-mails to engineers. In addition. during this important briefing session. and focused on the answer rather than considering the uncertainties on which this answer was based. they were so anxious that they crowded the briefing room. DAT members pondered their options after their requests for imagery had been cancelled. but did not reach any agreement on specific actions. This constrained them to squeeze a significant amount of information (some of it very important) in a few slides that were read off a screen. they could not get accurate measurements to make reliable predictions. The ³mandatory need´ policy confused them. An e-mail ( E-mail B ) sent by Thermal Protection System specialist Calvin Schomburg is an example of this. the DAT engineers indicated that they had no clear idea. In their second meeting. 157). One of these e-mails ( E-mail C ). since they interpreted the situation differently from management. However. as a result of their assessment. allowing standing room only. After this meeting. to Mission Evaluation Room manager. questioning the cancellation of the imaging request. Rocha replied that he did not want to jump the chain of command or to be seen as challenging management decisions. As the Report concludes. In their third meeting. DAT members reviewed updated impact analyses. Ironically. When later asked by the Accident Investigation Board what they understood by the term.

flawed analysis. who specialized in landing gear design. and the most favourable one to a wider NASA audience. This investigation would find that decisions made during the Mission µreflect missed opportunities. The engineers¶ concerns were mentioned during this briefing meeting. Don McCormack then conveyed DAT¶s results to the Mission Management Team. an engineer at Langley Research Center. using different degrees of damage. The loss of Columbia was physically caused by the . temperature and pressure gauges went off the scale. No definite action was recommended or taken as a result of DAT findings or Daugherty¶s simulations. In fact. 191). they were so subordinated to other issues that no mention of them exists in the minutes of the meeting. the Board was alarmed to find that the Mission Management µdisplayed no interest in understanding a problem and its implications¶ (CAIBR. gauges on the shuttle¶s shattered left wing failed. On 1 February 2003. engineers remained worried about the effects of the debris strike. contacted his friend Bob Daugherty. the engineers¶ fears were confirmed.E-mail D ). a DAT member. Daugherty could only do this after hours. Since this request was not supported by Mission Management. When NASA Mission Control heard reports of the shuttle¶s disintegration. including DAT (see Daugherty¶s e-mail to Campbell. assessing the situation. Upon re-entry in the Earth¶s atmosphere. Carlisle Campbell. Campbell asked Daugherty to simulate some scenarios of landing. Having completed the simulations. Daugherty sent the most unfavourable simulation result to his peers. and all mission data was preserved for a selected Board of specialists to carry out the inevitable Accident Investigation. and ineffective leadership¶ (CAIBR. and all vehicle data was lost: the shuttle broke apart piece by piece above Texas. In particular. blocked or ineffective communication channels. but they were not highlighted. ³Lock the doors.´ The meaning of his words was clear to all involved: nobody was allowed to enter or leave the room. 170).was ineffectively organized. the flight director told the ground controller. 170) ± actually a communication issue. After the results of DAT had been submitted. and therefore they were not communicated to anyone who did not attend the meeting. Columbia¶s scheduled landing date. selected Johnson Space Center engineers. compounding the confusion about what the recommended action was (CAIBR.

. faulty communication was also clearly responsible in failing to prevent the disaster.damage incurred at launch when debris struck the left wing. However.