The Columbia Space Shuttle

The Space Shuttle program was initiated by NASA on April 12, 1981, with the primary
objective of transporting large payloads for scientific, commercial, and national security
purposes. After its inaugural flight, NASA replaced more than 300 tiles in response to a
request from the Department of Defense, as mandated by the White House. This action was
taken to enhance the shuttle's safety.

The program utilized a reusable thermal protection system (TPS) as an investment to

safeguard the space shuttle during re-entry into Earth's atmosphere. Despite the associated
costs, NASA accepted this expense due to the necessity of funding.

In January 1990, the Columbia experienced a second incident involving foam shedding from
the left bipod ramp, the first of which occurred with the Challenger in 1983 and the Atlantis
when a tile was dislodged due to debris. Recognizing the recurring nature of this problem,
NASA managers deemed it an anomaly and classified it as a "safety-of-flight issue." NASA
was tasked with demonstrating that the problem could be resolved or that it would not
compromise the safety of the shuttle's crew. However, over the years, NASA failed to find a
satisfactory solution. Consequently, they chose to downplay the issue, specifically renaming
it as a flight risk that could be accepted within the Integration office at the Johnson Space
Center (JSC). Simultaneously, the External Tank Project at the Marshall Space Flight Center
concluded that debris strikes posed no threat to the safety of the flight.

In June and October of 1992, two additional instances of foam shedding occurred, followed
by another incident in October 1994. Despite NASA's attempts to address the issue in
November 1997, no resolution was achieved, and the anomaly was registered as an "accepted
risk." The final occurrence of bipod ramp foam loss from the Columbia took place, with no
further missions planned for the shuttle.

Relevant Events during the Columbia’s final mission

First Day:

- The Inter-center Photo Working Group identifies a strike on the left wing of the space
shuttle, prompting requests for imagery to Wayne Hale and reports to other NASA
members and its contractors.
 - Wayne Hale informs Ron Dittemore and Linda Ham of the situation.
- Foam loss is classified as "out-of-family."
- The Debris Assessment Team (DAT) is formed to investigate the issue.

Second, Third, and Fourth Day:

- Boeing analysts introduce Crater, a mathematical tool used to calculate worst-case

scenarios.
- Crater predicts a hole in the Thermal Protection System (TPS) tile.
- DAT members do not consider this prediction due to a lack of relevant data.
- On the fourth day, DAT decides not to draw conclusions without additional images.

Fifth Day:

- DAT briefs Mission Evaluation Room manager Don McCormack on the results of the
Crater analysis.
- McCormack informs the Mission Management Team (MMT).
- MMT chairperson Linda Ham downplays the situation, stating it's "not really a factor
during the flight because there is not much we can do about it."
- Linda classifies the issue as "lousy."
- Paul Shack informs Roca that the issue has been classified as a "Safety-of-Flight"
issue.
- Austin requests imagery of the Columbia from the defense department.
- Rocha requests NASA for outside agency support to obtain new imagery of the
Columbia.

Sixth Day:

- Wayne Hale finally replies to the imagery request from the first day, but no formal
request is made.
- Austin informs Ham about the imagery request to the Department of Defense.
- NASA cancels the request.
- Shack informs Rocha about the imagery situation.
- Rocha complains about this through email.

Seventh Day:

- Rocha and Schomburg have a heated argument about the severity of the situation.
 - NASA Liaison emails USSTRATCOM.

Eighth Day:

- Boeing and United Space Alliance managers present DAT with predictions from the
Crater analysis, indicating a threat for reentry of the Columbia shuttle.
- McCormack informs MMT about the situation.
- Linda Ham decides to ignore the issue, prioritizing not delaying the next mission
schedule.

Day Sixteenth:

- The Columbia accident occurs.

The ambiguity of the problem

The problem leading to the Columbia disaster was inherently ambiguous due to its
complexity, making it difficult to identify and fix. The elusive nature of foam strikes
damaging the shuttle's thermal protection system (TPS) hindered immediate recognition of
critical threats. Recurring foam loss incidents during shuttle launches were initially viewed as
anomalies, delaying the acknowledgment of a systemic issue.

Normalization of foam shedding events over time contributed to the identification challenge.
As shuttles completed missions without catastrophic consequences, NASA downplayed the
significance of foam strikes, fostering a culture of complacency. Fixing the problem was
hindered by the lack of a clear solution, with efforts impeded by inconclusive evidence about
the extent of foam-induced damage.

The inherent ambiguity influenced decision-makers to underestimate the potential impact of

foam strikes on shuttle safety. Foam strikes were categorized as an "accepted flight risk,"
downplaying safety concerns. This attitude permeated the organization, fostering a culture of
underestimating risks. The psychological impact of previous non-catastrophic incidents led to
cognitive dissonance, contributing to a bias toward underestimating the risks associated with
foam loss.

Ultimately, the ambiguity surrounding foam strikes played a pivotal role in the Columbia
disaster. The organizational culture that evolved, where risks were consistently
underestimated and issues downplayed, created an environment where crucial decisions were
made without a comprehensive understanding of potential consequences. Addressing such
ambiguous problems requires a proactive approach, challenging normalized behaviors, and a
commitment to continuous reassessment and improvement.

Assessment of the Organizational Structure:

NASA, a renowned agency dedicated to space research, is often associated with space
exploration and astronaut missions. However, examining organizational flaws within NASA
provides a new perspective on how bureaucratic structures can impact an agency's goals.

NASA's organizational structure comprises three main components: Programs, Centers, and
Contractors. While NASA has numerous divisions, we will primarily focus on those related
to the events surrounding the Columbia disaster.

The organizational structure appears clearly sequential, with a hierarchical reporting system.
Actions are contingent on approval from the higher authority, creating a bottleneck effect
where tasks are stalled until the person above takes action. This is evident on the first day of
the Columbia's final mission when the Photo Working Group requested additional imagery of
the shuttle's left wing on orbit. Despite their request to Wayne Hale, known for his familiarity
with the military assistance process, the reply was delayed by five days.

Another organizational failure occurred with the formation of the Debris Assessment Team
(DAT), tasked with assessing the severity of the debris issue. The DAT, based on the concept
of a "Tiger Team" focused on rapid problem-solving, lacked direct communication with the
Mission Management Team (MMT). Instead, communication occurred through third parties,
hindering efficient collaboration.

By the sixth day, communication breakdowns led to delays in the imagery request from day
one. Wayne Hale did not formally request information from the defense department, and
Linda Ham, upon learning of the situation, canceled the imagery request without
understanding the context or confirming with DAT. The bureaucratic structure, overly reliant
on hierarchical channels, impeded effective data flow to the MMT, affecting their ability to
assess the gravity of the debris situation.

On the eighth day, DAT reported the shuttle's danger to MER manager McCornack instead of
directly contacting the MMT. This triangulation of information resulted in McCornack not
clearly expressing the level of uncertainty from DAT. This miscommunication likely
contributed to the MMT manager's decision to downplay the risk.

The organizational structure at NASA, while essential for maintaining order, demonstrated
weaknesses during the Columbia disaster. Communication bottlenecks, delayed responses,
and a lack of direct communication channels contributed to a failure to address critical issues
promptly, ultimately impacting the outcome of the mission.

NASA’s Organizational culture

NASA's organizational culture has long been characterized by a combination of innovation,

resilience, and, at times, a positivity-driven approach. The agency's cultural elements are
deeply rooted in its history of overcoming challenges and achieving monumental successes.
However, the positive culture within NASA has occasionally contributed to a tendency to
downplay issues, as evidenced by the Columbia disaster.

NASA has a rich legacy of fostering a can-do attitude, where challenges are met with
innovative solutions and a commitment to mission success. This culture is crucial for pushing
the boundaries of human exploration and achieving ambitious goals. However, this positivity
culture may have inadvertently led to an underestimation of risks and an inclination to
downplay potential issues. The inherent optimism within the organization may have
contributed to a mindset that overlooked or underestimated the severity of problems, such as
the foam shedding issue on the Columbia's left wing.

In the case of the Columbia disaster, there were instances where organizational
communication and decision-making were influenced by the desire to maintain a positive
outlook. Linda Ham's downplaying of the foam strike issue during the Mission Management
Team (MMT) meeting on the fifth day is illustrative of this tendency. Her emphasis on not
delaying the next mission schedule and the characterization of the problem as "lousy"
reflected a disposition to minimize concerns. This optimism-driven culture, coupled with
bureaucratic challenges in communication channels, may have impeded a comprehensive
understanding of the risks involved.

Furthermore, NASA's historical successes, such as the Apollo moon landings, might have
instilled a confidence that sometimes bordered on overconfidence. The agency's positive
culture might have led to a belief that challenges could be overcome, possibly contributing to
a lack of urgency in addressing potential threats to mission safety. In complex organizations
like NASA, striking the right balance between positivity and a realistic assessment of risks is
crucial, as overreliance on a positive culture can inadvertently lead to a disregard for warning
signs and crucial safety concerns.

The lessons learned from the Columbia disaster have prompted NASA to reflect on and
address cultural aspects that may have contributed to the tragedy. Subsequent changes in
organizational culture and procedures have aimed to foster open communication, enhance
safety awareness, and ensure that potential issues are thoroughly evaluated and addressed.

Zeitgeist, Individual, and Situational Factors

The context leading up to the Columbia disaster was characterized by a complex interplay of
organizational culture, individual factors, and external pressures. The Zeitgeist at NASA
during this period was marked by a historical legacy of successful space missions, fostering
an atmosphere of optimism and confidence. However, this positive culture also carried the
risk of downplaying issues and underestimating potential threats.

Linda Ham, as the chairperson of the Mission Management Team (MMT), played a crucial
role in the decision-making process. Her eagerness to adhere to the mission schedule and
avoid delays illustrates the influence of individual factors on decision-making. The pressure
not to disrupt the tightly packed mission calendar may have led to an overconfident and
somewhat arrogant approach, downplaying the significance of the foam strike issue during
the MMT meeting on the fifth day. This attitude reflected a potential blind spot in
recognizing and addressing safety concerns promptly, prioritizing mission timelines over
thorough risk assessment.

Wayne Hale, responsible for responding to requests for imagery, exhibited a different facet of
individual influence. His failure to make a formal request for imagery in a timely manner
showcased a lack of attention to proper procedure and a potential underestimation of the
urgency of the situation. This behavior may have been influenced by a sense of complacency
or a belief that the issue was not as critical as it turned out to be.

Rodney Rocha's role in the context of the Columbia disaster highlighted the challenge of
exerting one's voice within a bureaucratic structure. Rocha, dissatisfied with the decision-
making process and the lack of urgency in addressing the issue, struggled to effectively
express his concerns. The organizational culture and communication channels within NASA,
coupled with individual factors such as Rocha's inability to assertively voice his worries,
contributed to a breakdown in conveying the gravity of the situation.

Externally, NASA faced intense pressure due to previous mission delays and the financial
stakes involved. The agency was under scrutiny from both a public relations perspective and
from those providing funding for the project. This external pressure added another layer of
complexity to the decision-making process, potentially influencing individuals like Ham to
prioritize maintaining the mission schedule despite warning signs.

The context of rivalry between NASA and the European Space Agency (ESA) in the
development and delivery of commercial payloads to space added significant pressure on
NASA. In an effort to secure customers and compete with ESA, NASA heavily subsidized
the cost of commercial launch contracts, offering its services for $42 million per launch—just
one-third of the actual costs. This aggressive pricing strategy aimed to attract commercial
clients and maintain NASA's dominance in the space launch market.

By 1985, NASA had successfully launched 24 communications satellites, showcasing its

capability to deliver commercial payloads. The high volume of missions, nine in that year
alone, demonstrated NASA's commitment to meeting demand and staying ahead of its
competitors. However, the increased number of missions also led to an unforeseen challenge
—the turnaround time between missions rose to 67 days, far exceeding the initially
anticipated 10 days at the beginning of the Shuttle Program.

The intensified competition with ESA and the need to subsidize commercial launches created
a dual pressure on NASA. On one hand, the agency had to showcase its reliability and
efficiency to maintain its commercial client base and secure its position in the market. On the
other hand, the pressure to cut costs and offer subsidized services led to challenges in
turnaround times, potentially compromising the efficiency and safety of the Shuttle Program.

This competitive environment likely influenced decision-making within NASA, pushing the
agency to prioritize the frequency of launches and cost-cutting measures over comprehensive
risk assessments. The emphasis on meeting demand and outperforming ESA may have
contributed to a culture that downplayed the importance of turnaround times and potentially
compromised safety protocols. These external pressures and the resultant decisions made
during this period could have had implications for NASA's later challenges, including those
leading to the Columbia disaster, underscoring the complex interplay between competition,
cost considerations, and operational constraints in the space industry.

The Columbia disaster was influenced by a combination of individual factors, including

overconfidence, complacency, and an inability to assert concerns within a bureaucratic
structure. These factors intersected with the broader organizational culture and external
pressures, creating a context where safety concerns were not given the necessary attention,
ultimately leading to a tragic outcome.

Downplaying culture at NASA

The instances of downplaying, overconfidence, and an optimistic culture within NASA,

spanning from the 1970s to the 1990s, contributed to a toxic organizational culture that
ultimately played a role in the Columbia disaster. The exchange for additional funding in the
1970s set the stage for overpromising and underdelivering. NASA, in its quest for more
resources, agreed to meet challenging Department of Defense specifications, leading to a
complex shuttle design. The agency's optimistic predictions of building a reusable spacecraft
that could perform 100 missions at a low cost per mission set unrealistic expectations. Sheila
Widnall's critique highlights the negative lesson learned: every time NASA over-promised, it
received more funding.

In the early 1980s, the comparison of flying the Space Shuttle to a routine flight to Disney
World showcased a level of overconfidence that permeated the organization. The disparity
between this analogy and the challenges faced by astronauts became a running joke. This
overconfident narrative likely contributed to a culture where the actual risks and difficulties
associated with space travel were downplayed.

By the 1980s, foam shedding during shuttle landings, initially considered a serious threat,
became normalized and accepted as an "in-family" event. The focus shifted from flight safety
to the turnaround schedule implications of foam strikes. This normalization of potentially
hazardous occurrences led to a culture where risks were downplayed and, in some cases, even
accepted as part of the norm. The classification of foam strikes as an "accepted flight risk"
and the conclusion that debris strikes were not a "safety-of-flight issue" further solidified this
complacent mindset within NASA.
Despite the Challenger disaster in 1986, where seven people lost their lives due to a faulty O-
ring, lessons learned were not effectively implemented. The decision-making culture within
NASA continued to downplay risks, evident in the gradual lessening of the severity of foam
strike classifications in 1992. The failure to adopt a more cautious approach and learn from
past mistakes, such as the Challenger tragedy, contributed to a toxic culture of
overconfidence and complacency within the organization.

The historical instances of downplaying risks, overconfidence, and an optimistic culture

within NASA created an environment where potential dangers were not adequately
addressed. This toxic culture ultimately played a role in the flawed decision-making process
leading to the Columbia disaster, demonstrating a failure to learn from past mistakes and
implement necessary changes to ensure the safety of space missions.

Tiger Team vs DAT

The Tiger Team assembled during the Apollo 13 mission in 1970 and the Debris Assessment
Team (DAT) formed during the Space Shuttle Columbia's STS-107 mission in 2003
demonstrate distinct differences in their structure, purpose, and effectiveness.

In the case of Apollo 13, Flight Director Gene Kranz quickly responded to the crisis by
assembling a Tiger Team consisting of experts with relevant expertise to address the
immediate challenges. Kranz had previously developed and trained teams through frequent
drills and practice sessions, ensuring they were well-prepared to handle emergencies. The
Tiger Team's key characteristics included its ability to think creatively, generate multiple
options, and perform rapid analysis of each alternative. This approach was instrumental in
devising ingenious and effective solutions that ultimately led to the safe return of the crew.
The Tiger Team operated around the clock for three days, showcasing adaptability, quick
decision-making, and a clear chain of command.

On the other hand, the DAT formed during the STS-107 mission faced challenges in terms of
structure and communication. Classified as an ad-hoc group, the DAT lacked a clear charter
and reporting structure. Unlike the well-defined roles and responsibilities of the Tiger Team
during Apollo 13, the DAT's purpose and reporting lines were vague. The DAT, chaired by
NASA engineer Rodney Rocha and United Space Alliance engineering manager Pam
Madera, did not have a direct line of communication with the Mission Management Team
(MMT). This lack of direct communication and uncertainty in reporting channels hindered
the DAT's ability to effectively convey concerns and request additional data.

The contrasting experiences of the Tiger Team and DAT highlight the importance of a well-
established structure, clear communication channels, and defined roles in crisis management.
The success of the Tiger Team in the Apollo 13 mission underscores the significance of
preparedness and a streamlined decision-making process in handling emergencies, while the
challenges faced by the DAT during STS-107 shed light on the potential consequences of a
vague charter and communication breakdowns within crisis response teams.

Leadership and taking responsibility

Assessing the leadership during the Space Shuttle Columbia disaster involves examining the
actions and decisions of key individuals, including Linda Ham, Rodney Rocha, and Calvin
Schomburg. Linda Ham, as the chairperson of the Mission Management Team (MMT),
played a pivotal role in decision-making. Rodney Rocha, a NASA engineer, was part of the
Debris Assessment Team (DAT), while Calvin Schomburg was involved in the discussions
around the severity of the situation.

Linda Ham's leadership during the Columbia disaster has been subject to scrutiny. Her focus
on not delaying the next mission schedule and downplaying the foam strike issue during the
MMT meeting on the fifth day reflects a prioritization of timelines over safety concerns. Her
decision to cancel the imagery request without a clear understanding of its context and
without confirming with DAT contributed to miscommunication. While external pressures
and a positive culture within NASA may have influenced her decisions, holding her
accountable for overlooking safety concerns is reasonable. The failure to prioritize crew
safety and adequately address potential risks indicates a lapse in leadership judgment.

Rodney Rocha, as a member of the DAT, faced challenges in asserting his concerns within
the bureaucratic structure. While he actively sought outside agency support and complained
about the lack of communication through emails, the limitations imposed by the hierarchical
system hindered his effectiveness. Rocha's attempts to express worry about the situation,
despite being met with resistance, suggest a degree of responsibility in pushing for more
comprehensive risk assessment. However, the broader organizational structure may have
limited his impact, making it crucial to consider systemic issues in the evaluation.
Calvin Schomburg's role in downplaying the severity of the situation also warrants
assessment. If he contributed to downplaying the risks, he might have played a role in
shaping the organizational response. Schomburg's stance, combined with Linda Ham's
minimization of the issue during the MMT meeting, suggests a collective failure in
recognizing the gravity of the situation. If Schomburg actively influenced the perception of
the problem, accountability for his role in the decision-making process is pertinent.

Examining the leadership in the Columbia disaster reveals systemic issues within NASA's
culture and decision-making processes. While individual accountability is essential, it's
crucial to address broader organizational factors that contributed to a culture of downplaying
risks and prioritizing mission schedules over safety concerns. Learning from these leadership
lapses is imperative to prevent similar incidents in the future and to foster a culture that
values safety above all else.

Confronting an ambiguous threat

I personally believe that this situation is not easy to handle, no matter from which position
you are. The context of so many external factors will directly influence my personal factors. I
really think that no one will recognize there is a problem until the problem is tangible. For
example, if the space shuttle had never crashed, then Linda Ham and anyone trusting her will
always think it wasn't a big deal, and Rocha was exaggerating.

We believe it's a big deal because it already happened. A similar example is, for instance, in
my country, usually, there are very dangerous curves when driving, so people suggest the
government put up some security fences, but the government decides to ignore this. Sadly,
only after an unfortunate event happens, and people die, does the government decide to
implement security fences.

I believe the prevention culture is severely underestimated. As I continued researching if

there were any culprits, I saw that there was a judgment for this event, and no one was
affected. I really feel it was unfair. I especially think Linda Ham was the culprit, but on the
other hand, it really makes sense because Linda Ham is just a victim as well of a toxic
organizational culture that influenced her personal goals. As one of the people in the jury
said, it is not one person's fault. Even if they changed a specific person or group of people,
the problem would keep being there.
It is a bit of a bittersweet answer because I think the main reason, they suggest it is an
organizational problem rather than an individual problem is that they just want, this time, to
properly work together, not blame anyone, and protect each other from any punishment. It's
too late to work together, in my opinion. And even though I believe they were just trying to
protect themselves; I do believe this disaster could have been prevented if the organizational
culture, leadership, and organizational structure had been changed since the Challenger
disaster. I believe proper changes were not made, and a proper assessment or outside
assessment to check the organizational culture was not conducted. That's how I would have,
hypothetically, prevented this disaster.
 References

Howell, E. (2023, January 25). Columbia Disaster: What happened and what NASA learned.
Space.com. https://www.space.com/19436-columbia-disaster.html#:~:text=NASA
%20suspended%20space%20shuttle%20flights,and%20breached%20the%20spacecraft
%20wing

Kluger, J. (2003, February 24). Space Shuttle Tragedy. Time, 161(8), n.p.
https://content.time.com/time/subscriber/article/0,33009,1004301,00.html

Bohmer, R. M. J., Edmondson, A. C., & Roberto, M. A. (2010, May 3). Columbia's Final
Mission. Harvard Business School Case Study.
https://www.hbs.edu/faculty/Pages/item.aspx?num=31131

Linda Ham. (n.d.). In Wikipedia. https://en.wikipedia.org/wiki/Linda_Ham#:~:text=In

%20this%20position%2C%20she%20chaired,reentry%20into%20the%20Earth%27s
%20atmosphere

Seconds from Disaster HD Columbia's last flight. (2022, June 11). [Video]. YouTube.
https://www.youtube.com/watch?v=a6cY3iqdpgg