Case Analysis

Columbia’s Final Mission

Course: Organizational Behaviour-II
Term-2

Introduction
The case ‘Columbia’s Final Mission’ is an attempt at understanding how ​inefficiencies at the
organisational level can go on to have a huge impact on the value that an organisation seeks to
create. In this case, NASA’s possibly preventable missions are discussed with a focus on the
‘Columbia’ mission to bring out the factors that go into play for effective decision-making. This case
shows how factors like interactions at different levels of organisations, structure, past way of
dealing with issues can have a significant influence on the working of an organisation. Also, it shows
how different failures that are discussed in the case can’t be attributed to one single person or a
group of people but to the way of ​dealing with the systemic issues​. So, essentially, if one was to
replace the entire team with another set of people, the same problems would still exist and this only
goes on to emphasise the importance of dealing with these organisational issues and ​having a
robust decision making process in place​.

Understanding Pros and Cons of NASA’s Organisational Culture

A key characteristic of NASA is its ​bureaucratic structure​. By 2003, it had over 15 centres across the
US. In order to maintain a clear division of labour and define accountability at various stages of the
process, it needed to have a structured organisation. But there was also a demerit associated with
it. With NASA being bureaucratic in nature, one had to navigate through many ranks higher up to
convey any information. This posed a great challenge in mitigating high-risk situations that required
prompt action or could have severe consequences.

One of the strengths was that NASA had ​long-standing relationships ​with various contractors like
Boeing, Lockheed Martin and ATK Thiokol Propulsion. It ​focused on research and development​,
came up with various new programs and outsourced the operational aspects to the private sector.

The weakness in NASA’s culture was that management ​didn’t take into account the
recommendation or concerns raised by collaborators and engineers​. The Challenger disaster
occurred because NASA failed to take into account the recommendations made by SRB
manufacturer Morton Thiokol. Similarly in the case of Columbia, the management didn’t respond to
repeated concerns raised by the engineers regarding the foam strike. This led to a ​culture of
negligence across the organisation and the DAT team failed to anticipate the consequences of the
foam strike leading to the failure of Columbia.

NASA’s ​decision making culture wasn’t conducive to an open environment ​where people could put
forward their concerns without any hesitation. NASA Engineers did not tend to send messages much
higher than their own rung in the ladder. Basically there were ​communication barriers between
different levels in the organisational hierarchy​.

Understanding the Role of History

The history of the space shuttle program played an important role in shaping people’s behavior
during the first eight days of the mission. Since the ​foam debris strike had become a common
phenomenon in almost every mission of the Space Shuttle Program, the management at NASA
started to see it as an​ acceptable risk​ and eventually categorised it as an ​“in-family” event​.

Historically, foam tended to fall off from the left bipod ramp but NASA ​never discovered the reason
for this discrepancy​. This attitude was carried on during the initial days of the mission too - no
efforts were made to resolve the problem or find out a way to prevent it.

An instance in the case shows how ​Atlantis(STS-112) ​had sustained a severe debris strike but the
mission management meetings never discussed anything related to the strike ​and instead, started
working on the subsequent missions. This goes on to show how lightly the issue had been taken up.

The DAT (Debris Assessment Team) which was formed by NASA engineers and United Space Alliance
managers ​didn’t consider the possibility of RCC damage by the foam strike. Their analysis depended
on past experiences and because they were able to succeed in the previous missions even with
lower technical standards, they did not see it as a major concern​.

NASA’s Responses in Different Missions - Apollo 13, Challenger and Columbia

Apollo 13 incident​:
Apollo 13 launched in 1970 saved itself from a catastrophe where its primary oxygen tank burst
which led to a critical situation for the lives of the astronauts. In this situation, NASA took quick
action to save the astronauts​. Firstly they made a Tiger team who had relevant expertise to focus on
specific problems. The ​group was pushed to come up with creative ideas and generate multiple
options on which analysis could be done. All these efforts led to safely getting the astronauts back
on earth. But, ​in the foam strike case it was not even considered a problem and looked at it as if it
was a part of the process which was normal - this much risk could be easily taken for the mission.
The management did not take the safety hazards into consideration since they did not want to delay
any scheduled missions or spend any extra money on finding the solution to the foam problem.

The Challenger fiasco​:

The Challenger was set to launch on its scheduled date but ​Roger argued about postponing the
launch because of a potential problem related to O-ring. Roger warned that O-ring might not
perform well at low temperatures which could lead to not sealing the joint properly but the
managers wanted more data ​and were not convinced by his argument. Eventually, the mission
failed due to the above stated reason. The criticality rating of the O-ring was high, but even after
that it was not taken seriously by the management and instead, the criticality rating was lowered
just two weeks prior to the launch. Here the issue which could be observed is that ​managers did not
consider the problem to be serious ​and hence ignored because the ​focus was again more on
completing the mission on time.

The Columbia Mission​:

Columbia shuttle space was broken apart on Feb 1, 2003 in 83,900 pieces. The technical reason given
was due to the impact of insulating foam in the Thermal Protection System (TPS).
Here, the failure on NASA’s end can be clearly seen that even after JSC classifying the debris event as
“out of family”, NASA did not take it seriously like the way it took quick action in the Apollo 13 case
where it formed the Tiger Team. Again saving the astronauts did not seem to be the priority instead
completing the mission on schedule seemed to be the focus of the management. Concerns raised by
people such as Rocha were not heard​, this shows us ​lack of proper communication channels​. There
was an ​issue with the decision-making process ​and the way information flowed through different
levels. According to CAIB’s investigations, we can infer that there was a ​structural and cultural
problem for the failure of the Columbia mission. ​Instead of learning from its mistakes, the
management at NASA repeated those mistakes ​which led to catastrophic consequences.

Understanding Behavioural Differences Between Managers and Engineers

Analysing the case, we observed some stark differences in the behaviour of managers and engineers:

The ​managers were more goal oriented and focused on keeping the launches timely and hence,
often ​overlooked the nitty gritties and technicalities of the mission. Managers did not want to delay
the process because they were focused on the external goals and problems - the upcoming shuttle
missions and the scrutiny that they were facing from white house office of management.

Managers like Ham and Paul Shack ​relied on past successes and intuitions rather than engineering
standards and experimental data​. On the other hand, Rocha, an engineer, was very much
concerned about the safety issue and was requesting for additional imagery to obtain more
information on the damage. This shows her personal dedication towards the tasks that she was
assigned.

The ​focus of managers was more on the strategic tasks​ such as resource allocation while the ​focus
of engineers was more towards operational tasks and technical expertise​.

Conclusion
What may seem as a tragic accident at first is nothing short of the culmination of the organisational
inefficiencies of NASA at different points in time is conveyed really well in this case. There are a lot of
key dimensions centered around organizational decision making that come out through the case.
- Information Flow: Due to the bureaucratic structure in place, it was really difficult for the
engineers to address the concerns to the people higher up in authority. This had two
implications- ​suppression of some of the key issues ​and formation of a culture that
exercised a lot of ​laxity in dealing with safety issues​.
- Decision criteria: ​The two key teams- ​managers and engineers needed to understand the
working style of each other to work together but that clearly wasn’t the case at NASA.
When it came to taking decisions, it was more about requiring a lot of data to prove your
point which left the people discouraged. Since engineers possessed a lot of critical technical
knowledge, the weightage that was given to their concerns in the decision making process
was not justified.
- Historical Account: ​The ​weaknesses of the processes for addressing the issues
encountered during the previous missions ​were not taken into consideration and that
ignorance manifested itself strongly in the way the organization worked.
- Ownership: ​NASA as an organization lacked the value of ownership of work which was very
essential in such a dynamic and fast paced environment. After the incident, instead of taking
accountability and working towards creating robust processes for addressing the systemic
issues, the managers engaged in passing on the blame to the engineers.