8.1 ECHOES OF CHALLENGER

¶As the investigation progressed, Board member Dr. Sally Ride, who also served on the Rogers Commission, observed that there were "echoes" of Challenger in Columbia. Ironically, the Rogers Commission investigation into Challenger started with two remarkably similar central questions: Why did NASA continue to fly with known O-ring erosion problems in the years before the Challenger launch, and why, on the eve of the Challenger launch, did NASA managers decide that launching the mission in such cold temperatures was an acceptable risk, despite the concerns of their engineers?

¶The echoes did not stop there. The foam debris hit was not the single cause of the Columbia accident, just as the failure of the joint seal that permitted O-ring erosion was not the single cause of Challenger. Both Columbia and Challenger were lost also because of the failure of NASAʼs organizational system. Part Two of this report cites failures of the three parts of NASAʼs organizational system. This chapter shows how previous political, budgetary, and policy decisions by leaders at the White House, Congress, and NASA (Chapter 5) impacted the Space Shuttle Programʼs structure, culture, and safety system (Chapter 7), and how these in turn resulted in flawed decision-making (Chapter 6) for both accidents. The explanation is about system effects: how actions taken in one layer of NASAʼs organizational system impact other layers. History is not just a backdrop or a scene-setter. History is cause. History set the Columbia and Challenger accidents in motion. Although Part Two is separated into chapters and sections to make clear what happened in the political environment, the organization, and managersʼ and

¶engineersʼ decision-making, the three worked together. Each is a critical link in the causal chain.

¶This chapter shows that both accidents were "failures of foresight" in which history played a prominent role.1 First, the history of engineering decisions on foam and O-ring incidents had identical trajectories that "normalized" these anomalies, so that flying with these flaws became routine and acceptable. Second, NASA history had an effect. In response to White House and Congressional mandates, NASA leaders took actions that created systemic organizational flaws at the time of Challenger that were also present for Columbia. The final section compares the two critical decision sequences immediately before the loss of both Orbiters – the pre-launch teleconference for Challenger and the post-launch foam strike discussions for Columbia. It shows history again at work: how past definitions of risk combined with systemic problems in the NASA organization caused both accidents.

¶Connecting the parts of NASAʼs organizational system and drawing the parallels with Challenger demonstrate three things. First, despite all the post-Challenger changes at NASA and the agencyʼs notable achievements since, the causes of the institutional failure responsible for Challenger have not been fixed. Second, the Board strongly believes that if these persistent, systemic flaws are not resolved, the scene is set for another accident. Therefore, the recommendations for change are not only for fixing the Shuttleʼs technical system, but also for fixing each part of the organizational system that produced Columbiaʼs failure. Third, the Boardʼs focus on the context in which decision making occurred does not mean that individuals are not responsible and accountable. To the contrary, individuals always must assume responsibility for their actions. What it does mean is that NASAʼs problems cannot be solved simply by retirements, resignations, or transferring personnel.2

¶The constraints under which the agency has operated throughout the Shuttle Program have contributed to both

196

¶Shuttle accidents. Although NASA leaders have played an important role, these constraints were not entirely of NASAʼs own making. The White House and Congress must recognize the role of their decisions in this accident and take responsibility for safety in the future.