COLUMBIA’S FINAL MISSION

1.Key Takeaway –
“There are multiple points where concerns were raised and even if once the
concerns were taken into consideration, the disaster awaiting could have
been foreseen.”
2.Case Summary

2.1 The root cause (O-rings):

The Rogers Commission had conclusively reported that the O-rings used in the “Challenger”
Space Shuttle Program, that had exploded during re-entry into atmosphere, had been the cause
of the accident since they were unable to seal the propellent gases well. This issue was notified
earlier to NASA by the Morton Thiokol Engineer, it wasn’t taken up since NASA’s culture
functioned in a way that did not facilitate constructive criticism and self-reflection well. This
is the first instance where the work culture around NASA is illustrated as well as a complicated
matrix where information flow has many blockades to such an extent that vital points brought
up are lost in the organizational void.
The structural hierarchy is tightly ingrained in NASA to such an extent that even after the
disastrous “Challenger” mission, it continued to employ the O-rings without resolving the
problem, and even downgrading the elevated criticality rating. This exhibits the flaws of a
tightly goal-oriented work environment due to the pressure because of massive claims made to
the US government. The hyper focus on achieving targets has veiled the organization and the
members views to such an extent that all they care is completing the work, regardless of
reflecting on whether it has been done right or there could be something that was missing.
While the lack of centralized decision making does save time, it avoids collaborative work
discussions and implies a lack of foreseeing gross errors earlier since no one is there to strongly
oppose the decisions made, right or wrong.
2.2 – A review of the week
2.2.1 Day 0 and 1
Delay in identifying the foam strike until 9:30 am on day 1 by the Intercenter Photo Working
Group post lift-off. The overlooking could have been an induced lethargy of the highly
objective-oriented work ethic which means the engineers felt the job was done and dusted as
soon as the lift-off happened instead of diligently reviewing and looking out for possible errors.
When they do find out about the foam strike, we realise that they couldn’t intercept it well due
to a “restrictive camera angle” and blurry image due to poor maintenance and update of the
camera equipment used for surveillance owing to budget cuts. This is also combined with the
ignorant view of the members that if it couldn’t be clearly detected, then probably it isn’t that
significant. The disregard is a reoccurring theme in the way NASA operates in various teams.
While the people at JSC exhibit concern, the MER which should be looking into resolving
classified it as “low concern” simply because it disrupted their flow in achieving their mandates
and they even avoid commissioning a Tiger Team as per protocol and went with a DAT.
This exhibits how NASA, divided into innumerable teams with a vision that splitting tasks
would result in efficiency ends up creating a hierarchical mess while also resulting in teams
performing as solely individual units and working rather selfishly towards their own goals
instead of seeing the bigger picture and the implications for the entire organisation on a large
scale. The vision and mission that drives individual teams into working towards a common
goal is missing, resulting in a lack of cohesion among the teams. NASA seems to be existent
only as a name and non-existent within the teams, so much that they subvert protocols for their
personal performances.
2.2.2 Day 2 through 4
The adamant refusal by DAT to believe the foam was of concern reiterates how counter-
arguments were not facilitated within the organization which proves to be detrimental in
hindsight. Information is interpreted in ways that favour their standpoint, rather than viewing
it analytically. Thus, even after constant requests, they refuse to budge.
2.2.3 Day 5 and 6
MMT tries to rationalise its stance on ignoring the issue by stating that “there is nothing that
could be done” even before trying to do anything about it. The avoidance of procedures to
conduct daily missions also again reiterate the lack of regard for the organizational values and
rules as each teams function in a highly individualistic manner.
Although the teams, particularly MMT, were aware of the serious implications of the hazard
being significant, they chose to ignore it since their objectives of launching node 2 of Int’l
Space Station would be jeopardized. Ham’s domineering management style is another proof of
a centralized power structure and decision making that completely leaves no rooms for
alternative viewpoints to be given weightage (in this case, the reporting by DAT). Both MMT
and MER choose to ignore this information as it doesn’t fit their respective schemes of things
to do.
Austin could have procured better imagery for assessing the Columbia while on-orbit but he
fails to get it done formally since his lack of knowledge on the imagery request procedures.
The lack of awareness of company policies is also attributed to the highly complicated way of
the distribution of tasks among the hierarchical web which makes causes terrible hinderances
to comprehend as well as execute. The complex design has its own structural flaws as it makes
it difficult for Ham to track who made the request and as a result, she cancels informal request
made since she is unable to track who made the request.
While everyone wants to achieve their team’s goals, nobody wants to accept responsibilities of
following up an issue, as Shack says he doesn’t want to be the “Chicken Little”. The absence
of Organizational Citizenship Behaviour is reiterated here as they see the imagery request as
something beyond their requirements of their designation and don’t want to be involved in it,
regardless of what implications it could have for the organization as a whole.
The adverse effects of high centralization is also exhibited here as DAT members conduct their
meeting and unanimously decide not to pursue imagery requests, even though Rocha badly
needs it to prove her hypothesis. There was no consideration of opinions outside the upper level
of management and majoritarian politics is at play, instead of assessing the implications.
2.2.4 Day 7 and 8
Repeated “Information is interpreted in ways that favour their standpoint…..” as she insists
that foam strikes were common and not to be taken seriously, Rocha is snubbed. NASA justifies
its high level of centralization by saying that informal requests that don’t come from the official
approval would cause unwanted hinderances and confusion and thus they are not to be
entertained by the Department of Defence, while not accounting for transparency of
information and discouragement of questioning.

Even when the scenarios by DAT predict the threat for Columbia’s re-entry is presented
methodically with ample insights, the MER decides not to take it as a serious concern and
refusing to budge. Lack of flexibility in the organizational structure is evident, since this new
information would be chaotic to MER and would seemingly disturb their stability in controlling
the completion of tasks. The larger goals are compromised for executional efficiency. Thus
they choose to ignore any information that would interrupt their stability.
 Assigned Questions
1) How would you characterise the culture of NASA? What are its strengths and
weaknesses?
In the words of Torarue Durden, “extremely bureaucratic”, “hard to navigate”,
NASA is a complex organization with a matrix form of organizational structure. Not only is
its structure complex, but also its operations are “rocket science”. It has many goals to
achieve and also its funding is dependent upon the productivity which gives a concrete reason
to be more focused on maintaining deadlines.
If we were to point out to one particular strength of the organization, it is that NASA’s tasks
are well defined and rank high on technicality. They are very much result oriented. It ranks
high on Task Significance, thus providing enough motivation to its employees.
We can observe that there are a great deal of task specific teams in the organization. The job
division on paper is done perfectly.
However, in the case under discussion, whatever seem to actually lead NASA to success,
unfortunately are some of the causes for the failure of few of its highly prestigious missions.
1) Though there are many teams, lack of agreeableness among different levels of
executives / technical specialists caused NASA to bear the brunt. This can be
illustrated in the fact that no one actually heeded to Morton Thiokol Engineer Roger
Boisjoly about the threat to the O-rings from the bad weather on that day.
The irony is that they failed to pick up a lesson from the above disaster, and even
downgraded the criticality rating of the O-ring.
2) With the main motive being to ensure that funding is not interrupted, they hurried
things up a bit and wanted the project to be done, rather than worry about its launch
quality. This can be observed in the fact that NASA associated Columbia with the
mantra “tough to launch; easy to fly”.
3) When the talent pool is too high in terms of technical skills, there is a high chance for
overconfidence to creep in.
4) Some of the problem lies even in the attitude of the higher level executives – notably
Linda Ham – called off the request for imagery, without even formally consulting the
DAT, just because members from MMT stated that “they weren’t aware of an official
request”
Rocha – has written an email but just showed it to his colleagues, since he felt that no
action would be taken in favour of his mail.

2) How did the history of the space shuttle program shape people’s behaviour during
the first 8 days of the mission?
The top team felt that Foam strikes are a regular unpreventable occurrence, and hence there is
nothing that can be done about it.
Also, due to having many successful missions, they tended to be slightly overconfident.
A walk through the first 7 days of the mission -
Day 1 -
A couple of teams were formed and most of them started analysing the situation.
Notable development – MER log entry read that foam strike was “low concern”
One more cause of concern is that the tiger team was not invoked, despite the situation being
of utmost concern.
Day 2 – 4 -
Mathematical model Crater was employed for analysing the situation.
Rodney Rocha emailed asking the manager to request the astronauts to have a look at the
impact area, without receiving a reply.
This presumably started building the heat up.
DAT met “informally”, and decided to obtain images of shuttle on orbit.
Day 5 –
The results were discussed among teams, and there were still a few experts who opined that
foam strikes shouldn’t be a problem.
Also, Rodney Rocha re-mailed the manager to pursue the image requests in an impatient
tone, as it was already late.

Day 6 –
Imagery requests were cancelled by the authorities as they couldn’t find a formal request for
the same.
Rocha got a reply from Paul that all requests have been cancelled, leaving Rocha in a fit of
anger.
This shows a lapse and a sense of irresponsibility on part of the management, and thus
increasing impatience in the engineers.

Day 7 –
As anticipated, heated arguments took place between Rocha and Schomburg, as Cain said he
considered the issue dead.
The top management seemed indifferent and thought it to be pointless to pursue a matter
which is completely out of hands
3) How would you characterize NASA’s response to the foam strike in comparison with
its response to the Apollo 13 incident? How does the Columbia mission compare to the
Challenger accident in 1986?
When the Apollo 13 incident occurred, the response was instant. Teams were formed with the
motive of creating alternative solutions to get the spacecraft and the crew home. Everyone
was focussed and optimistic, worked together ingeniously to achieve their objectives.
Columbia and Challenger can be compared to each other in many terms. In both cases, the
managers wanted to get the launch done as soon as possible and thus compromising on
practically many aspects.
They didn’t consider the opinions of engineers and experts seriously and thus fumbled in
their missions, achieving terrible results and also incurring the wrath of their talent pools.
There was lack of proper communication, and serious problems in information accessibility
and flow in the organization.