...hole that was punctured into the leading edge of the aircraft during takeoff (NASA). This hole resulted in an excess heating on the leading edge of the wing and then the failure of the wing. This was just the physical cause of the accident that destroyed the shuttle. There were other aspects of the entire NASA program that could have prevented this from occurring but there were failures in the system. Not one factor contributed Columbia accident, but a combination of factors are the root of the cause. The purpose of this case is to input the Columbia Accident Investigation Board (CAIB) in the Burke-Litwin model. This is not to reorganize the very through report by CAIB, but to see where the findings can fit in to show how both internal and external factors that affect change within NASA. One of the most important factors to understand with the Burke-Litwin model is that all 12 factors interact and affect each other. NASA just like any other organization can have negative traits that affect positive traits. This relationship is well demonstrated using the Burke-Litwin model. Body The first section of the Burke-Litwin model is based on the transformational variables within an organization. Within an organization these variables are the vision to an organization or its overall goal and sense of purpose. Drastic changes with these variables can cause wanted or unwanted change within an organization. NASAs...
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...organizational-dynamics.com ISSN 0090-2616/$ – see frontmatter doi:10.1016/j.orgdyn.2004.01.002 Lessons in Organizational Ethics from the Columbia Disaster: Can a Culture be Lethal? RICHARD O. MASON ‘‘Houston We Have a Problem.’’ A Message Never Sent or Received. On February 1, 2003, the Space Shuttle Columbia, on its way to its landing site in Florida, blew apart in the skies of East Texas. Its seven-member crew perished. The $2 billion ship was lost; some destruction occurred on the ground, and considerable cost was incurred to recover debris scattered over several states. The disaster sounded an eerie echo from the past. Seventeen years earlier the shuttle Challenger exploded 73 seconds into flight due to an O-ring malfunction. All seven crewmembers were also lost. And, about 11 years before that, the cabin of Apollo 1 burst into flames on its pad. Three crewmembers were killed. Within a day, as NASA policy requires, an internal investigation team of six ex officio members was formed. Harold Gehman Jr., a retired admiral who was NATO supreme allied commander in Europe, was appointed to chair it. A veteran of several military investigations, including the bombing of the U.S. Cole, Gehman, in an initially unpopular move, broadened the inquiry to include the agency’s organization, history and culture. Sean O’Keefe, NASA’s administrator, was incensed that the investigation would reach beyond the confines of the shuttle project alone, and his relations with Gehman became strained...
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...characterize the culture of NASA? What are its strengths and weaknesses? NASA was created in 1958 to give the United States of America a position in the “space race” after the Soviet Union launched the satellite “Sputnik” into orbit. The goal of NASA was to put a man into orbit before any other country and shortly after that was completed, the new goal was to put a man on the moon. NASA gained recognition from all over the world for it’s success in space exploration but soon, the pressure from the government caused changes would lead to major problems. Culture can be defined as, “a way of thinking, behaving, or working that exists in a place or organization.” During the time of the Columbia Mission I believe NASA’s culture was very static meaning it hadn’t changed in a long time. NASA’s culture focused on major values such as, safety, schedule efficiency, integrity, and communication. But out of these values, schedule efficiency took precedence over the others, which led to disaster. There are many strengths and weaknesses of NASA’s culture but the weaknesses caused the organization to become counterproductive in the long run. The strengths of NASA’s culture are that the organization has a very “can-do” attitude when it comes to task achievement, they have a legacy of excellence and technological advancement, the organization is bureaucratic, and there is a strong sense of pride and teamwork at NASA. There are also many weaknesses in NASA’s culture as well. Over time, NASA has grown...
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...Risk Tolerance The amount of risk NASA tolerated with the Challenger launch is absurd. NASA acted as though it were a busing system going to and from space. This high tolerance towards risk may have been caused by NASA falling into an overconfidence psychological trap. An overconfidence psychological trap is the process of estimating an overly narrow range of possible values, caused by initial impressions or past events (Hammond, Keeney & Raiffa, 1999). Prior to the Challenger, NASA had been extremely successful in its launches and achievements. NASA safely had launched shuttles 24 times before, and a sense of routine had crept in. This led to overconfidence and an unhealthy level of risk tolerance (Osgood, 2011). NASA was so confident in the safety of the mission that they allowed a school teacher to join the crew. The biggest risk of all is loss of life. It seems completely inappropriate that NASA allowed non astronauts on this mission. According to the NASA website, three conditions that can cause mission and safety failures are finite resources, task and organizational uncertainty, and changing, dynamic environments. Specific features common to all high-risk environments also include mission and systems complexity and distributed teams (engaged in both design and operations). Both features require huge amounts of coordination and information sharing, which are potential sources of risk (Mission, 2008). All three conditions occurred during the Challenger launch. The...
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...The chain of command did not allow for direct communication between engineers and the Missions Management Team, which led to the obfuscation and dilution of salient information. Columbia’s outcome could have been different had a system been in place that allowed engineers to bypass bureaucracy in voicing their concerns and requesting data. A direct result of NASA’s bureaucratic culture was an ambiguous vocabulary of safety. The precise term of “anomaly” was used interchangeably with the casual term of “out of family.” As one CAIB member stated, “Out of family is not as well defined, and if you see it enough it becomes part of the family.” The term’s ambiguity led to foam strikes being considered an accepted risk and thereby stunted management’s analysis of the STS-107...
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...Disaster was a preventable disaster that NASA tried to cover up by calling it a mysterious accident. However, two men had the courage to bring the real true story to the eyes of the public and it is to Richard Cook and Roger Boisjoly to whom we are thankful. Many lessons can be learned from this disaster to help prevent further disasters and to improve on organizations ethics. One of the many key topics behind the Challenger disaster is the organizational culture. One of the aspects of an organizational culture is the observable culture of an organization that is what one sees and hears when walking around an organization. There are four parts to the observable culture, stories, heroes, rites and rituals and symbols. The first one is stories, which is tales told among an organization’s members. In the Challenger Space Shuttle incident there were mainly four organizations thrown together to form one, Morton Thiokol, Marshall Space Flight Center, Johnson Space Center and NASA Headquarters. All of these organizations had the same type of stories to be told. At Morton Thiokol, they talked about their product and their big deal, which they received from NASA. At NASA, it’s members retold stories of the previous space missions and being the first people to have landed on the moon. Second are their heroes. At Morton Thiokol, their heroes might have been the founders of the organization or it’s top executives like Charles Locke or Jerry Mason. At NASA, their heroes might have been Neil Armstrong...
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...making process that allowed on space shuttle, called the Challenger to go up into space, but was destroyed upon take off. I will analyze the reasons why NASA allowed this aircraft to take off, and the reason why it should not have. I will also research the aftermath and how this huge error could have been avoided. The National Aeronautics and Space Administration was created on October 1, 1958 by the President of the United States and Congress. It was to provide research into the problems of flight within and outside the Earth’s atmosphere. The main reason NASA was invented was due to World War 2. The United States and the Soviet Union were engaged in a cold ward. During this time, space exploration become the one of the highest priority discussions. This became known as the space race. (American Psychological Association, 2011) The United States launched its first Earth satellite on January 31, 1958. It was called Explorer 1. Then the United States started several missions to the moon and other planets in 1950 and the 1960’s. It had 8,000 employees and an annual budget of $100 million. Nasa rapidly grew. They had three main laboratories. First, Langley Aeronautical Laboratory, Second, Ames Aeronautical Laboratory, and thirdly, Lewis Flight Propulsion Laboratory. They also created two small testing laboratories. As NASA was becoming more and more successful, they eventually created even more centers. Today they have 10 across the country. They also conducted several large...
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...Discuss the changes that NASA implemented after the Challenger disaster Really developing an organization consist of finding needs for change within an organization. It is also the time to quickly grasp the nature of the organization, identify the appropriate decision maker, and build a trusting relationship. The next step is the . Start-up and contracting. In this step, a company identify critical success factors and the real issues, link into the organization's culture and processes, and clarify roles for the consultant(s) and employees. This is also the time to deal with resistance within the organization. A formal or informal contract will define the change process. 3. Assessment and diagnosis. In this case the president needed to sit down and process their main issues in order to avoid another strike.(Grusenmeyer,2009) The Challenger disaster occurred in the first moments of launch on an unusually cold January 28, 1986. Because of the cold weather, an O-ring seal between SRB segments leaked hot combustion gas, which quickly triggered the explosion that destroyed the vehicle. The dynamics of launch cause the joints between SRB segments to flex, and to prevent leaks the O-rings must be resilient enough to "follow" this flexure and maintain their seal. The cold O-rings were too stiff to follow the joint flexure. (Coffey 2010)The Columbia disaster culminated during reentry on February 1, 2003, after completion of the mission's on-orbit tasks. During launch the external...
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...Secondary O-ring will protect the system from the outside, increasing the reliability of the system. Or at least that was the intent of the design; which worked during testing. The main problem was that all testing was conducted at warmer temperatures between 65 – 80°F and the launch day was about 50 degrees colder than the temperature during testing. In preparation to the Challenger mission testing on the SRB system was performed and it was noted during testing that the O-rings eroded to an extent. It was also noted that the erosion was not to the point of failure, therefore NASA decided the risk was minimal. The problem with this approach was that the erosion noted during test was, as stated above, at temperatures higher that launch the ambient temperature. Temperatures as the one experienced at launch caused the O-rings to contract further compromising their sealing value. With a good Risk Board NASA might have studied the O-Ring failure mode and extrapolate the behavior of the O-Rings at the ambient temperature of the launch. The...
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...without any mishaps. However, this never happened because the shuttle broke apart in the Texas skies. NASA had eagerly waited for the Columbia to bring back various important research results after completing its 16 day mission in space. NASA has faced three major crises that are well documented and accessible to the public. The first tragedy took place in 1967 involving the Apollo 1 Spacecraft. In 1986, exactly after two decades, the Challenger space shuttle tragically exploded off the Florida coast. The most worrying trend is that NASA has a well-documented history about the accidents and it was expected that they would have learned something from the previous crises. NASA has totally undermined its credibility with resistance to change. The Columbia mishap can be attributed to resistance to change the individual and structural culture of the organization. Individual and organizational sources of resistance The loss of lives and disintegration of the Columbia shuttle can be traced to the resistance of the NASA leaders to change. The cause of this accident can partly draw its roots to the policy environment that followed the turbulent post-Cold War era. In the period between 1960s and early 1980s, both the Soviet Union and USA were fighting to show their supremacy in every aspect of their lives. The space was one area where these battles took place. This means that NASA was allocated a huge chunk of money because the United States government considered it an important political...
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...disaster, as it pertains to the lack of leadership and communication of those involved. Relevancy of Leadership Leadership is necessary in all situations. It is especially essential in the case of accidents. The question I have to ask is why did this incident become an accident? What could have been done to prevent this disaster from happening? Was NASA aware of the possibilities of this space shuttles’ vulnerability?...
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...Challenger case study analysis Facts 1. Space shuttle challenger disaster leads to the death of its crew members 7. 2. NASA’S organizational culture and decision making process is a key contributing factor of the accident. 3. NASA managers had known contractor Morton Thiokol’s design of the SRB contained a potentially catastrophic flaw in the o-rings since 1977. 4. NASA disregarded warnings from engineers about the dangers of launching posted by the low temperature of that morning. 5. The ROGER”S commission offered NASA 9 recommendations that were to be implemented before shuttle flight resumed. 6. The o-rings had no test data to support any expectation of successful launch in such conditions. 7. Challenger was originally set to launch from Kennedy space center in Florida at 2:42 EST Jan 22. 8. Launch was delayed 1st to Jan 23 then 2nd to Jan 24, 3rd to Jan 25 due the bad weather at the TAL site in Senegal. NASA decided to use Casablanca as TAL site but it wasn’t equipped for night landings so they had to move it to the morning to Florida. 4th to Jan 27 9:37 as of unaccepted weather at Kennedy space center and5th to Jan 28 as by problems with the exterior access hatch. 9. Delayed 5 times shows lack of good decision making and management of NASA’s managers. 10. Morton Thiokol is the contractor responsible for the construction and maintenance of the shuttle’s SRBs. 11. Rockwell international is the shuttle’s prime contractor. ...
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...Mission Management Team (MMT) (leader, Linda Ham handled the entire situation. Could this disaster been prevented? NASA could have prevented the issue with all the new age technology that they posses. How are teams like Debris Assessment Team (DAT) and MMT prepared now to take action against problems that arise in the future? This disaster should not have occurred but it did, why did it? Who is responsible? Will it happen again? If more time was spend of trying to rectify the issue before it got out of hand, maybe the crew of the Columbia would have landed safely as it was supposed to. The space shuttle Columbia STS-107 launched on January 16, 2003 from Kennedy Space Center. During the launch a briefcase-size chunk of foam insulation fell away from a bi-pod ramp on the ships external tank 81.7 seconds after liftoff (Harwood). The foam chunk with velocity smashed a hole in one of the protective shields panels that make up the left wing leading edge. Photos and video shows this happening very clearly. What you cannot see is where the foam actually hit. The only thing that is visible is when the foam explodes after it hits the wing. So at this point the damage is done, NASA knows about it, MMT knows about it, and DAT knows about it. The engineers were getting worrisome with not knowing the extent of the damage. Then they all concluded that the foam did not pose a safety risk. As MMT Chairlady Linda Ham famously said at one point, "it's not really a factor during the flight because...
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...was too low to launch (-2.2 C lowest launch temperatures recorded) and that there was too much ice on the shuttle. O-rings would not perform correctly at this temperature. NASA management was told of this issue but it was deemed an acceptable risk and launch went ahead. After the incident, a new safety office was created to allow better communication and risk assessment. NASA’s apparent approach to risk management at this time was probable risk management1. For the space shuttle, linear analysis might be sufficient between probability, impact, and frequency2, with probability addressing how likely the risk event or condition is to occur, impact detailing the extent of what could happen if the risk materialized, and frequency meaning likelihood of occurrence of an event whose values lie between zero and one. 2. What additional risk measures would you recommend to NASA? Justify your recommendations? Firstly, NASA may need to change the organizational attitude to approach to risks. They are more preoccupied with success by asking “Prove that it is unsafe” rather than being preoccupied with failure by asking “Prove that it is safe.” This kind of optimistic approach to risks is very dangerous because some risk with low probability and medium level of consequence might be overlooked. Secondly, NASA may need to concern the risk from management level....
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...1. The decision makers from NASA and Morton Thiokol were under a litany of outside pressures to proceed with the launch. This particular launch had been delayed for over six months and rescheduled a handful of times. There was significant pressure placed upon the team by the U.S. government in order to compete with the space programs of rival nations. The longer the project was delayed the more expensive it became for the both the government and the private companies, resulting in intense economic pressure. Morton Thiokol was under pressure to deliver their product on time and without faults and wanted to maintain a successful relationship with NASA for financial purposes. The general public and the masses were all monitoring the situation and took notice when major national programs are substantially delayed, creating societal pressure. In 1986 the Cold War was still active, albeit in its later stages, and the pressure to “save face” and project dominance against Russia was very real. All of these forces and more made the decision to cancel the launch bigger than a simple mechanical issue. It’s easy to say with hindsight that the decision makers should have stayed in a vacuum and prioritized safety and nothing else, but a combination of the 100% success rate and outward pressure to launch created an atmosphere more akin to “the show must go on” than safety first. I think its safe to say that type of atmosphere vanished for good shortly thereafter. 2. Roger Boisjoly was a...
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