GRRCON 2017 - Shuttle Columbia - Risk Management Lessons That Were Not Learned
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17 years after the Challenger disaster, NASA suffered another loss of life when Columbia burned up on re-entry. Compounding this tragedy was the fact that all the failures of Challenger were repeated. This talk looks at some of those reasons and how to learn the lessons so they won't be repeated.
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GRRCON 2017 - Shuttle Columbia - Risk Management Lessons That Were Not Learned
- 3. • 833: The total number of crewmembers of all 135 space shuttle missions. • 789: The number of astronauts and cosmonauts who have returned to Earth on a NASA shuttle. Some spaceflyers actually launched into orbit on Russian Soyuz vehicles and returned home on a shuttle. • 355: The actual number of individual astronauts and cosmonauts who have flown on the space shuttle. That breaks down to 306 men and 49 women hailing from 16 different countries. • 234: The total number of days space shuttle astronauts spent at the International Space Station between 1998 and 2011, the construction phase of the orbiting laboratory. • 180: The total number of satellites and other payloads, including components for the International Space Station, deployed by NASA space shuttles. • 135: Total number of NASA space shuttle missions that will have flown between 1981 and 2011.
- 5. APOLLO 1 ACCIDENT CAUSES • An ignition sourcemost probably related to "vulnerable wiring carrying spacecraft power" and "vulnerable plumbing carrying a combustible and corrosive coolant" • A pure oxygen atmosphereat higher than atmospheric pressure • A cabin sealed with a hatch coverwhich could not be quickly removed at high pressure • An extensive distribution of combustible materialsin the cabin • Inadequate emergency preparedness(rescue or medical assistance, and crew escape)
- 7. 19 YEARS LATER… (front row) Michael J. Smith, Dick Scobee, Ronald McNair; (back row) Ellison Onizuka, Christa McAuliffe, Gregory Jarvis, Judith Resnik.
- 8. CHALLENGER ACCIDENT CAUSES • The morning of the flight it was too cold, beyond tolerances • An o-ring that was meant maintain a seal during flight failed, allowing hot gasses to escape • The gasses ignited and created a chain reaction that caused the fuel tanks to ram into each other, and an explosion occurred • Massive failures in communication • They violated the Project Mercury Ground Rule
- 10. WHAT HAPPENED • During the launch of STS-107 a piece of foam broke away from the external tank and struck the left wing in the area of the Thermal Protection System • This created a hole in the wing • 12 days later, upon re-entry, hot gasses entered the wing structure, which destabilized the structures • The shuttle broke apart, and all hands were lost
- 13. THE LANDSCAPE OF POOR COMMUNICATION • The organization consists of regular and contract personnel, with different reporting structures • These employees cover an array of disciplines, and are dispersed cross various locations • Organizational complexity has evolved over time, and business directions have contributed to that complexity • The various centers evolved with different points of focus, causing divergence • Frequent reorganizations in an attempt to become more efficient
- 14. CAIB FINDINGS • The current Shuttle program culture is too insular • There is a potential for conflicts between contractual and programmatic goals • There are deficiencies in problem and waiver-tracking systems • The exchange of communication across the Shuttle program hierarchy is structurally limited, both upward and downward
- 15. RISK REGISTER • PROS • Catalog risks present in your organization • Categorize, rank and prioritize risks • List the risk triggers • CONS • Ritualistic decision making • Illusion of control • The map is not the territory
- 16. CRITICAL ITEMS LIST • 5,396 individual shuttle hazards • 4,222 (78%) were deemed “Criticality 1/1R” • Of these, 3,223 (76%) had exceptions or waivers – meaning the risks had been accepted without mitigation! • More than 36% of these waivers had not been reviewed in 10 years!
- 19. BE BRAVE! BE HONEST! • Your message needs to be heard, it contains business imperatives • You should seek to be a trusted advisor • Frame risk in context
- 20. FOAM SHEDDING WAS A CONSTANT PROBLEM • Damage caused by debris has occurred on every Space Shuttle flight • Most missions have had insulating foam shed during ascent • With each successful landing, it appears that NASA engineers and managers increasingly regarded the foam-shedding as inevitable, and as either unlikely to jeopardize safety or simply an acceptable risk.
- 21. MANAGEMENT WANTS US TO BE BRIEF • The initial damage assessment briefing prepared for the Mission Evaluation Room was cut down considerably in order to make it “fit” the schedule. Even so, it took 40 minutes. • It was cut down further to a three-minute discussion topic at the Mission Management Team. • Tapes of STS-107 Mission Management Team sessions reveal a noticeable “rush” by the meetingʼs leader to the preconceived bottom line that there was “no safety-of-flight” issue
- 25. THE PAST PREDICTS THE FUTURE • For both Challenger and Columbia, pre-flight safety checks were performed • These checks resulted in a go/no-go status for each flight • Challenger and Columbia flew multiple times without an incident, but experienced failures every time
- 27. NORMALIZATION OF DEVIANCE • Diane Vaughan, American Sociologist • Processes become corrupted without anyone noticing • Acceptance of the deviation becomes the norm and people within the organization cannot see it
- 28. BUDGET ISSUES ABOUND • In 2000, almost 3 years before the incident, NASA presented to Congress its budget • In the budget was a proposal to create the Space Shuttle Safety Upgrade Initiative • Every proposed safety upgrade – with a few exceptions – was either not approved or was deferred.